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A 12-year-old female with Gorham-Stout disease presented for progressive retro-orbital pain, headaches, and CSF leak as sequelae following T2-L1 anterior/posterior spinal fusion. Initial MRI of head and spine showed acquired Chiari malformation with syrinx and findings suggestive of CSF leak ( figure 1). CT myelogram of the lumbar and thoracic spine revealed contrast filling defect around the T9 screw into epidural space and vertebral body (figure 2). After initial placement of the needle into the target epidural location, during removal of the stylet a subtle whistling noise was heard. Immediate CT demonstrated a contralateral pneumothorax, and a syringe was immediately connected to the needle. Further imaging showed air within the epidural space, vertebral body, costo-vertebral joint, and rib (figure 3 & 4). We then decided to continue with the blood patch and injected a mixture of contrast and Tisseel fibrin glue filling the epidural space, vertebral body, and portion of the right T9 rib. The needle was withdrawn posteriorly, and additional fibrin glue was injected into the area around the T9 pedicle screw. Subsequent CT demonstrated increased density within the T9 vertebral body and left T9 pedicle, with unchanged volume of right posterior pneumothorax (figure 5). Chest X-ray on post-op day 1 showed resolution of pneumothorax. Patient remained in hospital for observation for 2 days before discharge with improved CSF hypotension symptoms at 3 months (figure 6).Disclosures P. Johnston: None.Abstract E-278 Figure 1FLAIR MRI 6-months prior showed typical findings of spinal CSF leak including splenium depression (yellow arrow), tented low lying tonsils (red arrow), and syrinx (orange arrow)Abstract E-278 Figure 2Myelogram contrast filling osseous pedicle and lateral mass defect around the T9 screw (white arrows) and epidural space (yellow arrow)Abstract E-278 Figure 3CT during needle placement into osseous defect showed air density in the T9 vertebral body (orange arrows) with associated contralateral pneumothorax (red arrow)Abstract E-278 Figure 4A slightly higher-level shows air within the contralateral lateral mass and rib (yellow arrow), demonstrating the cause of the pneumothorax (red arrow) via an epiduro-vertebro-costo-pleural fistulasAbstract E-278 Figure 5CT post-fibrin glue injection showed increased density of the vertebral fistula (yellow arrows) and unchanged contralateral pneumothoraxAbstract E-278 Figure 63-month follow-up MRI with normal position of cerebellar tonsils (yellow arrow) as well expansion of the mesencephalic cistern (orange arrow)