Abstract Background data Intracranial hypotension causing postural headaches has been described after occult and postsurgical cerebrospinal fluid (CSF) leaks and rarely isolated lumbar punctures. The occurrence of a CSF-pleural communication is much rarer, and a high level of suspicion aids in prompt recognition. Purpose Early detection and anatomic delineation of the site of CSF-pleural fistula allows prompt intervention, results in resolution of symptoms and prevents the complication of meningitis. Study design A case of intracranial hypotension with postural headaches is described after spinal surgery, with demonstration on computed tomography (CT) myelography of a rare CSF-pleural fistula. Methods The clinical presentation, postoperative intervention and imaging as well as laboratory data are presented. Results Chest X-ray showed recurrent pleural effusion after placement of chest tube, and serial head CT studies revealed decreasing ventricular size with development of severe headaches. Myelogram and CT postmyelogram demonstrate the CSF-pleural communication, allowing appropriate surgical repair. Conclusion Severe headaches with a recurrent pleural effusion after thoracic spinal surgery may indicate presence of a CSF-pleural fistula, an unusual complication of thoracic spinal surgery.