Review of Cerebrospinal Fluid Physiology and Dynamics: A Call for Medical Education Reform

BACKGROUND: The flow of cerebrospinal fluid (CSF) has been described as a unidirectional system with the choroid plexus serving as the primary secretor of CSF and the arachnoid granulations as primary reabsorption site. This theory of neurosurgical forefathers has been universally adopted and taught as dogma. Many neuroscientists have found difficulty reconciling this theory with common pathologies, and recent studies have found that this “classic” hypothesis may not represent the full picture. OBJECTIVE: To review modern CSF dynamic theories and to call for medical education reform. METHODS: We reviewed the literature from January 1990 to December 2020. We searched the PubMed database using key terms “cerebrospinal fluid circulation,” “cerebrospinal fluid dynamics,” “cerebrospinal fluid physiology,” “glymphatic system,” and “glymphatic pathway.” We selected articles with a primary aim to discuss either CSF dynamics and/or the glymphatic system. RESULTS: The Bulat–Klarica–Orešković hypothesis purports that CSF is secreted and reabsorbed throughout the craniospinal axis. CSF demonstrates similar physiology to that of water elsewhere in the body. CSF “circulates” throughout the subarachnoid space in a pulsatile to-and-fro fashion. Osmolarity plays a critical role in CSF dynamics. Aquaporin-4 and the glymphatic system contribute to CSF volume and flow by establishing osmolarity gradients and facilitating CSF movement. Multiple studies demonstrate that the choroid plexus does not play any significant role in CSF circulation. CONCLUSION: We have highlighted major studies to illustrate modern principles of CSF dynamics. Despite these, the medical education system has been slow to reform curricula and update learning resources.