Background.-Postural headaches are commonly associated with spontaneous intracranial hypotension and cerebrospinal fluid (CSF) leakage from the spine. A subarachnoid-pleural fistula (SPF) is a very rare and serious type of CSF fistula that has mostly been reported following traumatic causes. Case Report.-Here, the case of a 36-year-old woman who suffered from postural headaches after chiropractic manipulation of her neck was reported. Brain and spinal magnetic resonance (MR) imaging showed brain sagging, a C7-T1 dural defect, and overt CSF leakage. Heavy T2-weighted MR myelography revealed paravertebral fluid collections, communicating with pleural effusions through bilateral SPFs. The postural headaches were relieved by 3 courses of epidural blood patches. Discussions.-From the patient's history, her severe SPFs were attributed to rupture of the spinal leptomeninges during vigorous chiropractic manipulation of her neck. Heavy T2-weighted MR myelography could delineate the route of SPFs and CSF leakages.