Cerebrospinal fluid-cutaneous fistula after neuraxial procedure and management: a case report

S. Nirmal Kumar, K. Senthil Kumar*, P. Sasi Kumar, S. Khaja Mohideen

Department of Anaesthesiology, Kauvery Hospitals, Trichy, Tamil Nadu

Background

Cerebrospinal fluid (CSF) -cutaneous fistula occurrence following neuraxial technique is very rare with incidence 1:220000 and less reported in India.

Case Presentation

A 65-year-old female, a long-standing diabetic, with past history of deep vein thrombosis, and with recent history of pulmonary embolism, underwent right hemicolectomy under general anesthesia with epidural catheter placed at lumbar level for perioperative analgesia. Accidentally epidural catheter placement was found intrathecal and removed on second postoperative day after timing anticoagulation withdrawal. 24 hrs after removal of epidural catheter, we noticed wet soakage of lumbar dressing. On removal of dressing, under asepsis, we noticed clear droplets coming out through epidural puncture site, draining at every 10 s in lateral position, with increased frequency at sitting position and also on Valsalva manoeuvre (Fig. 1).

Point of care testing of sugar for the clear fluid was 187mg%; simultaneous capillary sugar was 247mg%.

Patient did not have symptoms like headache, fever, neck rigidity or hypotension.

Compression bandage was applied and patient was advised bed rest and hydration for next 12 h, yet did not get resolved. Also, symptoms like headache and giddiness worsened in sitting position subsequently. Epidural blood patch was performed at level above the fluid leak with 20ml of fresh blood drawn from the patient; we could notice that the droplets immediately stopped leaking from previous epidural puncture site (Fig. 2).

Fig. 1. CSF leak at epidural puncture site.

Fig. 2. Nil soakage post procedure.

Discussion

CSF-cutaneous fistula is notably rare; they have been reported following spinal surgery, long- and short-term intrathecal catheters, diagnostic and therapeutic lumbar punctures, combined spinal-epidurals and epidural catheters. If this complication is not addressed early, apart from features of post dural puncture headache, it might lead to life threatening meningitis, intracranial hypotension and brain herniation [1].

Finding of fluid discharging from a previous epidural site following its removal may be far more common than is suggested in literature. The nature of such a fluid leak, however, may often be attributed to subcutaneous edema or local anesthetic solution, which may pool in the epidural or subcutaneous space and be discharged via the skin tract created by the epidural catheter. Hence to confirm the same we did a point of care testing of blood sugar of the discharging fluid, which showed 187mg% and simultaneous capillary blood sugar of 247 mg%, though point of care testing for sugar of cerebrospinal fluid is less sensitive. In our patient Valsalva manoeuvre increased the leakage of clear fluid at the epidural puncture site which was also a diagnostic of CSF-cutaneous fistula. Multiple laboratory analytics may be performed on the leaking fluid to assist with diagnosis, including tests for glucose, protein and β-2-transferrin [2]. β-2-transferrin detection is more specific for identifying CSF, but it is not rapidly available everywhere and also time consuming.

Treatment options vary (as per previous authors), in which conservative measures includes sterile dressings, fluids, bed rest in positions to minimize CSF pressure on the presumed dural defect as well as minimize dural traction,lateral decubitus +/– hip flexion, prone +/– a pillow under the abdomen and slight Trendelenburg position. Invasive procedures like cutaneous stitching of the outflow defect, epidural blood patch and tetra starch patch, use of fibrin glue, tract scarification and surgical correction are reported [3].

Conclusion

CSF-cutaneous fistulas are rare events that should be recognized early due to the potential for infections and neurologic complications. By all practical means, diagnosis by Valsalva manoeuvre and point of care glucose testing helps in early diagnosis, though β-2-transferrin detection is more specific in diagnosing CSF-cutaneous fistula and epidural blood patch is more effective technique in managing CSF fistulas.

References

Abaza K,Bogod D. Cerebrospinal fluid-cutaneous fistula and pseudomonas meningitis complicating thoracic epidural analgesia. Brit J Anaesth. 2004;92(3):429-31.
Thong S.Cerebrospinal fluid cutaneous fistula after uneventful epidural analgesia. Glob J Anesthesiol.2015:3-5.
Tsai A, Ahmed S, Wang J.Persistent cerebrospinal fluid-cutaneous fistula after epidural analgesia: a case report and review of literature. JAnesthesiol Clin Sci.2014;3(1):2.