Cerebrospinal Fluid-Cutaneous Fistula After Continuous Spinal Catheter in an Obstetric Patient

[Postdural puncture headache in obstetrics : Pathogenesis, diagnostics and treatment]

Postdural puncture headache (PDPH) is one of the most important complications of peripartum neuraxial analgesia. Loss of cerebrospinal fluid volume and pressure as well as compensatory intracranial vasodilation are assumed to be responsible. Potentially severe long-term sequelae necessitate the correct diagnosis of PDPH, exclusion of relevant differential diagnoses (with atypical symptoms and when indicated via imaging techniques) and rapid initiation of effective treatment. Nonopioid analgesics, caffeine and occasionally theophylline, gabapentin and hydrocortisone are the cornerstones of pharmacological treatment, while the timely placement of an autologous epidural blood patch (EBP) represents the gold standard procedure when symptoms persist despite the use of analgesics. Procedures using neural treatment are promising alternatives, especially when an EBP is not desired by the patient or is contraindicated. Interdisciplinary and interprofessional consensus standard procedures can contribute to optimization of the clinical management of this relevant complication.

Cerebrospinal fluid fistula after combined spinal-epidural block

Neuraxial anaesthesia is an essential technique in obstetric anaesthesia practice. Cerebrospinal fluid (CSF) fistula is a rare complication and there is no consensus about its clinical approach. We present a case of a 28-year-old nulliparous woman that developed a cutaneous CSF fistula following combined spinal and epidural block for caesarean delivery. After multidisciplinary discussion it was decided that hydration, absolute bed-rest and compressive dressing with abdominal binder was the best option and the patient fully recovered without any sequelae.Based on literature, symptoms of intracranial hypotension and leakage of clear fluid surrounding the puncture site usually motivate referral to anaesthesia. Management strategies can be both conservative and invasive, including direct suture of the skin puncture site and epidural blood patch.Regarding the anaesthesia practice on this topic, most of the available evidence is based on case reports, rendering the decision-making process challenging.

Meningitis following cerebrospinal fluid-cutaneous fistula secondary to combined spinal-epidural anaesthesia for elective caesarean delivery

Cerebrospinal fluid-cutaneous fistula is a rare complication associated with neuraxial procedures. Here, we describe a case of fistula formation related to combined spinal-epidural anaesthesia for elective caesarean delivery, where the epidural catheter was removed only two hours later. The clear fluid leaking persistently from the site of the skin puncture associated with the epidural insertion site was confirmed to be cerebrospinal fluid with an increased beta-trace protein, and the fistula was closed with skin sutures. Subsequently, the patient presented with neurological signs and symptoms consistent with meningitis and she was treated empirically with intravenous antibiotics. Cerebrospinal fluid-cutaneous fistula formation with secondary meningitis is an exceptionally rare event in obstetric anaesthesia.

A rare complication of accidental dural puncture during epidural insertion for labour analgesia

A 33-year-old multiparous term parturient requested an epidural for labour analgesia. An accidental dural puncture was noted at the time of epidural needle insertion and an intrathecal catheter was placed. The intrathecal catheter was removed 10 h later and was noted to be intact. The following day, there was a significant leak of clear fluid from the catheter insertion site. Cerebrospinal fluid was detected using beta-trace protein testing. The patient remained asymptomatic and we deduced the cause could be a cutaneous fistula. Similar published reports have suggested the causes of similar presentations could include leakage of interstitial oedema, local anaesthetic or cerebrospinal fluid. It is important to consider the diagnosis of clear fluid leakage following an accidental dural puncture and the management of a cerebrospinal fluid-cutaneous fistula in the absence of neurological symptoms.

Treatment of cerebrospinal fluid leak after spine surgery

Owing to the complexity of spinal surgery, there is a great prevalence of dural tear causing cerebrospinal fluid (CSF) leakage. Many studies focused on suture repair for dural tear to stop CSF leak. Now some new treatment strategies have shown a promising effect that is listed as follows: 1) creating watertight dural closure to stop CSF leak with the help of dural substitute material; and 2) retarding CSF leak by changing pressure difference, including reducing the subarachnoid fluid pressure, increasing the epidural space pressure and both. In fact several methods mentioned above are usually combined to treat CSF leak. However, no update review summarized the relevant studies implemented in recent years. In this review, the authors would compare the effects of different dural closure techniques, and introduce the latest treatment methods and mechanisms.