Journal of Anesthesiology & Clinical Science

Journal of Anesthesiology & Clinical Science

ISSN 2049-9752
Case report

Persistent cerebrospinal fluid-cutaneous fistula after epidural analgesia: a case report and review of literature

Andrea Tsai1, Shihab Ahmed2 and Jingping Wang2*

*Correspondence: Jingping Wang

1. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Clinical Fellow, Harvard Medical School, Boston, MA, USA.

Author Affiliations

2. Department of Anesthesia, Critical Care and Pain Medicine, Assistant Professor Massachusetts General Hospital, Boston, MA, USA.


Presented is a case of persistent high-output cerebrospinal fluid (CSF) leak following epidural catheter removal on postoperative day 5 for a 64-year-old patient after exploratory laparotomy. Epidural catheter placement required multiple attempts preoperatively and was complicated by a "wet tap". Diagnosis of CSF leak was made with glucose, protein and beta-2 transferrin testing. In our review of 30 cases with reported CSF-cutaneous fistula, a trend towards requiring epidural blood patch for symptom relief exists when larger bore needles are used (all 9 reports involving 14 gauge or larger needles and 2 reports of fistulas resulting from a surgical defect) and duration of catheter stay is long. Notably, there were 3 case reports of CSF-cutaneous fistulas occurring without the placement of a catheter. Among 9 cases of fistula reported in the obstetric population, only one patient needed EBP for symptom control. Location of the needle/catheter insertion site at different levels of the neuraxium does not appear to affect the risk of developing a CSF-cutaneous fistula. CSF-cutaneous fistulas are a rare event that should be recognized early due to the potential for infections and neurologic complications. Glucose and protein testing offer a rapid but less specific means of diagnosing a possible CSF leak and can be used as guidance while awaiting results from beta-2 transferrin or beta-trace protein testing for definitive identification of CSF. With literature review, we propose an algorithm to help early detection and management of CSF-cutaneous fistula.

Keywords: Epidural analgesia, cerebrospinal fluid-cutaneous fistula, beta-2 transferrin, postoperative pain management

ISSN 2049-9752
Volume 3
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