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