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CSF cutaneous fistula in the parturient with coagulopathy
Abstract Number: F3D-7
Abstract Type: Case Report/Case Series
Introduction: CSF cutaneous fistula is a rare complication of neuraxial anesthesia. Herein we describe the management of a CSF cutaneous fistula in a parturient with coagulopathy.
Case: A healthy 31 year old nulliparous female was admitted to L&D in labor. A combined spinal-epidural was placed using a 17g Tuohy needle and 26g Gertie Marx spinal needle. A 19g springwound multi-orifice, closed-tip epidural catheter was threaded and left at a depth of 12 cm at the skin. Upon aspiration, the catheter was noted to be intravascular, and was therefore removed and replaced at one level above, without complication. Approximately 1.5 hours after placement of CSE, patient delivered and the epidural was removed 2 hours post-partum. Her post-partum course was complicated by pre-eclampsia with severe features and HELLP syndrome.
The anesthesia team was notified on post-partum day 2 that the patient had fluid “leaking out” of her back. She denied fevers, chills, headache, or visual changes. She had no sensory or motor deficits. She had mild positional neck pain. On exam, the epidural puncture site was noted to be non-tender, with no erythema or fluctuance. The dressing that had been placed over the site was saturated with clear fluid. A few drops of clear fluid were expressed from the puncture site. A neurosurgical consult was called and she was diagnosed with a CSF leak based on history and exam. The neurosurgeon recommended an epidural blood patch and IV antibiotics. Given her history of placental abruption and HELLP syndrome, coags were checked and showed an INR of 1.7. Therefore a blood patch was deferred. Decision was made to place a stitch in the skin to prevent further leakage of fluid and reduce the chance of infection. A figure-of-8 stitch was placed with a 3-0 nylon suture. The next day, the INR was still elevated at 1.5. She no longer had any further leakage, and her symptoms resolved. She was discharged home with close follow-up. Post discharge, she denied having any fluid leakage, fevers or any symptoms of PDPH.
Discussion: CSF cutaneous fistulas are a rare complication of neuraxial anesthesia. Typically, these have been described in cases where an epidural catheter was left in place for extended periods of time. Our patient had an epidural for less than 4 hours. Diagnosis can be confirmed with fluid analysis, which was not done in our case. Our differential included leakage of edema fluid, residual local anesthetic or CSF leak. Given that the patient had mild symptoms of PDPH, a diagnosis of CSF leak was made. While it is surprising that a small pencil-point spinal needle would cause a persistent CSF leak, it is possible that there was an undiagnosed dural puncture with the Tuohy needle. The neurosurgeon was concerned that the fistula could lead to infection and therefore recommended EBP. However, coagulopathy contraindicated this approach, thus a stitch was placed in the skin to prevent leakage and decrease the risk of infection.