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• W3012144711 abstract "Editor, Cerebrospinal fluid-cutaneous fistula (CSFCF) is a very rare complication of epidural steroid injection (ESI). We present a case of CSFCF occurring 11 days after an ESI complicated by sepsis and severe intracranial hypotension, this latter being successfully treated by an epidural hydroxyethyl starch (HES) patch. The patient gave written consent for publication of this case report. A 41-year-old man was referred to our pain clinic for two ESIs for failed back surgery syndrome. He had a history of chronic obstructive pulmonary disease, type 2 diabetes, arterial hypertension, smoking and obstructive sleep apnoea. He had residual lower back pain after a lumbar recalibration for disabling neurogenic claudication. The second ESI was administered by an experienced anaesthesiologist in the L4 to L5 interspace under fluoroscopic control with a Tuohy Portex 16-gauge needle, and slow release methylprednisolone 80 mg (Depo-Medrol, Pfizer, Belgium) was injected. The procedure was uneventful; no blood or clear fluid were identified. Eleven days after this ESI, the patient complained of headaches and noticed clear fluid loss from his back. When referred to the emergency department, he had no fever and no photophobia. Neurological examination was not contributive, but clear fluid was dripping from a small hole on the lumbar scar. Lumbar MRI identified a dural breach at L4 to L5 with a fistulous pathway to the skin (Fig. 1). The skin hole was closed by a Donati stitch and the patient was admitted to hospital and managed conservatively with bed rest, hydration and analgesics.Fig. 1: T2-weighted MRI of the lumbar spine (L4 to S1). Right paramedian dural breach in L4 to L5 with demonstration of a fistulous pathway to the skin (white arrows). Please note the presence of an adhesive arachnoiditis of the sacral pairs.The next morning, he complained of nausea and developed fever with chills. Blood was taken for culture. Around noon, the nurses discovered a sub-comatose patient in a wet bed. He was intubated and transferred to the ICU. The diagnosis of meningitis was considered and empiric antibiotics were initiated with vancomycin and meropenem, changed to penicillin after identification of Streptococcus agalactiae. Three days later, a computed tomography (CT) scan revealed severe intracranial hypotension with onset of brain herniation. There was still fluid loss through the lumbar scar. A classic blood patch was contraindicated given his septic status. Because of previous reports describing the epidural injection of HES as a suitable alternative for treatment of postdural puncture headache if blood patch is contraindicated,1,2 an epidural injection of HES 130/0.4 (Voluven, Fresenius Kabi, Belgium) was performed. Fifty millilitres of HES were injected into the epidural space (injection until resistance was felt by the operator). The lumbar flow quickly dried up. His neurological state rapidly improved and he left the hospital 23 days after admission. Three days after discharge, he presented with a new onset of severe headaches with dizziness and nausea without recurrence of fluid loss through the lumbar scar. He was readmitted for 4 days and managed conservatively. His symptoms resolved and he has remained asymptomatic since. CSFCF is an extremely rare complication after neuraxial puncture. Risk factors include steroid use, access through surgical scar tissue, multiple attempts and insertion of a spinal catheter.3 Although ESI performed for failed back surgery syndrome combines several of the recognised risk factors, only two publications have reported three cases of CSFCF after ESI.4,5 When clear fluid loss occurs from a neuraxial puncture site, laboratory analysis of the fluid (glucose, proteins) has been recommended as a first step to differentiate CSFCF from subcutaneous oedema.3 Beta-2 transferrin or beta-trace protein detection is more specific for identifying CSF6 but is not rapidly available everywhere. In our patient, the lumbar MRI clearly identified a fistulous pathway from the dura to the skin. Therefore, MRI might be considered as a second-line assessment when the differential diagnosis remains difficult after laboratory analysis. First-line treatment is conservative management with bed rest, analgesics, sterile dressing, hydration and caffeine, and it usually results in a favourable outcome.3 If a CSFCF is identified, the skin puncture should be closed by a deep cutaneous stitch to stop the CSF flow and to prevent bacterial contamination.3 If symptoms persist or if severe intracranial hypotension develops, an epidural blood patch has been recommended.3 In the presence of sepsis or malignancy, injection of HES in the epidural space instead of blood can be considered, though this is an off-label use. This technique was first described by Vassal et al.1 and Sun and Huang2 for the treatment of postdural puncture headaches. Specific contraindications to tetrastarch injection in the epidural space include local infection and hypersensitivity to HES. In case of sepsis, the expected benefit of this intervention must be weighed against the risk of epidural or meningeal infection. The optimal volume to be injected is unknown. Previous authors have injected 15 to 30 ml.1,2 In our patient, it was decided to stop the injection when the operator felt resistance, which finally corresponded to 50 ml. This treatment appeared successful, although the headaches reappeared a few days after patient's discharge, requiring simple conservative measures. CSF-cutaneous fistula is a very rare complication after ESI, but the consequences can be serious. As presentation may be delayed, the patient should be asked to consult his physician if there is fluid loss from the back. Initially, laboratory analysis of the dripping fluid should be undertaken. If doubt persists, an MRI may be ordered. If conservative management fails or there is severe intracranial hypotension, and an epidural blood patch is contraindicated due to an infection, an epidural HES patch may be considered. An updated algorithm for the diagnosis and management of CSFCF is proposed in Fig. 2.Fig. 2: Diagnosis and management of cerebrospinal fluid-cutaneous fistulae. AB, antibiotics; CSFCF, cerebrospinal fluid cutaneous fistula; HES, hydroxyethyl starch; LA, local anaesthetics. aSee text." @default.
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• W3012144711 date "2020-04-01" @default.
• W3012144711 modified "2023-09-29" @default.
• W3012144711 title "Severe cerebrospinal fluid-cutaneous fistula treated by an epidural tetrastarch patch" @default.
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