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LETTERS TO THE EDITOR

Treatment of Persistent Cerebrospinal Fluid Leak with an Epidural Blood Patch

Department of Anesthesiology, University of Texas Medical School, Houston, TX, Dr. Chan does not wish to respond.

To the Editor:

Chan and Paech (1) describe three cases of persistent cerebrospinal (CSF) leak after combined spinal-epidural anesthesia. In all three cases, the leak was ultimately controlled by insertion of sutures, which supposedly disrupted the fistulous tract by which the CSF reached the skin.

In 1984 (2), this author successfully treated a subarachnoid-cutaneous fistula with an epidural blood patch. In this case, the leak followed subarachnoid catheter placement for CSF drainage during transphenoidal excision of a pituitary adenoma.

Suturing the skin closed is not adequate treatment if indeed a fistula was present, since the pathology would persist, namely a fistulous communication of the subarachnoid space with more superficial tissues. Perhaps conduction of an epidural blood patch in each case might have disrupted the fistula at the most proximal site of the leak, i.e., at the hole in the arachnoid-dura, and might have been less stressful to the patient In the case report of 1984 (2), injection of 18 mL of autologous blood into the epidural space resulted in immediate and sustained cessation of the leak, in a patient who most likely had a larger fistula than the three patients in this report. In the cases described by Chan and Paech (1), epidural blood patches could have been conducted on the Obstetrics floor with minimal disruption to the routine of the physicians and nurses and negated the need to refer these patients to other services. The mechanism by which an epidural blood patch successfully controlled the leak is of course speculative. However, I would suggest that epidural blood patch should be considered as a viable and perhaps better treatment in cases of subarachnoid-cutaneous fistulae.

References

1. Chan BO, Paech MJ. Persistent cerebrospinal fluid leak: a complication of the combined spinal-epidural technique. Anesth Analg 2004; 98: 828–30.[Abstract/Free Full Text]
2. Katz J. Treatment of a subarachnoid-cutaneous fistula with an epidural blood patch. Anesthesiology 1984; 60: 603–4.[Web of Science][Medline]

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