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LETTERS TO THE EDITOR

Does an Epidural Catheter Impede or Stimulate Dural Inflammatory Response and Normal Dural Closure After Dural Puncture?

Department of Anesthesiology, UCSD Medical Center, University of California, San Diego, San Diego, CA, kkuczkowski@ucsd.edu, Dr. Chan does not wish to respond.

To the Editor:

I read with interest the report by Chan and Paech (1) describing persistent cerebrospinal fluid (CSF) leak after combined spinal-epidural anesthesia for cesarean delivery. Although I agree with almost everything in this report, the statement "These cases raise several questions, for example, does the epidural catheter sometimes impede the dural inflammatory response, preventing normal closure and healing of the puncture site, and does injection of a large volume of epidural solution influence fistula formation?" seems in part (in italics) surprising and in contrary to the findings of others (2–4). Denny at al. (2) postulated that inserting a catheter in the dural hole leads to an inflammatory reaction, with edema or fibrin exudates subsequently sealing the dural tear after catheter removal. Yaksh et al. (3) described formation of fibrin around the catheter at the dural tear in an experimental animal study. Kuczkowski and Benumof (4) postulated that the long-term presence of the catheter might promote an inflammatory response around the dural hole, which facilitates dural closure after catheter removal. If epidural needle-induced dural puncture did occur in these 3 patients, epidural catheter (by stimulating not impeding inflammatory response) may have prevented postdural puncture headache; however, this should have prevented CSF leak.

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. Denny N, Masters R, Pearson D, et al. Postdural puncture headache after continuous spinal anesthesia. Anesth Analg 1987; 66: 791–4.[Free Full Text]
3. Yaksh TL, Noueihed RY, Durant PAC. Studies of the pharmacology and pathology of intrathecally administered 4-anilinopeperidine analogues and morphine in the rat and cat. Anesthesiology 1986; 64: 54–66.[Web of Science][Medline]
4. Kuczkowski KM, Benumof JL. Decrease in the incidence of post-dural puncture headache: maintaining CSF volume. Acta Anaesthesiol Scand 2003; 47: 98–100.[Web of Science][Medline]

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