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Possible asymptomatic cerebrospinal fluid leak following successful labour epidural catheter placement

Cleveland, Ohio

To the Editor:

We report the case of a parturient with a possible asymptomatic, cutaneous cerebrospinal fluid (CSF) leak 35 hr postepidural catheter placement, without a known dural puncture. The patient is a 21-yr-old, 61 kg G2P1, female, who accepted epidural analgesia for the management of labour pain. The epidural space was identified by loss of resistance to saline with an 18-gauge Hustead epidural needle. A non-styletted catheter was advanced 4 to 6 cm into the epidural space without resistance. Aspiration and a test dose were negative. The patient received a bolus of 0.2% ropivacaine (7 mL) with sufentanil 10 µg. A continuous epidural infusion of 0.1% ropivacaine with sufentanil 1 µg•mL^–1 was started at 7 mL•hr^–1 and pain relief was achieved for the next eight hours. One hour later, we were called for a Cesarean section for arrest of labour. The patient was given 0.5% bupivacaine with epinephrine 1:200000, incrementally to 20 mL. At incision, the patient complained of sharp pain in her left side, at which point general anesthesia was induced uneventfully. The emergence and recovery room stay were uneventful. On awakening, she had surgical anesthesia to T8 and complete motor block of the lower extremities.

Our anesthesia service removed the epidural catheter intact 21 hr postinsertion. We were called again 14 hr postcatheter removal because of fluid leakage at the dressing site. The patient was sitting and fluid was freely dripping from the epidural insertion site without any other symptoms. The clear fluid was collected. The nitrazide test showed a pH result of 7.0 to 7.5, glucose was 146 mg•dL^–1. Laboratory analysis revealed total protein 588 mg•dL^–1, specific gravity 1.009, and glucose 103 mg•dL^–1. With these results, the fluid leak was assumed to be CSF. Later that day, the sterile dressing was wet and a second dressing was applied, which remained dry and intact until discharge. Magnetic resonance imaging (MRI) showed a normal unenhanced lumbar spine, with no epidural or sc fluid collection. The patient was discharged four days postoperatively without complications.

Identifying the specific cause of this possible CSF leak is problematic. The epidural catheter placement was uneventful and infusion resulted in good pain relief for ten hours without any signs of subarachnoid block or local anesthetic toxicity. On emergence from general anesthesia the block was complete. The patient did not ever show any symptomatology from this possible CSF leak.

Testing for glucose is helpful in identifying CSF,¹ although it could be present in both inflammatory and non-inflammatory exudates.² If this was truly CSF, the increased protein level could be attributed to meningeal vasodilatation and subsequent diapedesis of proteins.³ Definitive tests include immunofixation electrophoresis for beta-2-transferrin⁴ and beta-2-transferrin found only in CSF and perilymph.⁵ Radiographic studies are helpful, including computed tomography, contrast myelography and cisternography. MRI is very sensitive in detecting CSF accumulation and pseudomeningocele.

References

1 Lauer KK, Haddox JD. Epidural blood patch as treatment for a surgical durocutaneous fistula. J Clin Anesth 1992; 4: 45–7.[Medline]

2 Eismont FJ, Wiesel FW, Rothman RH. Treatment of dural tears associated with spinal surgery. J Bone Joint Surg Am 1981; 63: 1132–6.[Abstract/Free Full Text]

3 Pannullo SC, Reich JB, Krol G, Deck MD, Posner JB. MRI changes in intracranial hypotension. Neurology 1993; 43: 919–26.[Abstract/Free Full Text]

4 Bosacco SJ, Gardner MJ, Guille JT. Evaluation and treatment of dural tears in lumbar spine surgery: a review. Clin Orthop 2001; 389: 238–47.

5 Skedros DG, Cass SP, Hirsch BE, Kelly RH. Beta-2-transferrin assay in clinical management of cerebrospinal fluid and perilymphatic fluid leaks. J Otolaryngol 1993; 22: 341–4.[Medline]

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