ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, No. 5, SEPT.-OCT., 1975
691
Case History Number 86:
An Unusual Complication of Lumbar Puncture: A CSF Cutaneous Fistula CLAYTON G. BALL, M.D.* FRANK T. D’ALESSANDRO, M.D.? JAIME ROSENTHAL, M.D.$ THOMAS A. DUFF, M.D.§ Charlottesville, Virginia//
C
fluid (CSF) cutaneous fistulas are not uncommon complications of some neurosurgical procedures1 and also have been reported as a delayed complication after trauma.2 However, we believe the following to be the only report of such a fistula after a lumbar puncture.
or sneezing. The pain was severe enough to force her to resign her teaching position, and she required 60 mg of codeine and 5 mg of diazepam, 4 or 5 times daily, to be comfortable. Other medical history included a hysterectomy 1 year previously; otherwise, she was in good health.
A 28-year-old woman was referred to the Anesthesiology Department Nerve Block Clinic for evaluation and treatment of low back pain. She had been involved in an automobile accident approximately 5 years before and dated the onset of her discomfort to approximately 1 year following the accident. She described her original discomfort as a feeling of pressure in her lower back, with sharp pain radiating down the back of her right leg. Two years previously, a laminectomy had been performed at L4-5 without definite relief of symptoms.
Pertinent physical findings included tenderness to palpation over her right sacroiliac region and along the midline laminectomy scar. Muscle strength was normal in both lower extremities but there was diminished sensation to pin prick over the lateral aspect of the left thigh. The knee jerk was diminished on the right but the other deep tendon reflexes were normal. She could raise her extended legs bilaterally to 90” without pain and LasBgue’s sign was absent.
EREBROSPINAL
On her initial visit, she complained of intermittent discomfort, characterized as “pressure,” in her lower back, with frequent episodes of aching in her left leg. The pain was made worse by standing, sitting, or stooping, but was not affected by coughing
A tentative diagnosis of pain secondary to postlaminectomy adhesions and nerve root irritation at the L5 and S1 levels was established. Therapy consisted of a series of three epidural injections of 60 mg of lidocaine and 50 mg of triamcinolone hydrochloride on alternate days, using the loss-ofresistance technic to identify the epidural
*Assistant Professor, Department of Anesthesiology ?Resident, Department of Anesthesiology $Resident, Department of Neurosurgery SResident,Department of Neurosurgery
[ IUniversity of Virginia Medical School, Charlottesville, Virginia 22901 This feature is conducted by David E. Longnecker, M.D., Contributing Editor, Department of Anesthesiology, University of Virginia Medical Center, Charlottesville, Virginia 22901
692
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54,No. 5, SEPT.-OCT., 1975
space before injections. On no occasion was CSF aspirated. Shortly after receiving her second epidural injection, the patient noted the onset of a severe headache, which was relieved by lying down and aggravated by the erect position and which persisted for several days after discharge from the hospital. As an unrecognized lumbar puncture was believed responsible for the headache, a fourth epidural injection was performed, this time with 8 ml of autologous blood. Two days later, she reported that her headache was gone but she noted a “wet spot” on her back that constantly soaked her clothing. Examination revealed a continuous discharge of clear fluid issuing from the site of one of her previous epidural injections in the region of the L4-5 interspace. Chemical analysis of this fluid revealed a protein of 117 mg/100 ml and glucose of 172 mg/100 ml. A diagnosis of persistent CSF leak was made. The patient was readmitted, placed prone with a pillow under her abdomen, and given 1 gm of cephalothin every 6 hours and 8 gm of glycerol every 3 hours by mouth (1.5 gm/kg/24 hr) Fluids were restricted in an attempt to produce dehydration. The apparent CSF leak continued undiminished for 96 hours until a figure-of-eight suture was placed in the skin at the drainage site. The flow of CSF promptly ceased and there has been no recurrence. The patient remained afebrile, and her white blood count was not elevated a t any time. On the 13th hospital day, a lumbar myelogram, performed by means of a suboccipital puncture, showed no evidence of an internal meningocele, arachnoidal cyst, or similar abnormalities. There was, however, an “anterior indentation in the contrast column opposite the L4-5 interspace. . . .” This was interpreted to represent a “new or current” anterior disc protrusion. A lumbar hemilaminectomy at the L4-5 and * L5-S1 areas revealed no herniated disc. A thin, dark fibrous tissue was identified around the dura in the area of the old laminectomy and was removed as much as possible. A spinal fusion was performed from L4 to S1. No evidence of arachnoidal cysts or other major abnormalities was found at operation. The patient tolerated the procedure well and experienced an uneventful postoperative recovery. She was placed in a body cast and discharged, to be followed as an outpatient.
DISCUSSION From the symptoms and complications of the blocks performed on this patient, it is obvious that the dura was punctured, probably during the second block. CSF leakage through a dural rent during and after a lumbar puncture is well recognized. Epidural collection of CSF following a spinal tap has been directly visualized during myeloscopy4 and has been demonstrated using I-human serum albumin intrathecally.5 However, review of the literature reveals no report of CSF leak through a cutaneous fistula after lumbar puncture, even in an extensive review of complications of regional anesthesia.6 The cause of the cutaneous fistula in this particular case may be twofold: (1) There were repeated needle penetrations of one puncture site, which may have promoted fistula formation; (2) there may have been inadvertent deposition of triamcinolone along the needle tract. The anti-inflammatory effect of steroids, triamcinolone in particular, is well known.‘ This may have prevented scar formation and closure of the needle tract, causing a cutaneous fistula and subsequent CSF leakage.
i
Thus, when steroids are injected into the epidural space, every effort must be made to prevent any steroid leakage when withi drawing the needle. Further, more than one puncture site should be used if repeated blocks are to be done.
REFERENCES 1. Rizzoli H, Horwitz N: Postoperative Complications in Neurosurgical Practice. First edition. Baltimore, The Williams & Wilkins Company, 1967, pp 251 and 262 2. Liebeskind AL, Herz DA, Rosenthal AD, et al: Radionuclide demonstration of spinal dural leaks. J Nucl Med 14:35&358, 1973
3. Rosenthal J, Hahn J, Martinez J: Technique for closure of spinal fluid leak, Technical Note. Surg Gynec Obstet (in press) 4. Pool JL: Myeloscopy: intraspinal endoscopy. Surgery 11:169-182, 1942
5. Gass H, Goldstein A, Ruskin R, et al: Chronic postmyelogram headache; isotopic demonostration of dural leak and surgical cure. Arch Neurol 25:168171, 1971 6. Moore DC: Complications of Regional Anesthesia. First edition. Springfield, Illinois, Charles C Thomas, Publisher, 1955, pp 258 and 263
7. Sayers G, Travis R: Adrenocorticotropic hormones: adrenocortical steroids and their synthetic analogs, The Pharmacological Basis of Therapeutics. Fourth edition. Edited by Goodman IS, Gilman A, New York, The Macmillan Company, 1970, pp 1615 and 1623
693
Case History Number 86
Comment DAVID E. LONGNECKER, M.D. The accompanying case report appears to be a unique observation in the medical literature. To the best of our knowledge, this is the first reported case of a CSF cutaneous fistula following needle puncture of the dura. Although this complication is extremely rare, it may be seen with increasing frequency with the increased use of peridural or subarachnoid steroid therapy in patients with postlaminectomy adhesions. Several important lessons can be gleaned from this most unusual case report. First, it may be unwise to introduce a large-bore needle through scar tissue resulting from a previous laminectomy. Perhaps it would be beneficial to use a lateral approach to the peridural or subarachnoid space, in order to avoid the actual scar. Second, since steroids are known to alter wound healing, perhaps it would be valuable to flush the needle with a small volume of saline solution to prevent deposition of small amounts of steroid in the needle tract upon removal of the needle. Third, it is important to be aware that conservative management, including the use of glycerol, as described in the report, resulted in closure of the fistula without the need for operation. The increasing role of anesthesiologists in the management of patients with acute and chronic back pain requires that we be thoroughly familiar with the potential iatrogenic complications of our therapy.
Comment JOSEPH MAROON, M.D. Department of Neurosurgery University of Pittsburgh Presbyterian University Hospital Pittsburgh, Pennsylvania The decreased knee jerk and right radicular pain is, of course, suggestive of radiculopathy involving either the L3 or the L4 nerve root, perhaps secondary to compression at either the L3-4 or L4-5 interspace. Depending on the severity of her pain at that time, we would have considered myelography earlier in her course, to rule out the possibility of a recurrent L4-5 or perhaps a new L3-4 herniated disc. Furthermore, it is imperative that one visualize the inferior portion of the spinal cord, to rule out the rare case of intraspinal tumor masking as “disc disease.” The patient was treated with a series of epidural injections of steroids and lidocaine, as advocated by Winnie and associates,l with the development of severe headaches, aggravated by the upright position, following her second epidural injection. These headaches lasted 12 days and required the fourth epidural injection of autologous blood into the epidural space for relief. The most disconcerting thing about the case is the development of the continuous discharge of
clear fluid from the site of her previous injections in the region of the L4-5 interspace. This discharge was profuse enough to require hospitalization. The chemical analysis, however, is disturbing in that there was a protein of 117 mg/100 ml and a sugar of 172 mg/100 ml. Both are markedly elevated, the protein being much higher than one usually sees following an uncomplicated laminectomy for disc removal. Unfortunately, no mention is made of CSF analysis following the subsequent myelogram. Despite various conservative measures, the persistence of the leak required suturing for closure 4 days after hospital admission. Although I have had several drops of spinal fluid continue to flow from the site of lumbar punctures for several seconds, I have never encountered a persistent CSF leak from this procedure. Neither has Dr. Ruben Tenicela, Head of the Pain Control Center at the University of Pittsburgh, heard of or seen such a phenomenon in the 15 years during which he personally has done approximately 15,000 to 20,000 lumbar and epidural punctures (personal communication). RecentIy, we have been using spinal fluid drainage in the treatment of postoperative CSF leaks; in our series, as well as in those we have reviewed, we have
694
ANESTHESIA AND ANALGESIA . . . Current Research.es VOL.54,No. 5, SEPT.-OCT.,1975
never encountered a case such as that presently described.2
infrequently, however, since the contrast agent cannot be removed, adequate volumes may be injected to clearly delineate small extradural defects in the upper lumbar area.
If not spinal fluid, what could the fluid have been? The presence of an extra-arachnoidal or extradural cyst appears to have been eliminated by the subsequent myelogram and operation. A subcutaneous seroma would have a much higher protein content, and it would be virtually impossible for a “pocket” of CSF to persist subcutaneously for 4 years following the initial surgical procedure, assuming that a CSF leak had occurred at that time. We are left then with the fact that the fluid comes closer to CSF than anything better that we can postulate, but the elevated protein and sugar remains disturbing.
Finally, additional information would be desirable with regard to the thickness and tenaciousness of the “dark fibrous tissue” found around the dura during the second operation. It would seem most likely that this represented residual organized blood from the previous autologous blood injected into the epidural space. In summary, more questions are raised than answers given in the above case report. If, indeed, it was truly CSF leaking from the site of a needle puncture for 4 days, this is a singularly unique observation and documentation.
A question must be raised concerning how much contrast material was inserted via the suboccipital puncture, and whether adequate oblique and cross-table lateral views were obtained at the L3-4 interspace to rule out the possibility of an extradural defect at a higher level than the L4-5 interspac‘e. We have given up the suboccipital puncture in favor of the lateral C1-2 puncture under fluoroscopic control for all myelography in which a lumbar puncture is either impossible or contraindicated. Not
REFERENCES 1. Winnie AP, Hartman JT, Meyers HL Jr, et al: Pain Clinic 11: Intradural and extradural corticosteroids for sciatica. Anesth & Analg 51:990-1003, 1972 2. McCallum JE, Maroon JC, Jannetta PJ: Treatment of post-operative cerebrospinal fluid fistulas by subaracbnoid drainage. J Neurosurg 42: 434-437, 1975
Life is never so bad a t its worst that i t is impossible t o live; it is never so good a t its best that it is easy to live. -Gabriel H e a t t e r
Show me the man you honor, and I will know what kind of a man you are, f o r i t shows me what your ideal of manhood is, and what kind of a man you long t o be. -Thomas Carlyle
I;
*
d
It’s great to be great, but it’s greater to be human.
--Will Rogers
691
Case History Number 86:
An Unusual Complication of Lumbar Puncture: A CSF Cutaneous Fistula CLAYTON G. BALL, M.D.* FRANK T. D’ALESSANDRO, M.D.? JAIME ROSENTHAL, M.D.$ THOMAS A. DUFF, M.D.§ Charlottesville, Virginia//
C
fluid (CSF) cutaneous fistulas are not uncommon complications of some neurosurgical procedures1 and also have been reported as a delayed complication after trauma.2 However, we believe the following to be the only report of such a fistula after a lumbar puncture.
or sneezing. The pain was severe enough to force her to resign her teaching position, and she required 60 mg of codeine and 5 mg of diazepam, 4 or 5 times daily, to be comfortable. Other medical history included a hysterectomy 1 year previously; otherwise, she was in good health.
A 28-year-old woman was referred to the Anesthesiology Department Nerve Block Clinic for evaluation and treatment of low back pain. She had been involved in an automobile accident approximately 5 years before and dated the onset of her discomfort to approximately 1 year following the accident. She described her original discomfort as a feeling of pressure in her lower back, with sharp pain radiating down the back of her right leg. Two years previously, a laminectomy had been performed at L4-5 without definite relief of symptoms.
Pertinent physical findings included tenderness to palpation over her right sacroiliac region and along the midline laminectomy scar. Muscle strength was normal in both lower extremities but there was diminished sensation to pin prick over the lateral aspect of the left thigh. The knee jerk was diminished on the right but the other deep tendon reflexes were normal. She could raise her extended legs bilaterally to 90” without pain and LasBgue’s sign was absent.
EREBROSPINAL
On her initial visit, she complained of intermittent discomfort, characterized as “pressure,” in her lower back, with frequent episodes of aching in her left leg. The pain was made worse by standing, sitting, or stooping, but was not affected by coughing
A tentative diagnosis of pain secondary to postlaminectomy adhesions and nerve root irritation at the L5 and S1 levels was established. Therapy consisted of a series of three epidural injections of 60 mg of lidocaine and 50 mg of triamcinolone hydrochloride on alternate days, using the loss-ofresistance technic to identify the epidural
*Assistant Professor, Department of Anesthesiology ?Resident, Department of Anesthesiology $Resident, Department of Neurosurgery SResident,Department of Neurosurgery
[ IUniversity of Virginia Medical School, Charlottesville, Virginia 22901 This feature is conducted by David E. Longnecker, M.D., Contributing Editor, Department of Anesthesiology, University of Virginia Medical Center, Charlottesville, Virginia 22901
692
ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54,No. 5, SEPT.-OCT., 1975
space before injections. On no occasion was CSF aspirated. Shortly after receiving her second epidural injection, the patient noted the onset of a severe headache, which was relieved by lying down and aggravated by the erect position and which persisted for several days after discharge from the hospital. As an unrecognized lumbar puncture was believed responsible for the headache, a fourth epidural injection was performed, this time with 8 ml of autologous blood. Two days later, she reported that her headache was gone but she noted a “wet spot” on her back that constantly soaked her clothing. Examination revealed a continuous discharge of clear fluid issuing from the site of one of her previous epidural injections in the region of the L4-5 interspace. Chemical analysis of this fluid revealed a protein of 117 mg/100 ml and glucose of 172 mg/100 ml. A diagnosis of persistent CSF leak was made. The patient was readmitted, placed prone with a pillow under her abdomen, and given 1 gm of cephalothin every 6 hours and 8 gm of glycerol every 3 hours by mouth (1.5 gm/kg/24 hr) Fluids were restricted in an attempt to produce dehydration. The apparent CSF leak continued undiminished for 96 hours until a figure-of-eight suture was placed in the skin at the drainage site. The flow of CSF promptly ceased and there has been no recurrence. The patient remained afebrile, and her white blood count was not elevated a t any time. On the 13th hospital day, a lumbar myelogram, performed by means of a suboccipital puncture, showed no evidence of an internal meningocele, arachnoidal cyst, or similar abnormalities. There was, however, an “anterior indentation in the contrast column opposite the L4-5 interspace. . . .” This was interpreted to represent a “new or current” anterior disc protrusion. A lumbar hemilaminectomy at the L4-5 and * L5-S1 areas revealed no herniated disc. A thin, dark fibrous tissue was identified around the dura in the area of the old laminectomy and was removed as much as possible. A spinal fusion was performed from L4 to S1. No evidence of arachnoidal cysts or other major abnormalities was found at operation. The patient tolerated the procedure well and experienced an uneventful postoperative recovery. She was placed in a body cast and discharged, to be followed as an outpatient.
DISCUSSION From the symptoms and complications of the blocks performed on this patient, it is obvious that the dura was punctured, probably during the second block. CSF leakage through a dural rent during and after a lumbar puncture is well recognized. Epidural collection of CSF following a spinal tap has been directly visualized during myeloscopy4 and has been demonstrated using I-human serum albumin intrathecally.5 However, review of the literature reveals no report of CSF leak through a cutaneous fistula after lumbar puncture, even in an extensive review of complications of regional anesthesia.6 The cause of the cutaneous fistula in this particular case may be twofold: (1) There were repeated needle penetrations of one puncture site, which may have promoted fistula formation; (2) there may have been inadvertent deposition of triamcinolone along the needle tract. The anti-inflammatory effect of steroids, triamcinolone in particular, is well known.‘ This may have prevented scar formation and closure of the needle tract, causing a cutaneous fistula and subsequent CSF leakage.
i
Thus, when steroids are injected into the epidural space, every effort must be made to prevent any steroid leakage when withi drawing the needle. Further, more than one puncture site should be used if repeated blocks are to be done.
REFERENCES 1. Rizzoli H, Horwitz N: Postoperative Complications in Neurosurgical Practice. First edition. Baltimore, The Williams & Wilkins Company, 1967, pp 251 and 262 2. Liebeskind AL, Herz DA, Rosenthal AD, et al: Radionuclide demonstration of spinal dural leaks. J Nucl Med 14:35&358, 1973
3. Rosenthal J, Hahn J, Martinez J: Technique for closure of spinal fluid leak, Technical Note. Surg Gynec Obstet (in press) 4. Pool JL: Myeloscopy: intraspinal endoscopy. Surgery 11:169-182, 1942
5. Gass H, Goldstein A, Ruskin R, et al: Chronic postmyelogram headache; isotopic demonostration of dural leak and surgical cure. Arch Neurol 25:168171, 1971 6. Moore DC: Complications of Regional Anesthesia. First edition. Springfield, Illinois, Charles C Thomas, Publisher, 1955, pp 258 and 263
7. Sayers G, Travis R: Adrenocorticotropic hormones: adrenocortical steroids and their synthetic analogs, The Pharmacological Basis of Therapeutics. Fourth edition. Edited by Goodman IS, Gilman A, New York, The Macmillan Company, 1970, pp 1615 and 1623
693
Case History Number 86
Comment DAVID E. LONGNECKER, M.D. The accompanying case report appears to be a unique observation in the medical literature. To the best of our knowledge, this is the first reported case of a CSF cutaneous fistula following needle puncture of the dura. Although this complication is extremely rare, it may be seen with increasing frequency with the increased use of peridural or subarachnoid steroid therapy in patients with postlaminectomy adhesions. Several important lessons can be gleaned from this most unusual case report. First, it may be unwise to introduce a large-bore needle through scar tissue resulting from a previous laminectomy. Perhaps it would be beneficial to use a lateral approach to the peridural or subarachnoid space, in order to avoid the actual scar. Second, since steroids are known to alter wound healing, perhaps it would be valuable to flush the needle with a small volume of saline solution to prevent deposition of small amounts of steroid in the needle tract upon removal of the needle. Third, it is important to be aware that conservative management, including the use of glycerol, as described in the report, resulted in closure of the fistula without the need for operation. The increasing role of anesthesiologists in the management of patients with acute and chronic back pain requires that we be thoroughly familiar with the potential iatrogenic complications of our therapy.
Comment JOSEPH MAROON, M.D. Department of Neurosurgery University of Pittsburgh Presbyterian University Hospital Pittsburgh, Pennsylvania The decreased knee jerk and right radicular pain is, of course, suggestive of radiculopathy involving either the L3 or the L4 nerve root, perhaps secondary to compression at either the L3-4 or L4-5 interspace. Depending on the severity of her pain at that time, we would have considered myelography earlier in her course, to rule out the possibility of a recurrent L4-5 or perhaps a new L3-4 herniated disc. Furthermore, it is imperative that one visualize the inferior portion of the spinal cord, to rule out the rare case of intraspinal tumor masking as “disc disease.” The patient was treated with a series of epidural injections of steroids and lidocaine, as advocated by Winnie and associates,l with the development of severe headaches, aggravated by the upright position, following her second epidural injection. These headaches lasted 12 days and required the fourth epidural injection of autologous blood into the epidural space for relief. The most disconcerting thing about the case is the development of the continuous discharge of
clear fluid from the site of her previous injections in the region of the L4-5 interspace. This discharge was profuse enough to require hospitalization. The chemical analysis, however, is disturbing in that there was a protein of 117 mg/100 ml and a sugar of 172 mg/100 ml. Both are markedly elevated, the protein being much higher than one usually sees following an uncomplicated laminectomy for disc removal. Unfortunately, no mention is made of CSF analysis following the subsequent myelogram. Despite various conservative measures, the persistence of the leak required suturing for closure 4 days after hospital admission. Although I have had several drops of spinal fluid continue to flow from the site of lumbar punctures for several seconds, I have never encountered a persistent CSF leak from this procedure. Neither has Dr. Ruben Tenicela, Head of the Pain Control Center at the University of Pittsburgh, heard of or seen such a phenomenon in the 15 years during which he personally has done approximately 15,000 to 20,000 lumbar and epidural punctures (personal communication). RecentIy, we have been using spinal fluid drainage in the treatment of postoperative CSF leaks; in our series, as well as in those we have reviewed, we have
694
ANESTHESIA AND ANALGESIA . . . Current Research.es VOL.54,No. 5, SEPT.-OCT.,1975
never encountered a case such as that presently described.2
infrequently, however, since the contrast agent cannot be removed, adequate volumes may be injected to clearly delineate small extradural defects in the upper lumbar area.
If not spinal fluid, what could the fluid have been? The presence of an extra-arachnoidal or extradural cyst appears to have been eliminated by the subsequent myelogram and operation. A subcutaneous seroma would have a much higher protein content, and it would be virtually impossible for a “pocket” of CSF to persist subcutaneously for 4 years following the initial surgical procedure, assuming that a CSF leak had occurred at that time. We are left then with the fact that the fluid comes closer to CSF than anything better that we can postulate, but the elevated protein and sugar remains disturbing.
Finally, additional information would be desirable with regard to the thickness and tenaciousness of the “dark fibrous tissue” found around the dura during the second operation. It would seem most likely that this represented residual organized blood from the previous autologous blood injected into the epidural space. In summary, more questions are raised than answers given in the above case report. If, indeed, it was truly CSF leaking from the site of a needle puncture for 4 days, this is a singularly unique observation and documentation.
A question must be raised concerning how much contrast material was inserted via the suboccipital puncture, and whether adequate oblique and cross-table lateral views were obtained at the L3-4 interspace to rule out the possibility of an extradural defect at a higher level than the L4-5 interspac‘e. We have given up the suboccipital puncture in favor of the lateral C1-2 puncture under fluoroscopic control for all myelography in which a lumbar puncture is either impossible or contraindicated. Not
REFERENCES 1. Winnie AP, Hartman JT, Meyers HL Jr, et al: Pain Clinic 11: Intradural and extradural corticosteroids for sciatica. Anesth & Analg 51:990-1003, 1972 2. McCallum JE, Maroon JC, Jannetta PJ: Treatment of post-operative cerebrospinal fluid fistulas by subaracbnoid drainage. J Neurosurg 42: 434-437, 1975
Life is never so bad a t its worst that i t is impossible t o live; it is never so good a t its best that it is easy to live. -Gabriel H e a t t e r
Show me the man you honor, and I will know what kind of a man you are, f o r i t shows me what your ideal of manhood is, and what kind of a man you long t o be. -Thomas Carlyle
I;
*
d
It’s great to be great, but it’s greater to be human.
--Will Rogers
