J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

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Case Report

Volume 13, Number 7, July 2022, pages 318-321

Intermittent Cerebrospinal Leak After Inadvertent Dural Puncture During Epidural Catheter Placement for Postoperative Analgesia

**Table 1.** Reports of CSF-Cutaneous Fistula in Children
References	Demographic data	Clinical course and outcome
CSF: cerebrospinal fluid; POD: postoperative day.
Kumar et al, 1991 [10]	A 6-year-old boy with CSF rhinorrhea after an orbital fracture and a 6-year-old girl with an ethmoid tumor. Lumbar intrathecal catheter (14-gauge needle, 16-gauge catheter) was kept in place for 9 and 3 days respectively in both the cases.	In the first case, CSF leak persisted for 3 days after catheter removal. Epidural blood patch was used twice, 1 day apart and a figure of eight suture was placed. CSF leak stopped after the second epidural blood patch. In the second case, CSF leak continued after the catheter removal despite bed rest and epidural blood patch was placed on the fifth day along with a figure of eight suture around the fistula, which resulted in complete cessation of CSF leak.
Sanders et al, 2004 [11]	A 3-year-old child with B-cell lymphoma. Omaya reservoir placed for chemotherapy with an intrathecal catheter (12 - 14 gauge) to facilitate CSF access and allow continued intrathecal chemotherapy.	CSF leak began from the wound site on the day after the catheter and reservoir placement. CSF leak continued despite sutures, staples, and collodion glue. Four weeks later, the catheter and reservoir were removed, but the leak continued. CSF leak stopped after epidural blood patch on the fifth day of the catheter removal.
Kowbel et al, 1995 [15]	A 4-year-old child with acute lymphoblastic leukemia who had multiple lumbar punctures for chemotherapy.	Subarachnoid cutaneous fistula developed after multiple lumbar punctures. Epidural blood patch via the caudal approach 72 h after the leak was detected resulted in prompt cessation of CSF leakage.
Rusy et al, 2019 [17]	An 11-month-old infant for nephrectomy.	Epidural catheter was placed at L3 after three attempts. On day 3 following removal of the catheter, there was an asymptomatic CSF leak from the puncture site. Neurosurgeon placed a subcutaneous skin suture and the CSF leak ceased.
Franklin et al, 2013 [20]	A 25-month-old child following thoracotomy for division of a vascular ring.	Epidural catheter was placed at T6-T7. On POD 2, catheter was removed. Persistent leakage from the epidural insertion site was noted. Patient was fussy and periodically touched her head with her hand. On POD 4, an epidural blood patch was placed at T6-T7, and the CSF leak stopped immediately.
Hosu et al, 2008 [21]	A 5-year-old girl for ureteral reimplantation.	Epidural catheter was placed at L3-L4, after an unsuccessful attempt at L1-L2. The catheter was removed on POD 2. Persistent CSF leakage noted from the epidural site. She was sleepy, had occasional emesis, diaphoresis, and intermittent headache. On POD 5, an epidural blood patch was placed with prompt resolution of the CSF leak.

Table 1. Reports of CSF-Cutaneous Fistula in Children

References

Demographic data

Clinical course and outcome

CSF: cerebrospinal fluid; POD: postoperative day.

Kumar et al, 1991 [10]

A 6-year-old boy with CSF rhinorrhea after an orbital fracture and a 6-year-old girl with an ethmoid tumor. Lumbar intrathecal catheter (14-gauge needle, 16-gauge catheter) was kept in place for 9 and 3 days respectively in both the cases.

In the first case, CSF leak persisted for 3 days after catheter removal. Epidural blood patch was used twice, 1 day apart and a figure of eight suture was placed. CSF leak stopped after the second epidural blood patch. In the second case, CSF leak continued after the catheter removal despite bed rest and epidural blood patch was placed on the fifth day along with a figure of eight suture around the fistula, which resulted in complete cessation of CSF leak.

Sanders et al, 2004 [11]

A 3-year-old child with B-cell lymphoma. Omaya reservoir placed for chemotherapy with an intrathecal catheter (12 - 14 gauge) to facilitate CSF access and allow continued intrathecal chemotherapy.

CSF leak began from the wound site on the day after the catheter and reservoir placement. CSF leak continued despite sutures, staples, and collodion glue. Four weeks later, the catheter and reservoir were removed, but the leak continued. CSF leak stopped after epidural blood patch on the fifth day of the catheter removal.

Kowbel et al, 1995 [15]

A 4-year-old child with acute lymphoblastic leukemia who had multiple lumbar punctures for chemotherapy.

Subarachnoid cutaneous fistula developed after multiple lumbar punctures. Epidural blood patch via the caudal approach 72 h after the leak was detected resulted in prompt cessation of CSF leakage.

Rusy et al, 2019 [17]

An 11-month-old infant for nephrectomy.

Epidural catheter was placed at L3 after three attempts. On day 3 following removal of the catheter, there was an asymptomatic CSF leak from the puncture site. Neurosurgeon placed a subcutaneous skin suture and the CSF leak ceased.

Franklin et al, 2013 [20]

A 25-month-old child following thoracotomy for division of a vascular ring.

Epidural catheter was placed at T6-T7. On POD 2, catheter was removed. Persistent leakage from the epidural insertion site was noted. Patient was fussy and periodically touched her head with her hand. On POD 4, an epidural blood patch was placed at T6-T7, and the CSF leak stopped immediately.

Hosu et al, 2008 [21]

A 5-year-old girl for ureteral reimplantation.

Epidural catheter was placed at L3-L4, after an unsuccessful attempt at L1-L2. The catheter was removed on POD 2. Persistent CSF leakage noted from the epidural site. She was sleepy, had occasional emesis, diaphoresis, and intermittent headache. On POD 5, an epidural blood patch was placed with prompt resolution of the CSF leak.