Cerebrospinal Fluid - Cutaneous Fistula After Combined Spinal Epidural Anesthesia in a Non-Obstetric Patient Treated With an Epidural Blood Patch: A Case Report.

Background: We aimed to discuss the successful treatment of cerebrospinal fluid (CSF)-cutaneous fistula which is caused by combined spinal epidural anesthesia (CSE), with an autologous epidural blood patch (EBP), further investigation and antibiotherapy. Case: CSE was applied for a total hip replacement. Since CSF was seen in the first attempt, CSE was achieved in the second attempt using the same Tuohy needle. Postoperatively epidural catheter was used for analgesic purposes for 2 days. After the catheter removal, anesthesia consultation was requested due to the patient's wet back. A clear fluid leak at the needle insertion point was observed. A sample was taken and the differential diagnosis of CSF-skin fistula was made biochemically with the presence of glucose and chloride. The patient denied headaches. Neurological examination was normal. With patient's consent, EBP was performed. During the injection CSF leak was slowed down, the last drops were macroscopically hemorrhagic and eventually the leak stopped. Headache, dizziness, and nausea occurred on the 2nd day after EBP. Neurological examination was normal. No dural defect or CSF collection was observed in brain CT, brain diffusion MR and contrast-enhanced MR myelography. Ceftriaxone, metronidazole and a pneumococcal vaccine were added for meningitis prophylaxis in consensus with infection and neurology consultants. 1-month follow-up was performed telephonically and the patient was completely cured. Conclusion: Cerebrospinal fluid (CSF)-cutaneous fistula is a rare complication of neuraxial anesthesia techniques. Since there are no sufficient guidelines for management, the decision on the treatment method depends on the clinician's aspect. We consider that it would be advantageous to prefer EBP primarily in cases with CSF-skin fistula and that the benefit/harm ratio is higher than the complications to be caused by a subarachnoid space that is fistulized to skin and opened out to cutaneous flora. In the literature, the development of meningitis has been reported in some cases followed up under conservative treatment or skin sutures. Although prophylactic use should be avoided as possible due to increasing antibiotic resistance, our opinion is that clinicians should decide for each case, taking into account the conditions such as hospital infection surveillance and the flora of inpatient service. [ABSTRACT FROM AUTHOR]