Case Reports: Case Report
Bone marrow harvest (BMH) for transplantation is a commonly performed procedure requiring spinal or general anesthesia. The technique involves multiple punctures in the region of the iliac crest by using a large bore trochar to facilitate aspiration of bone marrow. A rare complication of BMH is unintentional dural puncture, resulting in postdural puncture headache (PDPH) (1). We report a case of severe headache and formation of a spinosubcutaneous fistula after unrecognized dural puncture with a 12-gauge bone marrow trochar. This patient was treated successfully with a single epidural blood patch (EBP).
A 42-yr-old man, weighing 82 kg, 177 cm in height, was seen 3 days after a BMH performed under general anesthesia. The patient reported the onset of severe fronto-occipital headache and neck pain immediately upon awakening from anesthesia. His pain was accompanied by nausea and vomiting with marked exacerbation symptoms when in the upright position. He denied any changes in vision or other neurologic symptoms.
No nuchal rigidity or fever existed. Marked pitting edema was in the soft tissues of the back extending from the sacrum to the lower thoracic region. There was no ecchymosis; however, several puncture sites were noted over the iliac crests bilaterally, with one site being 3-cm lateral to the midline. A magnetic resonance scan of the lumbosacral spine (Fig. 1) revealed cerebrospinal fluid (CSF) accumulation in the epidural space extending from approximately the 12th thoracic to the 2nd lumbar level. Additionally, a large collection of CSF was present in the subcutaneous tissue overlying the spine from the first lumbar to the second sacral level. A discreet linear tract of hyperintensity was also noted extending from the epidural space to the subcutaneous tissue between the 4th and 5th lumbar vertebra. This finding was reported as a fistula connecting the epidural space with a collection of CSF in the subcutaneous tissue.
The patient was informed of the various management options including conservative therapy with parenteral fluids and analgesics as well as EBP. He was also informed that the large size of this dural puncture might require surgical repair. After electing to be treated with an EBP, the patient received a single injection of autologous blood (20 mL) into the L4-5 epidural space, which resulted in immediate relief of his headache. He also received IV dexamethasone, 8 mg, to decrease meningeal inflammation. Because of the large caliber of the dural puncture, the patient was also treated with bedrest for 48 h to decrease lumbar hydrostatic pressure after the EBP. After 6 mo, the patient has remained free of symptoms.
When PDPH occurs after BMH, it is usually associated with spinal anesthesia (2); however, inadvertent puncture of the dura with the bone marrow trochar should be included in the differential diagnosis of headache after BMH whether spinal or general anesthesia is used. The CSF leak resulting from dural puncture with a 12-gauge bone marrow trochar is unique in that it is of an unusually large caliber. In addition, the path of the trochar to the dura is most likely oblique, originating from the iliac crest.
The formation of a spinosubcutaneous fistula in this patient is unusual, but consistent with the physical finding of extensive pitting edema over the lumbosacral area in this patient. Although fistulas have been reported after placement of intrathecal catheters for CSF drainage (3) or continuous spinal anesthesia (4), these have all drained to the skin (spinocutaneous). There are no previous reports of spinosubcutaneous fistula formation as demonstrated in this patient. It is possible that an oblique trajectory of the trochar facilitated passage of CSF from the epidural space to the subcutaneous tissue rather than to the skin.
Although this dural puncture was unusually large (12-gauge), a single EBP was effective in treating the PDPH. There are few data at present describing the size limit of dural tear that can be treated successfully by using EBP. Certainly, EBP is a more conservative treatment for CSF leak than laminectomy and surgical repair.
As BMH becomes increasingly used as a therapeutic modality, inadvertent dural puncture will continue to be a potential complication. It is important to recognize the signs and symptoms of PDPH to assure proper and timely management. As this case illustrates, EBP can be effectively used to treat large dural punctures that may occur in this setting.
1. Lieberman F, Gulati S. Headaches after inadvertent lumbar puncture during bone marrow harvest. Neurology 1996; 46: 268–9.
2. Buckner CD, Clift RA, Sanders JE, et al. Marrow harvesting from normal donors. Blood 1984; 64: 630–4.
3. Katz J. Treatment of subarachnoid-cutaneous fistula with an epidural blood patch. Anesthesiology 1984; 60: 603–4.
4. Hullander M, Leivers D. Spinal cutaneous fistula following continuous spinal anesthesia. Anesthesiology 1992; 76: 139–40.