Cases reported "Cutaneous Fistula"

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1/4. Epidural blood patch under fluoroscopic control: non-surgical treatment of lumbar cerebrospinal fluid fistula following implantation of an intrathecal pump system.

    The treatment of lumbar cerebrospinal fluid fistula in the presence of an intrathecal catheter is known to be difficult. Open revision surgery is recommended in the literature, although the rate of recurrence is high. The epidural blood patch technique is well established as a successful treatment for post-dural-puncture headaches. Recent work about the distribution of the injected blood and theoretical considerations about the mechanism of action make this method suitable for the occlusion of spinal leakage even in the presence of an intrathecal catheter. In this note technical details are given for a successful therapy of lumbar cerebrospinal fluid fistula including the right positioning of the opening of the needle (cerebrospinal fluid can be expected intrathecally and epidurally) by injection of contrast medium first for myelography then for epidurography. In this procedure the (epidural) distribution of autologous blood can be indirectly controlled by compression of the dural sac. The method is easy to perform, and the possible risks are small.
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2/4. Accidental intrathecal mercury application.

    The authors present a case of accidental intrathecal mercury application. A 69-year-old white woman was admitted to our department with suspected meningitis following surgery for spinal stenosis at another hospital. Postoperatively, she had developed a cerebro-spinal fluid (CSF) fistula with a subcutaneous cavity. Local wound irritation had been suspected and, unfortunately, mercury-containing disinfectant was injected into the cavity. Within 24 h the patient demonstrated acute neurological deterioration due to meningitis and encephalitis and was admitted to our clinic with suspected meningitis due to postoperative CSF fistula. Lumbar puncture revealed desinfectant-stained, non-bloody CSF, while lumbar MRI demonstrated the large lumbar subcutaneous cavity. Additionally, CSF fistula was visualized on MRI. Laboratory examination revealed extremely high mercury levels in CSF, blood and urine. Treatment consisted in insertion of a lumbar drainage to wash out the mercury. The patient underwent medical detoxication using chelating agents (DMPS: RS-2,3-dimercapto-1-propansulfonacid, DMSA: meso-2,3-dimercaptosuccinatacid). Surgery was performed in order to close the cavity and the fistula. Postoperatively, the patient was admitted to the intensive care unit and remained intubated for 3 days. Within 4 weeks after surgery, she demonstrated good recovery. Eighteen months after intoxication, polyneuropathy and slight neuropsychological deficiencies were detectable.
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3/4. Caudal epidural blood patch for the treatment of a paediatric subarachnoid-cutaneous fistula.

    This clinical report describes the performance of an epidural blood patch in a four-year-old child with acute lymphocytic leukaemia, who developed a subarachnoid-cutaneous fistula from repeated lumbar punctures for chemotherapy. The epidural blood patch was performed using an #18-gauge epidural catheter threaded through a #16-gauge intravenous catheter via the caudal approach. This approach was successful in a child whose lumbar epidural anatomy was distorted due to a collection of subcutaneous cerebrospinal fluid making identification of the epidural space by the usual lumbar approach very difficult. This report demonstrates an alternative technique for the performance of an epidural blood patch.
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4/4. Post-laminectomy cerebrospinal fluid fistula treated with epidural blood patch.

    OBJECTIVES AND SUMMARY OF BACKGROUND DATA. cerebrospinal fluid fistula after spinal surgery is associated with a definite risk of meningitis or discitis, and as a result, early active intervention usually is recommended. methods AND RESULTS. This report describes the successful use of an epidural blood patch after a more conventional intervention--namely, surgical re-exploration--had failed to control a postoperative cerebrospinal fluid leak. CONCLUSIONS. The techniques involved in performing a blood patch after spinal surgery may well differ from those usually recommended in the management of spinal headache resulting from other causes of dural puncture.
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