Discussion
TCS presents various symptoms depending on age and its cause. Neurologic
symptoms, sensory or motor dysfunction, dysuria, and deformation of the
feet or spine are usually developed by progressive stretching of and
increased tension in the spinal cord in
children.[4] Cutaneous stigmata, hair tufts, skin
tags, dimple, nevi, hemangioma, lumps, lipomas, etc. could be surface
(cutaneous) findings that suspect TCS.[4] Our
patient had subcutaneous fluid collection following the caudal approach
and
it
looked like it was concealing the existence of a subcutaneous lipoma. If
a physician at a local clinic had performed a physical examination of
the procedure site before the practice, he would have found a lesion
suspected as a lump or lipoma. We suspected that she had a CSF leakage
based on physical examination and bedside US and finally confirmed a
rare case of TCS and subarachnoid-cutaneous fistula by MRI. Based on our
experience, it is difficult to predict dural puncture before caudal
epidural block without expensive imaging studies such as CT or MRI.
In children, an inelastic filum is attached to the caudal end of the
spinal cord which adds continuous tension to the spinal cord causing
severe neurological symptoms. Surgical treatment of TCS should maintain
neural functions and circulation of CSF, and reconstruct the dural sac;
additionally, there should be no adverse effects, such as infection or
adhesion.[5] Major symptoms of TCS, such as pain,
bowel or urinary dysfunction, may not improve after surgery in adults,
and postoperative complications of old age may be three times higher
than that in young patients. Asymptomatic adult TCS patients could be
followed up only for symptoms, and conservative management could be
applied to non-aggressive and bearable
symptoms.[6-8] There is a controversy over the
superiority of conservative management and surgical management. This
case showed that conservative management could improve symptoms in adult
TCS patients, therefore, we should be careful in our decision about
employing surgical treatment.[6-8] In our patient,
surgical release of the filum terminale anchored to the spinal cord
could be considered, but we decided to maintain the conservative
management with an abdominal binder and observation of the symptoms
because her mild neurologic symptoms (pain of the left leg and foot)
improved and PDPH decreased.
In the structures of the epidural cavity, the incomplete lateral wall
could cause peritoneal pressure to be transmitted to the epidural cavity
through the intervertebral foramina. Therefore, increased abdominal
pressure could induce an increase in the epidural
pressure.[9] In this respect, the compression of
the abdomen with an abdominal binder would be helpful to decrease the
PDPH after spinal tapping in postpartum patients by increasing the
peritoneal pressure. The preventive effects of an abdominal binder in
PDPH’s occurrence were similar to that of the injection of normal saline
into the epidural space.[10] We applied an
abdominal binder obliquely for two main purposes. First, we tried to
maintain high epidural pressure by increasing peritoneal pressure to
reduce pressure variations due to change in posture. Second, compressive
dressing with gauze and adhesive tape was insufficient, especially in
the coccyx area because the movable and soft buttocks would offset the
adhesive tape’s compression. Considering these points, we applied an
abdominal binder to surround the lower abdomen, buttocks, and coccyx,
obliquely from the upper anterior pelvis to the lower posterior pelvis.
This placement, fastening the binder around the pelvis, prohibited
lateral movement of the buttocks and provided evenly distributed
compression of the lipoma and large subcutaneous CSF collection. The
abdominal binder was able to compress a surface area of 8 × 7
cm2.
The EBP was a very effective treatment for spontaneous intracranial
hypotension; therefore, 90% of the patients showed improvement
regardless of the presence or location of CSF
leakage.[11] However, complications and/or side
effects—ranging from mild to severe—make EBP a challenging procedure
for anesthesiologists. Mild events include temporary nerve compression
syndrome, dizziness, vertigo, or tinnitus, while the rare, severe
adverse effects include epidural abscess or cord
compression.[12] Our patient had a history of body
fluid leakage, which could be expected as the puncture site had swelling
and fluctuation on physical examination of the coccygeal area, which
appeared as a subcutaneous fluid collection. Because we confirmed that
this fluid collection communicated with the intrathecal space via MRI
(Fig 3A and B), we thought that the EBP through the sacral hiatus had a
high risk of meningitis. It was reported that the large volume of blood
infused into the epidural space ran in the cephalad direction during EBP
in MRI,[13] and thus, the lumbar site for EBP in
our patients seemed ineffective and large volumes of blood would be
needed in contrast to that in the sacral approach if it was performed.
Based on the findings of this case, the following points should be kept
in mind during the caudal procedure.
- Careful physical examination of the procedure site before the caudal
pain procedure should be performed because it could show the patient’s
abnormal anatomical conditions.
- When a subcutaneous fluid collection after a neuraxial procedure is
suspected by peripheral swelling or fluctuation, fluid collection can
be examined by easily accessible US. If it has been proven, CSF
leakage must be ruled out by an MRI scan, and then EBP should be
considered later.
- An abdominal binder could be used effectively in a patient showing CSF
leakage in the coccygeal area, which is not controlled by conventional
compressive dressing.