Case report
A 59-year-old female visited our hospital due to posterior head and neck
pain that developed after a coccygeal procedure. She was referred to the
pain clinic for EBP.
She underwent the caudal approach procedure a week ago at a local clinic
due to pain in the left leg and foot. Reports about the procedure
performed from the clinic were inaccessible, but following the patient’s
description, a caudal epidural block was presumed to have been used. One
day after the procedure, she found clear fluid leakage from the
coccygeal area and started experiencing posterior headache. She received
a disinfection and compressive dressing on the coccygeal area and was
prescribed bed rest and pain killers from the local clinic, but her
symptoms did not improve within a week.
The numerical rating scale (ranging from 0 to 10, with a score of 0
representing no pain and 10 corresponding to intractable pain) score for
pain severity was 5 and the pain was frequent, throbbing, and worsened
by the orthostatic position.
On physical examination, the compressive dressing looked clean except
for some swelling around the sacral area, and no leakage was observed.
Bedside ultrasound (US) showed subcutaneous edema and fluid collection
in the swollen peri-coccygeal area (Fig1). There were no suspicious
signs of meningeal irritation such as fever or neck stiffness.
Laboratory examination revealed no leukocytosis and normal C-reactive
protein levels.
We conducted the following treatments under suspicion of PDPH with
subarachnoid-cutaneous fistula after the caudal procedure.
First, she was admitted for absolute bed rest, hydration with
intravenous fluid, and was prescribed acetaminophen as a painkiller. A
neurologist referred her to a pain clinic for EBP because her headache
lasted for more than a week despite conventional conservative management
from a local clinic. We initially did not consider EBP through the
sacral hiatus as a treatment plan, because there was a possibility of
infection in the presence of a fistula or repeated CSF leakage. MRI was
scheduled for checking the presence of subcutaneous CSF leakage and its
cause. Additionally, we decided to disinfect the wound and apply
compressive dressing using an obliquely applied abdominal binder around
the patient’s buttocks and the lower abdomen for better compact
compression than that with the previous conventional compressive
dressing, which comprised of adhesive tape and gauze.
After admission, a radiologist reported MRI, showed a low-lying conus
medullaris (which reached down to the inferior border of the S2
vertebra, Fig 2)
with
a thickened filum terminale, an 8 × 7 cm2 sized fatty
contiguous mass with a placode at the sacrococcygeal area, and
interspersed fluid around the mass. (Fig 3A and B)
This showed that she had a rare TCS
that was now discovered late in adulthood. A surgical procedure should
have been considered for TCS, but since she did not have any symptoms of
the cauda equina syndrome or any other severe neurologic symptoms,
except the initial symptoms of left leg and foot pain, we decided to use
reinforced conservative management with an abdominal binder first for a
week.
On the 3rd day of hospitalization, the headache and neck pain decreased,
but reappeared after a short walk. On the 4th day, she could walk
without headache and neck pain, but she could still sometimes experience
mild posterior neck pain. On the 5th day, US still showed irregular and
mild hypoechoic subcutaneous edema around the coccyx area and
suspicious fluid collection, but its size had decreased. On the 6th day,
she was discharged with an abdominal binder.
One week after discharge, she visited the pain clinic and had no
complaints even without the abdominal binder.