Cerebrospinal Fluid Cutaneous Fistula Following Neuraxial Anesthesia in a Placenta Previa Case: A Rare Complication

Cerebrospinal fluid (CSF) cutaneous fistula is a rare complication of neuraxial anesthesia, caused by CSF leakage through the epidural puncture site, usually after catheter removal. It may present with symptoms of intracranial hypotension, but some cases remain asymptomatic, making diagnosis and management less straightforward. Evidence is scarce, mostly from case reports, and no standardized treatment exists. Our case emphasizes that early recognition and a stepwise, minimally invasive approach can effectively manage cerebrospinal fluid fistulas, even in asymptomatic obstetric patients. We present a case report of a 36-year-old nulliparous woman at 37 weeks with placenta previa who underwent elective cesarean section under combined spinal-epidural anesthesia (CSE) at L4-L5. The procedure was uneventful, and postoperative pain was well controlled. On postoperative Day 2, after epidural catheter removal, a clear fluid leak was observed at the puncture site, increasing with the Valsalva maneuver. The patient remained apyretic and asymptomatic, with no headache, photophobia, or neurological signs. Given the classical cesarean section (vertical hysterotomy), increased intra-abdominal pressure was suspected to contribute to persistent leakage. A multidisciplinary discussion led to initial conservative management (bed rest, hydration, pressure dressing). As the leak persisted after 24 hours, a simple cutaneous suture was performed, resulting in immediate closure. She was discharged on day five and remained asymptomatic at four-week follow-up. This case illustrates that CSF fistula may occur even after uncomplicated neuraxial anesthesia and remain clinically silent. High suspicion is essential, as bedside tests and beta-2 transferrin have limitations. Conservative measures are usually effective, but a simple suture is a safe, minimally invasive option when leakage persists. Multidisciplinary collaboration optimizes management, especially in obstetric patients.