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Indian Journal of Anaesthesia 2007; 51 (5) : 434-437 Case Report

Indian Journal of Anaesthesia, October 2007

Epidural Catheter Breakage:A Dilemma


Deepanjali Pant1, Pradeep Jain 2, Pravesh Kanthed3 , Jayashree Sood4
Summary
Placement of an epidural catheter in epidural space is a routine practice for providing anaesthesia/analgesia in a myriad of
surgical procedures and various painful conditions. Breakage of an epidural catheter, though rare, is a well-known complication.
We present a case report of such an event and a comprehensive review of do’s and don’ts in this setting.
Key words Epidural catheter, Breakage, Management.
Introduction
A broken spinal or epidural catheter, although an relocate the epidural space. While the catheter was be-
uncommon occurrence, remains an area of utmost di- ing removed with gentle traction along with Tuohy needle,
lemma to the practising anaesthesiologist. While the in- it sheared off at 6 cm mark. (Fig.1)
sertion of a spinal or epidural catheter is usually safe,
they have been known to break during removal, leaving
a segment lodged in patient’s back.1 Since surgical re-
moval of a broken catheter is not recommended and the
severed nonbiodegradable catheter is situated in an ana-
tomical region which does not permit it to be naturally
extruded, it is left in the patient permanently. 2 The dis-
comfort to the patient and the formidable complication
that may rarely result from such a mishap could greatly
deter surgeons, anaesthesiologists and patients from this
most useful anaesthetic technique. .
Case report
A 70 -yr - old, 65 kg male, presented with history
of road traffic accident leading to multiple rib fractures
on right side. He was a known case of COPD, on inter-
mittent bronchodilator therapy. Due to severe pain re- Fi g.1 Epidural catheter-broken at 6 cm mark.

lated to rib fracture, the patient was unable to cough out A new epidural catheter was placed at the T 11-T 12
secretions effectively. He was referred to acute pain interspace and fixed at 9 cm mark (skin to epidural dis-
services for pain relief. tance = 5 cm). Patient controlled epidural analgesia
A thoracic epidural analgesia was planned and us- (PCEA) was initiated with a combination of 0.0625%
ing the loss-of-resistance technique with air, an 18G ra- bupivacaine hydrochloride and fentanyl citrate (5g.ml -
dio opaque epidural catheter [Perifix® 401 G18x31/4”(B/ 1
). The patient had adequate pain relief and chest condi-
Braun)] was inserted through an 18G Tuohy needle into tion improved satisfactorily. PCEA was used for 7 days
the epidural space at T8-T9 interspace in left lateral posi- and the epidural catheter was removed uneventfully.
tion. The epidural space was encountered at 5 cm from Subsequently the patient was discharged without any
skin and catheter was advanced cephalad upto 15 cm at neurological sequelae.
hub of the needle. Resistance was encountered while
injecting the test dose and therefore it was decided to

1.M.D, Consultant, 2.MD, Senior Consultant, 3.DA, DNB, Senior Resident, 4.MD, FFARCS, PGDHHM, Senior Consultant, Chairperson
Correspondence to: Deepanjali Pant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga
Ram Hospital Marg, New Delhi – 110060, India, Email: deepapant@hotmail.com Accepted for publication on:30.8.07

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Deepanjali Pant et al. Epidural catheter breakage

After informing the surgeon and the patient, an if a length of the catheter was protruding from the
MRI and CT scan were done. Sagittal 3-mm (with 1- tip. 7
mm gap) and axial 5-mm (with 1.5-mm gap) T 1 - 8. Catheter damage is often related to excessive in-
weighted spin-echo (TR 500 ms/TE 16 ms/ 2 excitation) sertion into the epidural space. 8, 9
and proton density and T 2- weighted (TR 2600 ms/TE
Prevention of catheter breakage – recommenda-
16,96 ms/2 excitation) fast spin-echo images were ob-
tions
tained in a 1.5T MRI scanner (General electric signal)
(matrix 256x256, field of view 20 cm axial, 28 cm sagit- 1. Lateral decubitus position when removing an epi-
tal). Axial and sagittal T1 -weighted images after IV dural catheter as this results in least force of ex-
gadolinium DTPA were obtained. CT scan (4-mm im- traction. 10
ages obtained at 3-mm interval) with sagittal and coro- 2. The force required to remove a catheter should be
nal reconstruction was done. But the severed epidural minimal. If resistance is encountered, a number of
catheter was not visualized. simple maneuvers may help to enable removal of
Thepatient wascounselled thatthis eventhad occurred catheter without stretching or tearing. These include
and was advised to reportin case of any adverse symptoms. (stepwise): -
a. Maximal flexion of back in lateral decubitus po-
Discussion
sition
Not many cases have been reported and there is b. Rotation of spine
always a dilemma in the mind of all – doctor to patient,
regarding the sequence of leaving the catheter fragment c. Returning the patient to the position used at time
in situ. So we thought of briefly reviewing the literature of insertion e.g. sitting position with legs ex-
about various possible causes, ways to prevent, diag- tended or kneeling position with hands down
nose and manage such a case. and back flexed
d. Allowing tissues to soften for 15- 30 minutes
Causes of severed epidural catheter before reattempting11
1. Application of undue force in removing a catheter e. Filling the catheter with a rapid injection of sa-
trapped between vertebral spinous processes or in line to increase the turgor of the catheter and
ligamentum flavum or knotted, kinked or curled cath- to lubricate it.
eter in epidural space causes the catheter to stretch
or tear. 3, 4 f. Complete relaxation with GA with muscle re-
laxation
2. Shearing of catheter by needle when attempts are
made to withdraw the catheter through the Tuohy g. Surgical removal
needle. 3. The needle should be checked for barbs on bevel
3. Nicking of a catheter by a barb on the bevel of the and the catheter for manufacturing defects before
needle. insertion.
4. Shredding of catheter if the needle is advanced over 4. No more than 4-5 cm of catheter should be ad-
the catheter after the catheter has been placed. vanced into the epidural space to reduce risk of kink-
ing /curling /knotting. 8,12,13
5. Weakness of the catheter by imperfect manufac-
turing. 5. Catheter should never be withdrawn through the
metal needle.
6. Damage to a catheter occurring after placement
i.e. fraying by pinching between two vertebral pro- 6. Catheters of high breaking strain (tensile strength)
cesses. 5, 6 and of a sufficient diameter (16/18G) should be ob-
tained from a reputable, reliable manufacturer.
7. The proposed mechanism for catheter that were
severed at time of insertion is to break or severely In our case, there was no obvious cause for break-
damage an epidural catheter by heavy contact be- age. Most probably it was kinked or curled, as there
tween tip of the epidural needle and a bony surface, was resistance during drug injection.

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Indian Journal of Anaesthesia, October 2007

Diagnosis rary epidural catheter is to leave them alone unless symp-


tomatic because surgical removal can produce more
Attempts to locate the torn catheter ultrasonically harm than good. 2 However, there are 3 situations where
are usually futile but xeroradiography, CT scanning or a policy of non-interference or reassurance does not apply.
MRI may prove more fruitful.
1. Where infection or symptoms supervene, a careful
Radio opaque epidural catheters are easier to lo- history and physical examination should help deter-
cate radiologically than non-radio opaque ones, but para- mine the spinal level involved.
doxically, they have a lower tensile strength than stan- 2. If the spinal catheter fragment is sitting partially
dard clear catheters. In fact, a radioopaque fragment intrathecally and is acting as a wick which allows
may be impossible to locate radiologically because the persistent CSF leakage.12 If a continuous spinal
surrounding structures are radio-dense. micro-catheter becomes separated within the in-
trathecal space, appropriate imaging, a neurosurgi-
MRI scanning is a non-invasive means of diagnos- cal consultation and aggressive surgical exploration
ing the complication of spinal stenosis secondary to epi- to retrieve the broken piece are warranted, even in
dural fibrosis/scar formation and assessing the extent of the asymptomatic patient. 17
spinal stenosis.
3. If the proximal end of the segment is located at or
However, CT scanning through level of interest is just beneath the skin such that it can be retrieved
more sensitive than MRI in detecting the high attenua- simple through a superficial incision made under lo-
tion catheter fragment within the epidural space and is cal anaesthesia. The broken distal piece is grasped
more sensitive than plain radiography, especially for small with a curved haemostat and drawn out by firm,
retained fragments. gentle traction. 6 Surgical removal is mandatory in
such a situation as bacteria can readily track along
In our case CT / MRI did not help to locate the the catheter remnant.
fragment – since they are helpful once there is a reac- On rare occasions, surgical exploration may be
tive mass around the catheter fragment. needed to remove lost catheter fragments and associ-
ated reactive scar tissue and relieve spinal stenosis.
Management
Successful localization of catheter fragment by medi-
Sequestered temporary epidural catheter pieces are cal imaging is no guarantee that task of finding the miss-
generally considered to be inert and should not produce a ing segment at subsequent surgery willbe made any easier.
foreign body reaction. Experiments with cats have shown
that a broken catheter becomes walled off by fibrous tis- If pain is caused by traction on catheter, the
sue after about 3 weeks –remaining innocuous within the anaesthesiologist should suspect that a loop may have
epidural space. 13 Foreign body in epidural space is not become curled around a nerve root. So removal of a
likely to migrate (although this is not impossible). catheter under anaesthesia may not help to alert the
medical team in such a case. Given the possibility that
However, Staats et al reported the formation of a avulsion might occur, it would probably be wise to ex-
reactive epidural mass (1.5 cm) around the catheter frag- tract the catheter under direct vision by open surgical
ment resulting in lumbar spinal stenosis, patient being as- laminectomy. 18 Sidhu et al described a parturient having
ymptomatic until 18 months of the incident and got re- epidural catheter coiled around L2-L3 nerve root, caus-
lieved with removal of catheter and reactive scar tissue. 14 ing severe pain and paresthesia on traction, but produc-
In contrast, the continued presence of indwelling ing no sensory or motor defect. Since the patient re-
catheter has resulted in complications. Chronic, implanted fused a surgical procedure, catheter was removed with-
intrathecal infusion catheters have been associated with out sequelae by gentle traction in various positions. 19
granuloma formation resulting in spinal cord compres- Any kind of trauma, like practice of securing the
sion. The changes may occur, rather quickly, as noted catheter by a suture at skin level, may cause microlesions
by Durant and Yatish, who reported that catheters can and deteriorates the energy adsorbing capacity of cath-
be walled off by tissue reaction after 72 hours.15 This eter considerably – therefore, it should be practiced only
local reaction was reported by Coombs et al, who found when absolutely indicated.20
“cocoon” formation with dural thickening around im-
planted catheters in post-mortem examination. 16 Our patient has not reported any adverse symp-
toms so far till the writing of this article – a time period
Therefore, in most cases the current standard of of roughly two years.
care application to the retained segments of a tempo-
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Deepanjali Pant et al. Epidural catheter breakage

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