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

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

434
Deepanjali Pant et al. Epidural catheter breakage
After informing the surgeon and the patient, an
MRI and CT scan were done. Sagittal 3-mm (with 1-
mm gap) and axial 5-mm (with 1.5-mm gap) T 1 -
weighted spin-echo (TR 500 ms/TE 16 ms/ 2 excitation)
and proton density and T 2- weighted (TR 2600 ms/TE
16,96 ms/2 excitation) fast spin-echo images were ob-
tained in a 1.5T MRI scanner (General electric signal)
(matrix 256x256, field of view 20 cm axial, 28 cm sagit-
tal). Axial and sagittal T1 -weighted images after IV
gadolinium DTPA were obtained. CT scan (4-mm im-
ages obtained at 3-mm interval) with sagittal and coro-
nal reconstruction was done. But the severed epidural
catheter was not visualized.
Thepatient wascounselled thatthis eventhad occurred
and was advised to reportin case of any adverse symptoms.
Discussion
Not many cases have been reported and there is
always a dilemma in the mind of all – doctor to patient,
regarding the sequence of leaving the catheter fragment
in situ. So we thought of briefly reviewing the literature
about various possible causes, ways to prevent, diag-
nose and manage such a case.
Causes of severed epidural catheter
1. Application of undue force in removing a catheter
trapped between vertebral spinous processes or in
ligamentum flavum or knotted, kinked or curled cath-
eter in epidural space causes the catheter to stretch
or tear. 3, 4
2. Shearing of catheter by needle when attempts are
made to withdraw the catheter through the Tuohy
needle.
3. Nicking of a catheter by a barb on the bevel of the
needle.
4. Shredding of catheter if the needle is advanced over
the catheter after the catheter has been placed.
5. Weakness of the catheter by imperfect manufac-
turing.
6. Damage to a catheter occurring after placement
i.e. fraying by pinching between two vertebral pro-
cesses. 5, 6
7. The proposed mechanism for catheter that were
severed at time of insertion is to break or severely
damage an epidural catheter by heavy contact be-
tween tip of the epidural needle and a bony surface,
435
if a length of the catheter was protruding from the
tip. 7
8. Catheter damage is often related to excessive in-
sertion into the epidural space. 8, 9
Prevention of catheter breakage – recommenda-
tions
1. Lateral decubitus position when removing an epi-
dural catheter as this results in least force of ex-
traction. 10
2. The force required to remove a catheter should be
minimal. If resistance is encountered, a number of
simple maneuvers may help to enable removal of
catheter without stretching or tearing. These include
(stepwise): -
a. Maximal flexion of back in lateral decubitus po-
sition
b. Rotation of spine
c. Returning the patient to the position used at time
of insertion e.g. sitting position with legs ex-
tended or kneeling position with hands down
and back flexed
d. Allowing tissues to soften for 15- 30 minutes
before reattempting11
e. Filling the catheter with a rapid injection of sa-
line to increase the turgor of the catheter and
to lubricate it.
f. Complete relaxation with GA with muscle re-
laxation
g. Surgical removal
3. The needle should be checked for barbs on bevel
and the catheter for manufacturing defects before
insertion.
4. No more than 4-5 cm of catheter should be ad-
vanced into the epidural space to reduce risk of kink-
ing /curling /knotting. 8,12,13
5. Catheter should never be withdrawn through the
metal needle.
6. Catheters of high breaking strain (tensile strength)
and of a sufficient diameter (16/18G) should be ob-
tained from a reputable, reliable manufacturer.
In our case, there was no obvious cause for break-
age. Most probably it was kinked or curled, as there
was resistance during drug injection.

Diagnosis
Attempts to locate the torn catheter ultrasonically
are usually futile but xeroradiography, CT scanning or
MRI may prove more fruitful.
Radio opaque epidural catheters are easier to lo-
cate radiologically than non-radio opaque ones, but para-
doxically, they have a lower tensile strength than stan-
dard clear catheters. In fact, a radioopaque fragment
may be impossible to locate radiologically because the
surrounding structures are radio-dense.
MRI scanning is a non-invasive means of diagnos-
ing the complication of spinal stenosis secondary to epi-
dural fibrosis/scar formation and assessing the extent of
spinal stenosis.
However, CT scanning through level of interest is
more sensitive than MRI in detecting the high attenua-
tion catheter fragment within the epidural space and is
more sensitive than plain radiography, especially for small
retained fragments.
In our case CT / MRI did not help to locate the
fragment – since they are helpful once there is a reac-
tive mass around the catheter fragment.
Management
Sequestered temporary epidural catheter pieces are
generally considered to be inert and should not produce a
foreign body reaction. Experiments with cats have shown
that a broken catheter becomes walled off by fibrous tis-
sue after about 3 weeks –remaining innocuous within the
epidural space. 13 Foreign body in epidural space is not
likely to migrate (although this is not impossible).
However, Staats et al reported the formation of a
reactive epidural mass (1.5 cm) around the catheter frag-
ment resulting in lumbar spinal stenosis, patient being as-
ymptomatic until 18 months of the incident and got re-
lieved with removal of catheter and reactive scar tissue. 14
In contrast, the continued presence of indwelling
catheter has resulted in complications. Chronic, implanted
intrathecal infusion catheters have been associated with
granuloma formation resulting in spinal cord compres-
sion. The changes may occur, rather quickly, as noted
by Durant and Yatish, who reported that catheters can
be walled off by tissue reaction after 72 hours.15 This
local reaction was reported by Coombs et al, who found
“cocoon” formation with dural thickening around im-
planted catheters in post-mortem examination. 16
Therefore, in most cases the current standard of
care application to the retained segments of a tempo-
436
Indian Journal of Anaesthesia, October 2007
rary epidural catheter is to leave them alone unless symp-
tomatic because surgical removal can produce more
harm than good. 2 However, there are 3 situations where
a policy of non-interference or reassurance does not apply.
1. Where infection or symptoms supervene, a careful
history and physical examination should help deter-
mine the spinal level involved.
2. If the spinal catheter fragment is sitting partially
intrathecally and is acting as a wick which allows
persistent CSF leakage.12 If a continuous spinal
micro-catheter becomes separated within the in-
trathecal space, appropriate imaging, a neurosurgi-
cal consultation and aggressive surgical exploration
to retrieve the broken piece are warranted, even in
the asymptomatic patient. 17
3. If the proximal end of the segment is located at or
just beneath the skin such that it can be retrieved
simple through a superficial incision made under lo-
cal anaesthesia. The broken distal piece is grasped
with a curved haemostat and drawn out by firm,
gentle traction. 6 Surgical removal is mandatory in
such a situation as bacteria can readily track along
the catheter remnant.
On rare occasions, surgical exploration may be
needed to remove lost catheter fragments and associ-
ated reactive scar tissue and relieve spinal stenosis.
Successful localization of catheter fragment by medi-
cal imaging is no guarantee that task of finding the miss-
ing segment at subsequent surgery willbe made any easier.
If pain is caused by traction on catheter, the
anaesthesiologist should suspect that a loop may have
become curled around a nerve root. So removal of a
catheter under anaesthesia may not help to alert the
medical team in such a case. Given the possibility that
avulsion might occur, it would probably be wise to ex-
tract the catheter under direct vision by open surgical
laminectomy. 18 Sidhu et al described a parturient having
epidural catheter coiled around L2-L3 nerve root, caus-
ing severe pain and paresthesia on traction, but produc-
ing no sensory or motor defect. Since the patient re-
fused a surgical procedure, catheter was removed with-
out sequelae by gentle traction in various positions. 19
Any kind of trauma, like practice of securing the
catheter by a suture at skin level, may cause microlesions
and deteriorates the energy adsorbing capacity of cath-
eter considerably – therefore, it should be practiced only
when absolutely indicated.20
Our patient has not reported any adverse symp-
toms so far till the writing of this article – a time period
of roughly two years.
Deepanjali Pant et al. Epidural catheter breakage
Newer inventions
More recently, it has been proposed to provide an
improved epidural catheter which maintains its structural
integrity for intraoperative and postoperative period and
eliminates the necessity for an additional surgical proce-
dure or any outside intervention in order to remove a
portion of the catheter should breakage occur.It exhibits
good handling properties, has adequate tensile strength,
is sterilizable and can be uniformly manufactured using
conventional techniques. It is made up of biodegradable
material (synthetic polymers of absorbable material)
which dissolves with time upon contact with moisture
found in body fluids with no undesirable degradation sub-
stance released into body. 21 Since it is adversely affected
by moisture it is preferably packaged in a substantially
moisture-free environment prior to use and in sealed ster-
ile packages.
In general, the material should generally maintain its
original integrity for at least 3 days and should be com-
pletely absorbed in living tissue in a period of time from
approximately 20 to 120 days. The degradation time of
the biodegradable material can be selectively altered by
adjusting the molecular weight or chemical make-up of
the synthetic polymers or through irradiation with gamma
rays that simultaneously sterilizes the catheter without any
significant loss of other desirable properties.
In conclusion, inspite of the best intentions and ex-
ercise of utmost care it can still result in tearing of an
epidural catheter. But fortunately in only a small propor-
tion of these cases, it is prudent to attempt to remove the
offending retained portion of the catheter.
The usual guidelines for insertion and removal of
catheter should be strictly followed on a routine basis to
prevent the occurrence.
The presence of a retained epidural catheter frag-
ment should be documented and communicated to the
patient, surgeon and primary care physician because the
development of symptoms related to the catheter may
occur months or years later and the patient should be
reviewed periodically to ensure that there is no discom-
fort, infection or radiculopathy. If symptoms develop,
spine imaging to find out the level of involvement and
surgery is advocated.
437
References
1. Tio T, Macmurdo S, McKenzie R. Mishap with an epidural
catheter. Anesthesiology 1979; 50:260-62.
2. DeVera H, Ries M. Complication of continuous spinal
microcatheter: should we seek their removal if sheared? Anes-
thesiology 1991; 74:794.
3. Gough JD,Johnston KR,Harmer M. Kinking of epidural cath-
eters. Anaesthesia 1989; 40:1060.
4. Jongleux EF,Miller R,Freeman A. An entrapped epidural catheter
in a postpartum patient.Reg Anesth Pain Med 1998;23:615-17.
5. Simpson P. Defective epidural cannulae. Anaesthesia 1981;
36:72.
6. DeArmendi A,Ryan J,Chang H, et al. Retained caudal catheter
in a paediatric patient. Paed Anaes 1992; 2:325-27.
7. Collier C. Epidural catheter breakage: a possible mechanism.
Int J Obstet Anesth 2000; 9: 87 –93.
8. Dawkins M. An analysis of the complications of extradural
and caudal block. Anaesthesia 1969; 24:554-63.
9. Dounas M,Peillon P, Lebonhomme JJ, et al .Difficulties in the
removal and rupture of a peridural catheter.Ann Fr Anesth
Reanim 2002;21:600-2.
10. Morris GN,Warren BB,Hanson EW,et al.Influence of patient
position on withdrawal forces during removal of lumbar extra-
dural catheters. Anesthesiology 1997; 86:778-84.
11. Demiraran Y, Yucel I, Erdogmus B. Subcutaneous effusion re-
sulting from an epidural catheter fragment. Br J Anaesth 2006;
96:508-9.
12. Pasquariello C,Betz R. A case for the removal of the retained
intrathecal catheter. Anesth Analg 1991;72:562.
13. Bromage PR.Epidural Analgesia. Philadelphia,WB Saunders.
1978 pp 664-66.
14. Staats PS,Stinson MS,Lee R.Lumbar stenosis complicating re-
tained epidural catheter tip.Anesthesiology 1995;83:1115-18.
15. Durant PA,Yatish JL. Epidural injection of bupivacaine, mor-
phine, fentanyl, lofentanil and DADL in chronically implanted
rats: a pharmacologic and pathologic study. Anesthesiology
1986; 64:43-53.
16. Coombs DW,Franklin JD,Meier FA,et al.Neuropathologic le-
sions and CSF morphine during chronic continuous intraspinal
morphine infusion: a clinical & post mortem study.Pain
1985;22:337-51.
17. Ugboma S, Au – Truong X, Kranzler LI, et al. The breaking of
an intrathecally placed epidural catheter during extraction.
Anesth Analg 2002; 95: 1087 – 9.
18. Bromage PR.Epidural Analgesia.Philadelphia.WB Saunders
1978,pp240.
19. Sidhu MS,Asrani RV,Bassell GM. An unusual complication of
extradural catheterization in obstetric anaesthesia. Br J Anaesth
1983; 55:473-75.
20. Schummer W, Schummer C. Another cause of epidural catheter
breakage ? Anesth Analg 2002;94:233.
21. http://www.freepatentsonline .com/5129889.html. (US Patent
no 5129889)