Epidural Catheter Breakage:A Dilemma - medIND

Indian Journal of Anaesthesia 2007; 51 (5) : 434-437 Indian Journal of Anaesthesia, October Case Report 2007
Summary
Epidural Catheter Breakage:A Dilemma
Deepanjali Pant 1 , Pradeep Jain 2 , Pravesh Kanthed 3 , Jayashree Sood 4
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
uncommon occurrence, remains an area of utmost dilemma
to the practising anaesthesiologist. While the insertion
of a spinal or epidural catheter is usually safe,
they have been known to break duringremoval, leaving
a segment lodged in patient’s back. 1 Since surgical removal
of a broken catheter is not recommended and the
severed nonbiodegradable catheter is situated in an anatomical
region which does not permit it to be naturally
extruded, it is left in the patient permanently. 2 The discomfort
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 intermittent
bronchodilator therapy. Due to severe pain related
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 using
the loss-of-resistance technique with air, an 18G radio
opaque epidural catheter [Perifix® 401 G18x3 1 / 4 ”(B/
Braun)] was inserted through an 18G Tuohy needle into
the epidural space at T 8 -T 9 interspace in left lateral position.
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
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
relocate the epidural space. While the catheter was beingremoved
with gentle traction along with Tuohy needle,
it sheared off at 6 cm mark. (Fig.1)
Fi g.1 Epidural catheter-broken at 6 cm mark.
A new epidural catheter was placed at the T 11 -T 12
interspace and fixed at 9 cm mark (skin to epidural distance
= 5 cm). Patient controlled epidural analgesia
(PCEA) was initiated with a combination of 0.0625%
bupivacaine hydrochloride and fentanyl citrate (5g.ml -
1 ). The patient had adequate pain relief and chest condition
improved satisfactorily. PCEAwas used for 7 days
and the epidural catheter was removed uneventfully.
Subsequently the patient was discharged without any
neurological sequelae.

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 1mm
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 obtained
in a 1.5T MRI scanner (General electric signal)
(matrix 256x256, field of view 20 cm axial, 28 cm sagittal).
Axial and sagittal T 1 -weighted images after IV
gadolinium DTPA were obtained. CT scan (4-mm images
obtained at 3-mm interval) with sagittal and coronal
reconstruction was done. But the severed epidural
catheter was not visualized.
Thepatientwascounselled thatthis eventhad occurred
andwas advised to reportin caseof anyadversesymptoms.
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, diagnose
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 catheter
in epidural space causes the catheter to stretch
3, 4 or tear.
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 manufacturing.
6. Damage to a catheter occurring after placement
i.e. fraying by pinching between two vertebral pro-
5, 6 cesses.
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 between
tip of theepidural 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-
8, 9
sertion into the epidural space.
Prevention of catheter breakage – recommendations
1. Lateral decubitus position when removing an epidural
catheter as this results in least force of extraction.
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 position
b. Rotation of spine
c. Returningthe patientto theposition used at time
of insertion e.g. sitting position with legs extended
or kneeling position with hands down
and back flexed
d. Allowing tissues to soften for 15- 30 minutes
before reattempting 11
e. Fillingthe catheter with a rapid injection of saline
to increase the turgor of the catheter and
to lubricate it.
f. Complete relaxation with GA with muscle relaxation
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 advanced
into the epiduralspace to reduce risk of kinking
/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 obtained
from a reputable, reliable manufacturer.
In our case, there was no obvious cause for breakage.
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 locate
radiologically than non-radio opaque ones, but paradoxically,
they have a lower tensile strength than standard
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 diagnosing
the complication of spinal stenosis secondary to epidural
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 attenuation
catheter fragment within the epidural space and is
more sensitivethan plain radiography, especiallyfor small
retained fragments.
In our case CT / MRI did not help to locate the
fragment – since they are helpful once there is a reactive
mass around the catheter fragment.
Management
Sequestered temporary epidural catheter pieces are
generally considered to beinert and should not produce a
foreign bodyreaction. Experiments with cats have shown
that a broken catheter becomes walled off by fibrous tissue
after about3 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 (1.5cm) around the catheter fragment
resulting in lumbar spinal stenosis, patientbeing asymptomatic
until 18 months of the incident and got relieved
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 compression.
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 implanted
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 epiduralcatheter is to leavethem aloneunless symptomatic
because surgical removal can produce more
harm than good. 2 However, there are 3 situations where
apolicy of non-interferenceor reassurancedoes not apply.
1. Where infection or symptoms supervene, a careful
historyand physicalexamination should help determine
the spinallevel 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 intrathecal
space, appropriate imaging, a neurosurgical
consultation and aggressivesurgical 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 superficialincision made under local
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 associated
reactive scar tissue and relieve spinal stenosis.
Successfullocalization ofcatheter fragmentby medical
imaging is no guarantee that task of finding the missing
segmentat subsequentsurgery willbe madeany 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 extract
the catheter under direct vision by open surgical
laminectomy. 18 Sidhu et al described a parturient having
epidural catheter coiled around L 2 -L 3 nerve root, causing
severe pain and paresthesia on traction, but producing
no sensory or motor defect. Since the patient refused
a surgical procedure, catheter was removed without
sequelae by gentle traction in various positions. 19
Any kind of trauma, like practice of securing the
catheter bya sutureat skin level, may cause microlesions
and deteriorates the energy adsorbing capacity of catheter
considerably – therefore, it should be practiced only
when absolutely indicated. 20
Our patient has not reported any adverse symptoms
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
integrityfor intraoperativeand postoperativeperiod and
eliminates the necessity for an additional surgical procedure
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 bodyfluids with no undesirabledegradation substance
released into body. 21 Since it is adversely affected
by moisture it is preferably packaged in a substantially
moisture-freeenvironment prior to use and in sealed sterile
packages.
In general, the material should generally maintain its
original integrity for at least 3 days and should be completely
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 syntheticpolymers or through irradiation with gamma
rays thatsimultaneously sterilizes the catheter without any
significant loss of other desirable properties.
In conclusion, inspite of thebest intentions and exercise
of utmost care it can still result in tearing of an
epidural catheter. Butfortunately in only a small proportion
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 routinebasis to
prevent the occurrence.
The presence of a retained epidural catheter fragment
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 discomfort,
infection or radiculopathy. If symptoms develop,
spine imaging to find out the level of involvement and
surgery is advocated.
437
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