|Year : 2007 | Volume
| Issue : 5 | Page : 434
Epidural Catheter Breakage: A Dilemma
Deepanjali Pant1, Pradeep Jain2, Pravesh Kanthed3, Jayashree Sood4
1 MD, Consultant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India
2 MD, Senior Consultant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India
3 DA, DNB, Senior Resident, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India
4 MD, FFARCS, PGDHHM, Senior Consultant, Chairperson, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India
|Date of Acceptance||30-Aug-2007|
|Date of Web Publication||20-Mar-2010|
Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060.
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.
Keywords: Epidural catheter, Breakage, Management.
|How to cite this article:|
Pant D, Jain P, Kanthed P, Sood J. Epidural Catheter Breakage: A Dilemma. Indian J Anaesth 2007;51:434
| 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 during removal, leaving a segment lodged in patient's back.  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.  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 relocate the epidural space. While the catheter was being removed with gentle traction along with Tuohy needle, it sheared off at 6 cm mark. [Figure 1]
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 (5pg.ml1 ). The patient had adequate pain relief and chest condition improved satisfactorily. PCEA was used for 7 days and the epidural catheter was removed uneventfully. Subsequently the patient was discharged without any neurological sequelae.
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 1weighted spin-echo (TR 500 ms/TE16 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.
The patient was counselled that this event had occurred and was advised to report in 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, diagnose and manage such a case.
| Causes of severed epidural catheter|| |
- Application of undue force in removing a catheter trapped between vertebral spinous processes or in ligamentum flavumor knotted, kinked or curled catheter in epidural space causes the catheter to stretch or tear. ,
- Shearing of catheter by needle when attempts are made to withdraw the catheter through the Tuohy needle.
- Nicking of a catheter by a barb on the bevel of the needle.
- Shredding of catheter if the needle is advanced over the catheter after the catheter has been placed.
- Weakness of the catheter by imperfect manufacturing.
- Damage to a catheter occurring after placement i.e. fraying by pinching between two vertebral processes. ,
- 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 the epidural needle and a bony surface, if a length of the catheter was protruding from the tip. 
- Catheter damage is often related to excessive insertion into the epidural space. ,
| Prevention of catheter breakage - recommendations|| |
In our case, there was no obvious cause for breakage. Most probably it was kinked or curled, as there was resistance during drug injection.
- Lateral decubitus position when removing an epidural catheter as this results in least force of extraction. 
- 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. Returning the patient to the position 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 
e. Filling the 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
- The needle should be checked for barbs on bevel and the catheter for manufacturing defects before insertion.
- No more than 4-5 cm of catheter should be advanced into the epidural space to reduce risk of kinking /curling /knotting. ,,
- Catheter should never be withdrawn through the metal needle.
- Catheters of high breaking strain (tensile strength) and of a sufficient diameter (16/18G) should be obtained from a reputable, reliable manufacturer.
| 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 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 reactive 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 tissue after about3 weeks -remaining innocuous within the epidural space.  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, patient being asymptomatic until 18 months of the incident and got relieved with removal of catheter and reactive scar tissue. 
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.  This local reaction was reported by Coombs et al, who found "cocoon" formation with dural thickening around implanted catheters in post-mortem examination. 
Therefore, in most cases the current standard of care application to the retained segments of a temporary epidural catheter is to leave them alone unless symptomatic because surgical removal can produce more harm than good.  However, there are 3 situations where a policy of non-interference or reassurance does not apply.
On rare occasions, surgical exploration may be needed to remove lost catheter fragments and associated reactive scar tissue and relieve spinal stenosis. Successful localization of catheter fragment by medical imaging is no guarantee that task of finding the missing segment at subsequent surgery will be made any easier.
- Where infection or symptoms supervene, a careful history and physical examination should help determine the spinal level involved.
- If the spinal catheter fragment is sitting partially intrathecally and is acting as a wick which allows persistent CSF leakage.  If a continuous spinal micro-catheter becomes separated within the intrathecal space, appropriate imaging, a neurosurgical consultation and aggressive surgical exploration to retrieve the broken piece are warranted, even in the asymptomatic patient. 
- 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 local anaesthesia. The broken distal piece is grasped with a curved haemostat and drawn out by firm, gentle traction.  Surgical removal is mandatory in such a situation as bacteria can readily track along the catheter remnant.
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.  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. 
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 catheter considerably - therefore, it should be practiced only when absolutely indicated. 
Our patient has not reported any adverse symptoms so far till the writing of this article - a time period of roughly two years.
| 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 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 body fluids with no undesirable degradation substance released into body.  Since it is adversely affected by moisture it is preferably packaged in a substantially moisture-free environment 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 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 exercise of utmost care it can still result in tearing of an epidural catheter. But fortunately 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 routine basis 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.
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