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Neuraxial blockade is an efficient anesthetic technique, routinely practiced by anesthesiologists. Placement of an epidural catheter is a relatively safe and routine process but it can have complications like abscess, hematoma, dislodgement and breakage [1,2,3]. This retained piece of broken fragment usually may have a benign outcome when left undisturbed but it can also have undesired sequelae. There have been cases of radicular compression syndrome, foreign body reaction, and lumbar stenosis attributed to the retained fragment [4,5,6]. In such cases radiological imaging is not always conclusive and hence creates a conundrum about the management. Several case reports recommend that surgical removal of catheter should not be done considering the intra-operative and peri-operative complications. Nevertheless literature also shows cases that mandate surgical intervention [7]. We report a successful surgical extraction of an epidural catheter, stuck in the interspinous space and tissues, by superficial exploration aided by X-ray imaging before any catheter related complications occurred.

A seventy year old female, operated case of fracture neck of femur was posted for total hip replacement surgery. The patient was classified as ASA PS I, all necessary investigations were checked and starvation was confirmed. After informed and written consent, patient was taken in the operating room. As per ASA guidelines standard monitors were attached and wide bore 18G intravenous was secured. Under all aseptic precautions, a 16G (PORTEX Epidural Minipack System 1 with radio-opaque catheter) 8 cm TUOHYS needle was used for the epidural catheter insertion at L4-L5 level. After two attempts, epidural space was entered at 6 cm depth from the skin through paramedian approach and catheter was advanced upto 10 cm. Placement of catheter was confirmed by meniscus sign and negative aspiration of blood and CSF and the catheter was fixed at 10 cm mark. Through midline approach subarachnoid block was given subsequently in the same space with 3.5 cc 0.5% heavy bupivacaine and 30 units of clonidine after confirming free flow of CSF and negative aspiration of blood. Patient was then given supine position and spinal level was established. After ten minutes of induction, the level of spinal anaesthesia was confirmed at T10. 

The patient was then positioned for the surgery when there was accidental removal of epidural catheter. At this time the tip of catheter was not visible and the distal 2.5 cm of catheter was found to be broken. Images from portable fluoroscopy machine in the OT failed to locate the catheter. The patient was then shifted to the X-ray department, available on the same floor as that of operation theatre, for further imaging. A radiopaque tubular structure was found lying superficial to the spinous process and lodged in subcutaneous tissue at the level of L4 vertebra which warranted surgical intervention. As patient was still under the effect of the subarachnoid block consent was taken from the patient and next of kin, and patient was taken up for exploration. As per the orthopedic surgeons the plan was to explore up to the superior interspinous ligament, so as to protect the epidural space. Patient was given prone position, standard monitors were attached. Under all aseptic precautions patient was explored immediately upto subcutaneous tissue and in the interspinous space at the back over L4 vertebra with a skin incision of 3.5 cm and up-to 4 cm deep. After a superficial yet blunt dissection of tissue a total length of 2.5 cm catheter was extracted intact from the tissue.

The patient was shifted to the post-operative recovery and observed and given intravenous antibiotics for 48 hours and then discharged after confirmation of normal sensory and motor examination for lumbosacral spine. No neurological or local wound complication was noted in next follow up.

Broken epidural catheter fragment, getting trapped in the tissues, is a known entity with an incidence of 0.15% for a knotted epidural catheter [8]. The broken fragment gets walled off by fibrous tissue within the epidural space after about 3 weeks. However, symptoms can arise when the catheter impinges a nerve, causes traction on it, a superimposed infection occurs, or on rare occasion if patient presents with low backache due to foraminal stenosis. Surgical intervention becomes a rule for the removal of catheter in such cases [9]. In rare cases, the catheter has been reported to be trapped in tight intervertebral spacing, facet joint, or even in ligamentum flavum without any knot [10,11]. In few cases of entrapment a couple of nonsurgical maneuvers like injecting saline are recommended before surgical intervention [12,13]. Although the neurological consequences of a broken catheter are rare, many reports still advocate surgical removal be considered first [14].

It is recommended that all patients with retained epidural catheter fragment should undergo proper radio imaging studies [15]. MRI scan shows the epidural fibrosis/scar formation and the extent of spinal stenosis, hence it is recommended for follow-up cases. CT scan is more sensitive in detecting the high attenuation catheter fragment within the epidural space, however due to lack of resources it was unavailable at our center. As the catheter was radio-opaque and the X-ray department was conveniently located on the same floor as the operation theatre, to expedite mobilisation of the patient, further imaging was performed with an X-ray to arrive at a conclusion to the next step in management. A tubular structure, lying superficial to the spinous process and lodged in the subcutaneous tissue at the level of L4 vertebra was noticed.

Anaesthetists are often faced with a dilemma as there are insufficient case reports and inadequate literature available for the optimum management of broken epidural catheter. In our case, we suspect that difficult insertion, with calcified ligaments was most probably the cause of catheter getting lodged and traction at the time of positioning broke it into fragments. Nevertheless, X-ray imaging assisted in localisation of the catheter and guided us in further intervention.

Epidural drug delivery technique is used by anesthesiologist globally has its own side-effects; rare yet not unheard being a broken epidural catheter fragment. Thereby, it is essential to take the appropriate steps for conservation or intervention when in dilemma. As in our case with difficult insertion, anticipation of the consequences and hence extra care of the catheter could have helped in prevention of this complication. Radiological imaging, that guided us in the appropriate management, is recommended for every case of sheared catheter lodged in situ for early identification, pertinent management and for follow up cases. Early intervention can protect a patient from the sequelae and long term neurological deficits caused by the catheter left in situ. Inspite of the perplexity of the management of a broken epidural catheter, the risk benefit ratio of surgical intervention and a thorough review of literature can guide an anesthesiologist in handling this complication of neuraxial anesthesia technique safely.

Contributors: DK conceived the presented idea, as well as drafted the manuscript; JSB and DeK edited the manuscript. DK will act as a study guarantor. All authors have read and approved the final manuscript and are accountable for all aspects of the final manuscript.

Funding: None; Competing interests: None stated.