Surgical removal of broken epidural catheter.

Sir,

Although broken epidural catheter is an uncommon recorded complication and There is no many cases reported in the literature it is an area of debate because the catheter itself is made from inert material and foreign body reaction should not be expected[1] but unfortunately reactive epidural mass surrounding the catheter fragment has been reported leading to lumbar compression[2] and in spite of the location of the catheter is usually will not permit its extrusion but there is no guarantee that it will not occurs as it is recorded that the catheter may be migrate and lead to nerve root irritationor dural fistula with or without a persistent CSF leak.[34]

The broken end of the catheter is usually not smooth due to traction which may lead the pin prick like sensation with the movement all of these expected complication in addition to the psychological burden of the patient motivate surgeon to remove it.

Removal of the broken catheter should be smooth without any resistance or violenceand under vision to prevent any further sequels as the catheter may be curled around the nerve root[5] which may lead to neurological deficit also the catheter may be hanged in contracted muscle or lamina specially these patient become irritable and most of the time they cannot relax their back muscle so any violence may lead further break so we recommend to remove the catheter under vision using general anesthesia.

We recorded A 33-year's-old female patient presented to our clinic with back pain and painful spinal movement after delivery of here 3rd kid by normal vaginal delivery under general anesthesia after failed epidural anesthesia with missed broken epidural catheter. The patient denied the appearance of this pain in the first and second delivery.

Clinical examination of the patient revealed tenderness over the spinal process at the level of L3-4 space with pin prick like sensation during spinal flexion but no motor or sensory deficit.

X-ray lumbar spine showed looped foreign body extending from spinal canal to subcutaneous tissue [Figure 1].

Figure 1

Preoperative X-ray showing the missed catheter

The patient informed about the finding and the two option whether to remove the catheter surgically or to leave the catheter with follow up and after confirmed consent the patient operated in the prone position under general anesthesia using intra operative X-ray guidance small skin incision has been don and dissection of subcutaneous tissue has been done using mosquito forceps until the lumbar fascia where the catheter could be identified immediately below the spinal process of L3.

Trial of removal by gentle extraction has been failed so small incision has been done in the sheath and dissection of the muscle all around the catheter was performed until the level of the lamina and ligamentat that time a second trial was performed and the catheter this time extracted smoothly which was found 17 Cm missed loop of the epidural catheter with sharpened external end.

Post extraction X-ray was done to avoid any other missed peace [Figure 2].

Figure 2

Postoperative X-ray showing complete removal of the missed catheter

Postoperative there is no CSF leak or any collection and the patient discharged in the 2nd day.

Follow up of the patient showed that the previous pain disappeared and the patient become satisfiedwithout any neurological compromise.