Surgical Management of the Retained Epidural Catheter Fragment Complicated by Postoperative Phlegmon

Abstract

Lumbar epidurals are an effective form of labor pain control. The breakage of an epidural catheter is an extremely rare complication. No clear management guidelines or algorithms exist for retained epidural fragments or entrapped catheters. Here we report a case of fractured and retained epidural catheter after uncomplicated placement with Dural puncture for confirmation of midline placement, the imaging done to locate the fragment, the decision to surgically remove the fragment, and subsequent surgical bed infection. We review the management options for difficult to remove epidural catheters, the optimal methods of locating the retained fragments, and the indications for surgical removal.

Retained epidural catheter: an update

“…From our review, 15 (41.6%) catheters were retained during removal, [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] and 8 (22.2%) catheters could not be removed due to knotting. [17][18][19][20][21][22][23] Knotted catheters mostly involved excessive lengths threaded during insertion ranging 4 to 17 cm with a median length of 7 cm.…”

“…7,10,26 In our review, 9 CT scans were performed with 7 (77.8%) scans correctly identifying the catheter. [7][8][9][10][11][12][13]26,27 However, the radio-opaque nature of most catheters would justify a simple radiograph in the absence of CT scan. All 6 case reports where X-rays were performed located the catheter.…”

“…Spine surgery is not without its own complications, with 1 case of surgical site infection 13 and 2 cases of transient postoperative lower back pain treated with physiotherapy. 30,34 From our review, factors that may influence the decision to operate have been summarised in Table 1.…”

“…Complications are rare Asymptomatic fragment Avoids complications of major surgery 13,30 Small retained fragment following patients up a month after discharge with subsequent intervals ranging between 6 months up to annually, with eventual discharge if they remain asymptomatic thereafter. A detailed documentation of the incidence, discussion, and decisions should be made for future reference.…”