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Journal of Clinical Anesthesia (2007) 19, 310–314

Special article

Management of the sheared epidural catheter: is surgical extraction really necessary?
Raj Mitra MD (Clinical Assistant Professor, Medical Director)*, Katharine Fleischmann MD
Pain Management Center, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA, USA
Received 28 April 2006; revised 31 October 2006; accepted 7 November 2006

Epidural catheter removal

Abstract Trauma to epidural catheters on insertion or removal may result in shearing or breakage. Although there is no evidence of neurologic sequelae from a sheared catheter, many reports still advocate eventual surgical removal. The literature suggests the following options: (1) using slow continuous force at all times; (2) discontinuing application of force if the catheter begins to stretch and reapplying traction several hours later; (3) placing of the patient in the same position as insertion; (4) placing the patient in the lateral decubitus position if possible; (5) attempting to remove in extreme flexion if the previous interventions are not efficacious; (6) attempting extension if flexion fails; (7) attempting removal after injection of preservative-free normal saline through the catheter; (8) considering use of a convex surgical frame; (9) considering computed tomographic scan to identify the etiology of entrapment; (10) considering leaving a retained epidural catheter in place in adult patients; (11) providing patient education regarding “red flags” to watch out for; and (12) neurosurgical consultation for all cases in which the catheter fragment is in the spinal canal. © 2007 Elsevier Inc. All rights reserved.

1. Introduction
Epidural catheters are routinely removed without complications with an intact tip by physicians. On rare occasions, inflicted trauma during insertion or removal results in shearing of the sheath or breakage of the catheter. Excessive applied tension also may cause stretching and even breakage. We review the current literature and treatment algorithm of an entrapped and subsequently sheared catheter.

2. Materials and methods
A computer-aided search of several databases—MEDLINE (US National Library of Medicine, Bethesda, MD), 1966 to August, 2006; EMBASE (Elsevier BV, Amsterdam, the Netherlands), 1982 to present; CINAHL (Cumulative Index to Nursing and Allied Health Literature, EBSCO Industries, Glendale, CA), 1982 to August, 2006; and all EBM (Evidence-Based Medicine, US National Library of Medicine, Bethesda, MD) reviews, including Cochrane DSR (Database of Systematic Reviews, Cochrane Collaboration,, ACP Journal Club (American College of Physicians, Philadelphia, PA); DARE (Database of Abstracts of Reviews of Effects; NHS CRD, University of York, York, UK), and CCTR (Cochrane Controlled Trials Register, now known as Cochrane Database of Systematic

⁎ Corresponding author. Stanford Interventional Spine Center, Department of Orthopedic Surgery, Stanford University Medical Center, Stanford, CA 94305, USA. Tel.: +1 650 725 9078; fax: +1 650 498 7546. E-mail address: (R. Mitra). 0952-8180/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.11.005

Epidural catheter removal and review Reviews; The Cochrane Collaboration, —was performed. The search terms were anesthesia, epidural, catheterization, retained, and sheared.

311 that the Wilson Convex Frame allowed relaxation of paraspinal muscles and spinal ligaments, which led to easier catheter retrieval. Pierre et al [9] reported a case in which there was difficulty removing an entrapped epidural catheter in a postpartum woman approximately 7.5 hours after insertion. It was found that cessation of traction for a period of three hours facilitated subsequent easy removal. This finding is interesting because it suggests that epidural catheters used for a prolonged period (ie, >24 hrs) may behave differently with applied traction than those epidural catheters that are used only for a short period, perhaps secondary to inflammation and subsequent fibrosis or catheter migration. Epidural catheters that are threaded more than 5 cm into the epidural space have an increased likelihood of knotting [10]. Various mechanisms may have caused entrapment of the catheter in our patient, including knotting, looping, excessive muscular tension, and entrapment in the foramen. Muscular tension, although possible, is less likely in patients with little muscle bulk or in patients in which a midline approach has been used. An epidural catheter inserted in a midline approach often misses the bellies of the semispinalis muscles where the muscle bulk is greatest.

3. Discussion
3.1. Epidural catheter removal
An extensive review of the literature, which included a MEDLINE search, did not result in a treatment algorithm for entrapped and sheared epidural catheters. However, we did identify numerous case reports regarding entrapped epidural catheters. Asai et al [1] reported that Arrow catheters (Arrow, Reading, PA) consistently broke at lower weights than did other epidural catheters (Perifix [B. Braun, Melsungen, Germany]; Perisafe [Becton, Dickinson and Co., Franklin Lakes, NJ]; Portex [SIMS, Portex, Hythe, UK]), especially at the 5-cm mark. The study also concluded that the catheter was more likely to snap at the site of fixation rather than being pulled at the distal aspect. Interestingly, it was concluded that faster speed was associated with greater force and an increased likelihood of catheter breakage. Several studies examined the effect of patient positioning on removal of epidural catheters. Blackshear et al [2] suggested that less tension is required to remove an epidural catheter when the patient is in the lateral decubitus position as opposed to a sitting position. Another study showed that catheters inserted in the lateral position required less force when removed in the lateral position [3]. Morris et al [4] also suggested that significantly less force was required to remove an epidural catheter when the patient was placed in the same position as at the time of insertion. Of note, the withdrawal force required to remove an epidural catheter was greatest in patients who had placement in the lateral decubitus position, and removal in the sitting position. In cases in which the epidural catheter is trapped despite placement of the patient in the lateral decubitus position, extreme flexion has been advocated [5]. When extreme flexion in the lateral decubitus position has not been beneficial, injection of normal saline into the epidural catheter has been proposed. This maneuver may increase the turgor of the catheter, allowing it to be removed with increased ease [6]. There are no reported data to support this approach. A case report described a sterile Tuohy needle to be passed over the epidural catheter and advanced into the epidural space, after which the Tuohy needle as well as the lodged catheter were withdrawn together [7]. This technique has obvious dangers of catheter shearing during insertion and removal. Start et al [8] reported a case study in which the Wilson Convex Surgical Frame was used to provide maximal flexion in a patient, and facilitated easy removal of an otherwise irretrievable epidural catheter. It was postulated

3.2. Catheter characteristics
A number of investigations have studied the tensile characteristics of commonly used epidural catheters (Table 1). Asai et al [1] compared the 19-gauge Flex Tip Plus Arrow Catheter with 19-gauge Perifix Catheter, Perisafe Catheter, and the Portex Catheter with regard to their degree of stretching, force required to snap, and site of breakage. Interestingly, the authors concluded that although the Arrow Catheter stretched more than other catheters, it also broke at significantly lower weight. Ates et al [11] performed a controlled laboratory investigation to assess the mechanical performances (stretch and breaking point) of three different catheter types: polyurethane, radiopaque, and clear nylon. The catheters were subdivided into control (intact) and traumatized groups (with needle bevel). The authors observed that polyurethane catheters did not break within the limits of the study. The study concluded that polyurethane catheters had the highest toughness value, whereas radiopaque catheters had the highest elasticity. Another study compared the commercial strengths of 6 types of commercially available, 20-gauge epidural catheters [12]. A calibrated electronic force gauge was used to determine the force required for catheter breakage. The catheters analyzed were from Abbott (nylon; Abbott Laboratories Inc, Abbott Park, IL), Baxter (nylon; Baxter Healthcare Corp, Deerfield, IL), Becton Dickinson (nylon; Becton, Dickinson and Co., Franklin Lakes, NJ), Burron (polyamide; Burron, Bethlehem, PA), Concord-Portex (nylon; Concord

Table 1 Study
Asai et al [1]

R. Mitra, K. Fleischmann
Summary of catheter characteristics Catheters examined
ArrowFlex Tip Plus, Perifix, Perisafe, Portex Polyurethane, Radio-opaque, Clear Nylon Abbott (nylon), Baxter (nylon), Becton Dickinson (nylon), Burron (polyamide), Concord/Portex (nylon), Kendall (nylon)

Amount of stretch Force to snap Breakage site Toughness Elasticity Force to catheter breakage

Arrow Catheter stretched the most, and broke at lowest weight Polyurethane most tough, Radio-opaque most elastic Abbott catheters strongest; Baxter the weakest

Ates et al [11] Blum et al [12]

Portex, Keene, NH), and Kendall (nylon; Tyco Healthcare/ Kendall, Mansfield, MA). Abbott epidural catheters were found to be significantly strongest, whereas Baxter catheters were significantly weakest.

3.3. The sheared catheter
There are few established reports on the management of a sheared epidural catheter fragment. The current literature suggests that retained catheter fragments are sterile, inert, and extremely unlikely to cause subsequent neurologic sequelae [13-15]. Therefore, it is believed that fragments are generally safe to leave in place as long as there are no neurologic signs or symptoms. In spite of these facts, all the identified reports advocated the eventual surgical removal of the catheter fragment [16-21]. Lenox et al [19] reported an interesting case of a sequestered epidural catheter tip in the caudal epidural space in a 23-month-old child. A computed tomogram (CT) of the pelvis was obtained and the child was eventually taken to the operating room for surgical removal. In a similar case, DeArmendi et al [22] reported a sheared tunneled pediatric catheter tip that also was removed surgically. The decision to remove the catheter fragment was justified in these cases in part because the patients were young and there was concern that future neurologic damage (secondary to infection, fibrosis, migration, or direct mechanical neural irritation) might occur with subsequent development.

Another report describes a 64-year-old man who underwent epidural anesthesia for hip replacement, with postoperative shearing of the catheter on withdrawal [24]. The catheter fragment was left in place until he developed pain and weakness approximately 18 months later, at which time magnetic resonance imaging (MRI) was performed. The MRI showed a well-circumscribed, posterior, epidural, cystic-appearing mass that was isointense to soft tissue on T1 and bright on T2, and showed enhancement with gadolinium. Although the neurologic sequelae was attributed to a retained catheter fragment, no catheter fragment was ever obtained during surgical decompression. A similar study described a 34-year-old parturient who presented with signs and symptoms consistent with an L3 radiculopathy 7 months after delivery [25]. The patient had a cesarean delivery during general anesthesia after failure to achieve epidural anesthesia. Subsequent MRI showed a coiled mass of epidural catheter in the anterolateral aspect of the spinal canal directly abutting the L3 nerve root; the patient eventually underwent decompressive surgery, with complete relief. In contrast to sheared temporary epidural catheters, there have been a variety of case reports documenting granuloma formation and fibrosis for chronic implanted epidural catheters [26-28].

3.5. Which test to order?
The initial diagnostic dilemma for the clinician is to identify exactly where the proximal and distal ends of the catheter fragment lie. If the fragment lies outside of the spinal canal, easy removal should be possible with a local incision. On the other hand, if the fragment is within the spinal canal, the risks and benefits for removal must be carefully weighed. Magnetic resonance imaging of the spine has traditionally been characterized as a poor choice for ferromagnetic catheters because of metallic artifact as well as a risk of neural damage secondary to heating of a wire-enforced catheter in the epidural space [24]. There have been no documented cases of injury occurring secondary to MRI in a patient with a sheared epidural catheter. Interestingly, a patient with a sheared Racz catheter fragment (which is

3.4. Sequelae of retained catheters
Despite the low risk of complications from a retained catheter fragment, a few reports document adverse effects. Ugboma et al [23] described the interesting case of a retained intrathecal catheter. In this case, a 9-cm polyurethane catheter had sheared off with uncoiling of the incorporated wire. A CT scan showed the posterior catheter portion near the spinous process of L4, with the anterior end terminating intrathecally at L3-L4. Despite a lack of motor or sensory deficits, the patient eventually underwent a laminectomy and catheter removal.

Epidural catheter removal and review ferromagnetic) lodged in the sacral canal had an uneventful MRI [29]. A similar case was reported in which an MRI was used to identify a coiled epidural catheter abutting the L3 nerve root without neurologic sequelae [23]. Nevertheless, many clinicians do not advocate MRI as the first diagnostic test because of the theoretical risk of thermal injury, dislodgment, or movement [30,31]. It has been suggested that CT be used to analyze entrapped catheters [32,33]. A CT scan would be preferable to fluoroscopy because of higher resolution, and if it is available quickly, it may be the best test. If a CT scan is not readily available, the clinician may use fluoroscopy as a first test to determine whether the entrapped catheter is outside the spinal canal. Staats et al [24] performed an interesting experiment in which a catheter fragment was simply placed in a water basin and scanned both by MRI and CT. Interestingly, the catheter fragment was more easily visible on CT scan, showing pronounced, high attenuation; on MRI, the catheter fragment was difficult to localize because it appeared hypointense on the T1- and T2-weighted images [24]. This study suggested that a CT scan may more clearly identify ferromagnetic sheared catheters than an MRI.

313 possible; (5) attempting to remove in extreme flexion if the previous interventions are not efficacious; (6) attempting extension if flexion fails; (7) attempting removal after injection of preservative-free normal saline through the catheter; (8) considering use of a convex surgical frame; (9) considering a CT scan to identify the etiology of entrapment; (10) considering leaving a retained epidural catheter in place in adult patients; (11) providing patient education regarding “red flags” to watch out for; and (12) neurosurgical consultation for all cases in which the catheter fragment is in the spinal canal.

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3.6. Suggestion
The management of retained fragments within the spinal canal is controversial. The fear of future development of infection has no support in the literature. Of the case reports available, possible neurologic sequelae include direct mass effect on neural structures [23] and potential fibrosis and cyst formation [22]. Neurologic sequelae seem to be more likely in cases in which the fragments are large enough to exert a direct mass effect on neural tissue. There is only one case report with an intrathecal retained fragment; despite the lack of neurologic deficits, the patient had decompressive surgery. For small fragments that are sheared off into the epidural space but do not cause any direct mass effect on neural structures, it may be reasonable to leave them in place. The CT scan seems to be the best choice because MRI does not show epidural fragments as clearly [24]. In the population of patients with immediate neurologic sequelae, a follow-up CT at 6 months and one year to monitor retained catheter fragments and ensure that there is no evidence of granulation tissue formation is reasonable [17].

4. Conclusions
Based on our case and a complete literature review, we recommend: (1) using slow continuous force at all times; (2) discontinuing application of force if the catheter begins to stretch and reapplying traction several hours later; (3) placing the patient in the same position as on insertion; (4) placing the patient in the lateral decubitus position if

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[31] [32]