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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

Keywords: Abstract Trauma to epidural catheters on insertion or removal may result in shearing or breakage.
Epidural catheter removal 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 2. Materials and methods

Epidural catheters are routinely removed without com- A computer-aided search of several databases—MED-
plications with an intact tip by physicians. On rare occasions, LINE (US National Library of Medicine, Bethesda, MD),
inflicted trauma during insertion or removal results in 1966 to August, 2006; EMBASE (Elsevier BV, Amsterdam,
shearing of the sheath or breakage of the catheter. Excessive the Netherlands), 1982 to present; CINAHL (Cumulative
applied tension also may cause stretching and even breakage. Index to Nursing and Allied Health Literature, EBSCO
We review the current literature and treatment algorithm of Industries, Glendale, CA), 1982 to August, 2006; and all
an entrapped and subsequently sheared catheter. EBM (Evidence-Based Medicine, US National Library of
Medicine, Bethesda, MD) reviews, including Cochrane DSR
(Database of Systematic Reviews, Cochrane Collaboration,
www.cochrane.org), ACP Journal Club (American College
of Physicians, Philadelphia, PA); DARE (Database of
⁎ Corresponding author. Stanford Interventional Spine Center, Depart-
ment of Orthopedic Surgery, Stanford University Medical Center, Stanford,
Abstracts of Reviews of Effects; NHS CRD, University of
CA 94305, USA. Tel.: +1 650 725 9078; fax: +1 650 498 7546. York, York, UK), and CCTR (Cochrane Controlled Trials
E-mail address: rmitra@stanford.edu (R. Mitra). Register, now known as Cochrane Database of Systematic

0952-8180/$ – see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.jclinane.2006.11.005
Epidural catheter removal and review 311

Reviews; The Cochrane Collaboration, www.cochrane.org) that the Wilson Convex Frame allowed relaxation of
—was performed. The search terms were anesthesia, paraspinal muscles and spinal ligaments, which led to easier
epidural, catheterization, retained, and sheared. 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.
3. Discussion It was found that cessation of traction for a period of
three hours facilitated subsequent easy removal. This
3.1. Epidural catheter removal finding is interesting because it suggests that epidural
catheters used for a prolonged period (ie, >24 hrs) may
An extensive review of the literature, which included a behave differently with applied traction than those epidural
MEDLINE search, did not result in a treatment algorithm for catheters that are used only for a short period, perhaps
entrapped and sheared epidural catheters. However, we did secondary to inflammation and subsequent fibrosis or
identify numerous case reports regarding entrapped epidural catheter migration. Epidural catheters that are threaded
catheters. Asai et al [1] reported that Arrow catheters (Arrow, more than 5 cm into the epidural space have an increased
Reading, PA) consistently broke at lower weights than did likelihood of knotting [10].
other epidural catheters (Perifix [B. Braun, Melsungen, Various mechanisms may have caused entrapment of the
Germany]; Perisafe [Becton, Dickinson and Co., Franklin catheter in our patient, including knotting, looping, excessive
Lakes, NJ]; Portex [SIMS, Portex, Hythe, UK]), especially at muscular tension, and entrapment in the foramen. Muscular
the 5-cm mark. The study also concluded that the catheter tension, although possible, is less likely in patients with little
was more likely to snap at the site of fixation rather than muscle bulk or in patients in which a midline approach has
being pulled at the distal aspect. Interestingly, it was been used. An epidural catheter inserted in a midline
concluded that faster speed was associated with greater approach often misses the bellies of the semispinalis muscles
force and an increased likelihood of catheter breakage. where the muscle bulk is greatest.
Several studies examined the effect of patient position-
ing on removal of epidural catheters. Blackshear et al [2]
suggested that less tension is required to remove an 3.2. Catheter characteristics
epidural catheter when the patient is in the lateral
decubitus position as opposed to a sitting position. A number of investigations have studied the tensile
Another study showed that catheters inserted in the lateral characteristics of commonly used epidural catheters (Table 1).
position required less force when removed in the lateral Asai et al [1] compared the 19-gauge Flex Tip Plus Arrow
position [3]. Morris et al [4] also suggested that Catheter with 19-gauge Perifix Catheter, Perisafe Catheter,
significantly less force was required to remove an epidural and the Portex Catheter with regard to their degree of
catheter when the patient was placed in the same position stretching, force required to snap, and site of breakage.
as at the time of insertion. Of note, the withdrawal force Interestingly, the authors concluded that although the Arrow
required to remove an epidural catheter was greatest in Catheter stretched more than other catheters, it also broke at
patients who had placement in the lateral decubitus significantly lower weight.
position, and removal in the sitting position. In cases in Ates et al [11] performed a controlled laboratory in-
which the epidural catheter is trapped despite placement of vestigation to assess the mechanical performances (stretch
the patient in the lateral decubitus position, extreme and breaking point) of three different catheter types:
flexion has been advocated [5]. polyurethane, radiopaque, and clear nylon. The catheters
When extreme flexion in the lateral decubitus position has were subdivided into control (intact) and traumatized groups
not been beneficial, injection of normal saline into the (with needle bevel). The authors observed that polyurethane
epidural catheter has been proposed. This maneuver may catheters did not break within the limits of the study. The
increase the turgor of the catheter, allowing it to be removed study concluded that polyurethane catheters had the highest
with increased ease [6]. There are no reported data to support toughness value, whereas radiopaque catheters had the
this approach. A case report described a sterile Tuohy needle highest elasticity.
to be passed over the epidural catheter and advanced into the Another study compared the commercial strengths of
epidural space, after which the Tuohy needle as well as the 6 types of commercially available, 20-gauge epidural
lodged catheter were withdrawn together [7]. This technique catheters [12]. A calibrated electronic force gauge was used
has obvious dangers of catheter shearing during insertion to determine the force required for catheter breakage. The
and removal. catheters analyzed were from Abbott (nylon; Abbott Labora-
Start et al [8] reported a case study in which the tories Inc, Abbott Park, IL), Baxter (nylon; Baxter Healthcare
Wilson Convex Surgical Frame was used to provide maximal Corp, Deerfield, IL), Becton Dickinson (nylon; Becton,
flexion in a patient, and facilitated easy removal of an Dickinson and Co., Franklin Lakes, NJ), Burron (polyamide;
otherwise irretrievable epidural catheter. It was postulated Burron, Bethlehem, PA), Concord-Portex (nylon; Concord
312 R. Mitra, K. Fleischmann

Table 1 Summary of catheter characteristics


Study Catheters examined Endpoint Conclusion
Asai et al [1] ArrowFlex Tip Plus, Amount of stretch Arrow Catheter stretched
Perifix, Perisafe, Portex Force to snap the most, and broke
Breakage site at lowest weight
Ates et al [11] Polyurethane, Toughness Polyurethane most tough,
Radio-opaque, Clear Nylon Elasticity Radio-opaque most elastic
Blum et al [12] Abbott (nylon), Baxter (nylon), Force to Abbott catheters strongest;
Becton Dickinson (nylon), catheter breakage Baxter the weakest
Burron (polyamide),
Concord/Portex (nylon),
Kendall (nylon)

Portex, Keene, NH), and Kendall (nylon; Tyco Healthcare/ Another report describes a 64-year-old man who under-
Kendall, Mansfield, MA). Abbott epidural catheters were went epidural anesthesia for hip replacement, with
found to be significantly strongest, whereas Baxter catheters postoperative shearing of the catheter on withdrawal [24].
were significantly weakest. The catheter fragment was left in place until he developed
pain and weakness approximately 18 months later, at which
3.3. The sheared catheter time magnetic resonance imaging (MRI) was performed. The
MRI showed a well-circumscribed, posterior, epidural,
There are few established reports on the management of a cystic-appearing mass that was isointense to soft tissue on
sheared epidural catheter fragment. The current literature T1 and bright on T2, and showed enhancement with
suggests that retained catheter fragments are sterile, inert, gadolinium. Although the neurologic sequelae was attributed
and extremely unlikely to cause subsequent neurologic to a retained catheter fragment, no catheter fragment was
sequelae [13-15]. Therefore, it is believed that fragments are ever obtained during surgical decompression.
generally safe to leave in place as long as there are no A similar study described a 34-year-old parturient who
neurologic signs or symptoms. presented with signs and symptoms consistent with an L3
In spite of these facts, all the identified reports radiculopathy 7 months after delivery [25]. The patient had a
advocated the eventual surgical removal of the catheter cesarean delivery during general anesthesia after failure to
fragment [16-21]. Lenox et al [19] reported an interesting achieve epidural anesthesia. Subsequent MRI showed a
case of a sequestered epidural catheter tip in the caudal coiled mass of epidural catheter in the anterolateral aspect of
epidural space in a 23-month-old child. A computed the spinal canal directly abutting the L3 nerve root; the
tomogram (CT) of the pelvis was obtained and the child patient eventually underwent decompressive surgery, with
was eventually taken to the operating room for surgical complete relief.
removal. In a similar case, DeArmendi et al [22] reported a In contrast to sheared temporary epidural catheters, there
sheared tunneled pediatric catheter tip that also was have been a variety of case reports documenting granuloma
removed surgically. The decision to remove the catheter formation and fibrosis for chronic implanted epidural
fragment was justified in these cases in part because the catheters [26-28].
patients were young and there was concern that future
neurologic damage (secondary to infection, fibrosis,
3.5. Which test to order?
migration, or direct mechanical neural irritation) might
occur with subsequent development.
The initial diagnostic dilemma for the clinician is to
identify exactly where the proximal and distal ends of the
3.4. Sequelae of retained catheters catheter fragment lie. If the fragment lies outside of the spinal
canal, easy removal should be possible with a local incision.
Despite the low risk of complications from a retained On the other hand, if the fragment is within the spinal canal,
catheter fragment, a few reports document adverse effects. the risks and benefits for removal must be carefully weighed.
Ugboma et al [23] described the interesting case of a retained Magnetic resonance imaging of the spine has traditionally
intrathecal catheter. In this case, a 9-cm polyurethane been characterized as a poor choice for ferromagnetic
catheter had sheared off with uncoiling of the incorporated catheters because of metallic artifact as well as a risk of
wire. A CT scan showed the posterior catheter portion near neural damage secondary to heating of a wire-enforced
the spinous process of L4, with the anterior end terminating catheter in the epidural space [24]. There have been no
intrathecally at L3-L4. Despite a lack of motor or sensory documented cases of injury occurring secondary to MRI in a
deficits, the patient eventually underwent a laminectomy and patient with a sheared epidural catheter. Interestingly, a
catheter removal. patient with a sheared Racz catheter fragment (which is
Epidural catheter removal and review 313

ferromagnetic) lodged in the sacral canal had an uneventful possible; (5) attempting to remove in extreme flexion if the
MRI [29]. A similar case was reported in which an MRI was previous interventions are not efficacious; (6) attempting
used to identify a coiled epidural catheter abutting the L3 extension if flexion fails; (7) attempting removal after
nerve root without neurologic sequelae [23]. Nevertheless, injection of preservative-free normal saline through the
many clinicians do not advocate MRI as the first diagnostic catheter; (8) considering use of a convex surgical frame;
test because of the theoretical risk of thermal injury, (9) considering a CT scan to identify the etiology of
dislodgment, or movement [30,31]. entrapment; (10) considering leaving a retained epidural
It has been suggested that CT be used to analyze catheter in place in adult patients; (11) providing patient
entrapped catheters [32,33]. A CT scan would be preferable education regarding “red flags” to watch out for; and (12)
to fluoroscopy because of higher resolution, and if it is neurosurgical consultation for all cases in which the
available quickly, it may be the best test. If a CT scan is not catheter fragment is in the spinal canal.
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 References
in a water basin and scanned both by MRI and CT.
Interestingly, the catheter fragment was more easily visible [1] Asai T, Yamamoto K, Hirose T, Taguchi H, Shingu K. Breakage of
on CT scan, showing pronounced, high attenuation; on MRI, epidural catheters: a comparison of an arrow reinforced catheter and
other nonreinforced catheters. Anesth Analg 2001;92:246-8.
the catheter fragment was difficult to localize because it [2] Blackshear RH, Gravenstein N, Rodson E. Tension applied to lumbar
appeared hypointense on the T1- and T2-weighted images epidural catheters during removal is much greater with patient sitting
[24]. This study suggested that a CT scan may more clearly versus lying. [Abstract] Anesthesiology 1991;75:A833.
identify ferromagnetic sheared catheters than an MRI. [3] Boey SK, Carrie LE. Withdrawal forces during removal of lumbar
extradural catheters. Br J Anaesth 1994;73:833-5.
[4] Morris GN, Warren BB, Hanson EW, Mazzeo FJ, Di Benedetto DJ.
3.6. Suggestion Influence of patient position on withdrawal forces during removal of
lumbar extradural catheters. Br J Anaesth 1996;77:419-20.
The management of retained fragments within the spinal [5] Sia-Kho E, Kudlak TT. How to dislodge a severely trapped epidural
catheter [Letter]. Anesth Analg 1992;74:933.
canal is controversial. The fear of future development of
[6] Gadalla F. Removal of tenacious epidural catheter. Anesth Analg 1992;
infection has no support in the literature. Of the case 75:1071-2.
reports available, possible neurologic sequelae include [7] Shantha TR, Mani M. A simple method to retrieve irretrievable
direct mass effect on neural structures [23] and potential epidural catheters. Anesth Analg 1991;73:508-9.
fibrosis and cyst formation [22]. Neurologic sequelae seem [8] Start RJ, Greenberg DJ, Herman NL. Use of a Wilson Convex Frame
in removing “irretrievable” epidural catheters. Anesth Analg 1992;75:
to be more likely in cases in which the fragments are large
305-6.
enough to exert a direct mass effect on neural tissue. There [9] Pierre HL, Block BM, Wu CL. Difficult removal of a wire-reinforced
is only one case report with an intrathecal retained epidural catheter. J Clin Anesth 2003;15:140-1.
fragment; despite the lack of neurologic deficits, the patient [10] Browne RA, Politi VL. Knotting of an epidural catheter: a case report.
had decompressive surgery. Can Anaesth Soc J 1979;26:142-4.
[11] Ates Y, Yucesoy CA, Unlu MA, Saygin B, Akkas N. The mechanical
For small fragments that are sheared off into the epidural
properties of intact and traumatized epidural catheters. Anesth Analg
space but do not cause any direct mass effect on neural 2000;90:393-9.
structures, it may be reasonable to leave them in place. The [12] Blum S, Sosis M. A comparison of the tensile strengths of six types of
CT scan seems to be the best choice because MRI does not 20 gauge epidural catheters. Reg Anesth 1996;21(2 Suppl):81.
show epidural fragments as clearly [24]. In the population of [13] Bromage PR. Epidural analgesia. Philadelphia: WB Saunders; 1978.
p. 664-6.
patients with immediate neurologic sequelae, a follow-up CT
[14] Brown D, Gottumukkala V. Spinal, epidural and caudal anesthesia:
at 6 months and one year to monitor retained catheter anatomy, physiology and technique. In: Chestnut DH, editor. Obstetric
fragments and ensure that there is no evidence of granulation anesthesia: principles and practice. 3rd ed. Phildelphia: Elsevier
tissue formation is reasonable [17]. Mosby; 2004. p. 171-89.
[15] Perebin A. Hazards of local and regional anesthesia. In: Taylor TH,
Major E, editors. Hazards and complications of anesthesia. 2nd ed.
Edinburgh: Churchill Livingstone; 1993. p. 591-612.
4. Conclusions [16] Chun L, Karp M. Unusual complications from placement of catheters
in caudal canal in obstetrical anesthesia. Anesthesiology 1966;27:96-7.
[17] Blass NH, Roberts RB, Wiley JK. The case of the errant epidural
Based on our case and a complete literature review, we catheter. Anesthesiology 1981;54:419-21.
recommend: (1) using slow continuous force at all times; [18] Riegler R, Pernetzky A. Unremovable epidural catheter due to a sling
(2) discontinuing application of force if the catheter begins and a knot. A rare complication of epidural anesthesia in obstetrics.
Reg Anaesth 1983;6:19-21.
to stretch and reapplying traction several hours later; (3) [19] Lenox WC, Kost-Byerly S, Shipley R, Yaster M. Pediatric caudal
placing the patient in the same position as on insertion; (4) epidural catheter sequestration: an unusual complication. Anesthesiol-
placing the patient in the lateral decubitus position if ogy 1995;83:1112-4.
314 R. Mitra, K. Fleischmann

[20] Sakuma N, Hori M, Suzuki H, et al. A sheared off and sequestered chronic continuous intraspinal morphine infusion. A clinical and post-
epidural catheter: a case report. Masui 2004;53:198-200. mortem study. Pain 1985;22:337-51.
[21] Manchikanti L, Bakhit CE. Removal of a torn Racz catheter from [28] Remley KB, Blount JP, Erickson DL, Yue S. Spinal complications
lumbar epidural space. Reg Anesth 1997;22:579-81. from chronic indwelling intrathecal infusion catheters: MR imaging.
[22] DeArmendi AJ, Ryan JF, Chang HM, Liu LM, Jaramillo D. Proceedings of 32nd Annual Meeting. Am Soc Neuroradiol
Retained caudal catheter in a paediatric patient. Paediatr Anaesth 1994:122.
1992;2:325-7. [29] Perkins WJ, Davis DH, Huntoon MA, Horlocker TT. A retained Racz
[23] Ugboma S, Au-Truong X, Kranzler LI, Rifai SH, Joseph NJ, Salem catheter fragment after epidural neurolysis: implications during
MR. The breaking of an intrathecally-placed epidural catheter during magnetic resonance imaging. Anesth Analg 2003;96:1717-9.
extraction. Anesth Analg 2002;95:1087-9. [30] Sawyer-Glover AM, Shellock FG. Pre-MRI procedure screening:
[24] Staats PS, Stinson MS, Lee RR. Lumbar stenosis complicating retained recommendations and safety considerations for biomedical implants
epidural catheter tip. Anesthesiology 1995;83:1115-8. and devices. J Magn Reson Imaging 2000;12:510.
[25] Blanchard N, Clabeau JJ, Ossart M, Dekens J, Legars D, Tchaoussoff [31] Shellock FG. Radiofrequency energy-induced heating during MR
J. Radicular pain due to a retained fragment of epidural catheter. procedures: a review. J Magn Reson Imaging 2000;12:30-6.
Anesthesiology 1997;87:1567-9. [32] Dam-Hieu P, Rodriguez V, De Cazes Y, Quinio B. Computed
[26] North RB, Cutchis PN, Epstein JA, Long DM. Spinal cord tomography images of entrapped epidural catheter. Reg Anesth Pain
compression complicating subarachnoid infusion of morphine: case Med 2002;27:517-9.
report and laboratory experience. Neurosurgery 1991;29:778-84. [33] Moore DC, Artru AA, Kelly WA, Jenkins D. Use of computed
[27] Coombs DW, Franklin JD, Meier FA, Nierenberg DW, Saunders RL. tomography to locate a sheared epidural catheter. Anesth Analg 1987;
Neuropathologic lesions and CSF morphine concentration during 66:795-6.

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