Rare Image of Epidural Catheter Fracture in Lumbar Analgesia

Objective Accidental fracture of epidural analgesia catheters has a very low incidence of 2.5 per 100,000 anesthesia. A rare image of the fracture is reported. Methods A 42-year-old female patient was attending a cesarean section eight years earlier to her consult. In the cesarean section, she received regional epidural anesthesia, and the main complaint was low back pain, specifically between the spinous processes L2 and L3. The somatic pain had been presenting intermittently for eight years. The sagittal section of magnetic resonance imaging of the lumbar spine showed a “golf club” image from the midline to the laminae of L2 and L3 with the subcutaneous tissue. Results A small right hemilaminectomy was performed to remove the complete catheter, which did not adhere, but was coiled in the S-shape. The catheter was trapped between the left facets of L2 and L3 laterally than through the midline. Several risk factors and therapeutic procedures have been proposed. Conclusion In a systematic review, 24 articles were reported on this specific issue. No surgical procedure and follow-up were informed by 8 authors. Surgical remotion by laminectomy was used in 9 articles, surgical explanation by skin incision was reported by 4 authors, and remotion by endoscopy was reported in 1 article. Two articles not reported solution.


Introduction
Complications derived from regional anesthetic procedures in the lumbar spine are rare.One of these complications is the accidental fracture of epidural analgesia catheters.Tis eventuality has been informed in regional anesthesia with a very low incidence of 2.5 per 100,000 anesthesia [1,2].Te epidural regional anesthesia technique has been used since the beginning of the 20th century [1].Te material used to elaborate the catheters is diverse, including nylon, polyethylene, polyurethane, and polyamide.Since 2015, the manufacture of steel guides [2,3] has begun.
Tis fracture is mainly due to the accidental excessive use of force when extracting the epidural tip.Visualization of catheters by a simple radiographic study has been reported, but this does not always occur.Extraction procedures have ranged from minimally invasive extraction to laminectomy approaches.Te solution carries out within 24 hours to a maximum of years [4][5][6][7][8].
Tis article presents the case of a patient who underwent surgery with a diagnosis of lumbar granuloma with an inconclusive magnetic resonance image that was secondary to the presence of an epidural catheter accidentally left eight years ago.

Case Report.
A 42-year-old female patient was attended by the neurosurgery service of Hospital Ángeles Pedregal in Mexico City.She had a signifcant history of hypothyroidism already treated with thyroid hormone and a cesarean section eight years earlier to her consult.In the cesarean section, she received regional epidural anesthesia.On this occasion, the main complaint was low back pain, specifcally between the spinous processes L2 and L3.Te somatic pain had been presenting intermittently for eight years.Te frequency and intensity of this symptom were increasing.So she sufered almost daily for a few minutes and during exercise.In the beginning, the pain was evaluated with a Visual Analog Score (VAS) of two and resolved with nonsteroidal antiinfammatory analgesics.Tere was a mild increase in volume in the lumbar region with painful sensation in the spinous processes L2 and L3.On general examination, neurologic exploration was normal.
Te catheter was not visualized by a simple X-ray image and did not show other alterations.Te sagittal section of magnetic resonance imaging (MRI) of the lumbar spine showed a "golf club" image from the midline to the laminae of L2 and L3 to the subcutaneous tissue (Figure 1).In the axial projection, a similar image of a collection of approximately 25 mm in diameter was observed.Tese images were hypointense on T1 and hyperintense on T2.Any additional alterations were found within the spinal canal or intrathecal space.Either alteration was shown in the neuronal structures.A probable dermal sinus or granuloma of unknown etiology was a possible diagnosis.A surgical midline exploration or granuloma resection was suggested to the patient, but she refused it.Te physicians ask her to keep a monthly follow-up and repeat MRI in six months.Te patient came back one year after; the pain had been increased to a VAS rating of four and in frequency.

Results
On this occasion, spine surgery was performed with a midline approach, gradually dissecting the lesion that was observed as gray-looking fbrosis from the subcutaneous region to the laminae of the vertebral body.One anesthetic perfusion catheter was found 10 mm outside of right recess (Figure 2).Tis catheter was continued into the epidural space for further 60 mm.A small right hemilaminectomy was performed to remove the complete catheter, which did not adhere, but was coiled in the S-shape (Figure 3).Te catheter was trapped between the left facets of L2 and L3 laterally than through the midline.
Once the catheter was explanted, hemostasis was verifed.Several samples for the culture were taken, and the surgical wound was closed by surgical planes.Te patient was followed up three years later without complications or additional symptoms.

Discussion
In this review, we found 17 articles where this complication was reported (Table 1).Several risk factors and therapeutic procedures have been proposed.In addition, no surgical procedure and follow-up were informed by 8 authors.Surgical remotion by laminectomy was used in 9 articles, surgical explanation by skin incision was reported by 4 authors, and remotion by endoscopy was reported in one article.Two articles did not report solution.Te median length of the catheter was 7.76 ± 5.45 cm.Local or neurological symptoms were reported in 8 articles.
In medicine, complications are always present in different spheres/stages.Regional anesthesia catheters can be broken accidentally during an anesthetic procedure.Te reported cases range from 0.002 to 0.04% [24] or 0.000025% [1].If the material is radiopaque, it facilitates localization in the immediate perioperative period, but in daily practice, their sections may be unnoticed and the material with which they were made may not be radiopaque.
It is considered that the fragmented catheter is inert and should not produce a reaction to a foreign body in the epidural space, but some studies reported infammation after three weeks [1,5].Case Reports in Anesthesiology Most of the reports that have been consulted report that the complication of catheter fracture resolves in hours or days [10,11].
Diferent ways to solve the problem have also been recommended, and there is even a current study that advocates not to perform a maneuver in the frst instance and that the patient shall only be medically supervised; depending on the clinical evolution, an intervention is performed [1,3,10,13].
Complications have already been described and include pneumocephalus, abscesses, meningitis, neuropathy due to direct damage, dural tears, inadvertent administration of drugs intrathecally, arterial hypotension, ventilatory depression, and lack of sphincter control.Other more bizarre complications have been reported.For example, Tarukado reported broken catheter migration after four weeks [23].
Te risk of rupture has been associated with degenerative changes in the spine that include foraminal stenosis, spondylolisthesis, hypertrophy of the ligamentum favum, and a history of facetography [18].Te catheter can become trapped close to the ligamentum favum, the posterior longitudinal ligament, the intervertebral foramen, pedicles, or the articular facets [18,24].
To prevent this type of complication, it is suggested that the needle be checked so that it does not have imperfections at the tip and that the resistance of the catheter is adequate.In addition, it is recommended not to introduce the catheter more than 4 -5 cm into the epidural space to avoid rolling, twisting, or knotting [26].Te most vulnerable site for rupture is between 7 and 8 cm.Tis length is considered that when introducing more than 4 cm into the epidural space, there is a risk of knotting.
When a patient reports pain when withdrawing the catheter, nerve root avulsion may occur.So this catheter should be explanted under direct vision.
Te symptoms most frequently associated with a catheter fracture are headache, local pain, and those that could be caused by nerve injury [18,24].
Various procedures have been suggested in the literature [17,26] to remove a catheter that is difcult to remove and thus prevent its rupture.For example: (i) We place the patient in the same position that was punctured and wait from 15 to 30 minutes and then apply a slow and continuous extraction force, the force applied should be between 130 and 1000 gr to prevent it from breaking.Some authors report that the rupture can be produced from 2.6 kg.(ii) Te patient can be subjected to sedation to facilitate muscle relaxation.(iii) Physiological saline solution be applied through the catheter trying to free the tube and eliminate probable twists.(iv) Te Tuohy needle be applied parallel to the catheter, and then, we try to pull the catheter together with the needle.(v) A CT scan of the spine be performed to fnd out the cause of the entrapment.(vi) It is suggested that the patient be subjected to general anesthesia to achieve muscle relaxation and position him in the same position in which the catheter was inserted.
From the surgical point of view, diferent surgical techniques have also been evaluated, including the removal of the foreign body by endoscopy and laminectomy.Regardless of the technique used to insert or remove the catheter, the patient's cooperation and catheter quality are factors that can infuence rupture.If there are no symptoms, it is recommended not to remove the retained catheter, as this is not well documented, and the catheter can migrate and cause distant lesions.
Catheters of nylon or polyurethane 20 G are safer than tefon catheters 19 G because the last one has tendency to break during traction [2].
Te other suggestion to avoid rupture of the catheter could be avoid getting approach parallel to or away from midline because this pathway increases the risk of rising lateral spine joints.Surgical sutures should not be used around the catheter.We should avoid introducing the catheter more than 5 cm into the peridural space.It is recommended to use nylon or reinforced polyurethane catheters.Te catheter should not be removed if the puncture needle is still inserted because it increases the risk of rupture.
Te present case only follows the case reported by Pinciroli with a catheter retained for 12 years, in which the catheter did not cause discomfort and was detected as it was radiopaque [22].In this paper, the case presented a local infammatory process that manifested itself eight years after the anesthetic procedure, a very characteristic and unusual image that can help other professionals to suspect the presence of this type of foreign body.

Immediately
Most frequent management is surgical remotion in perioperative time.However, in some cases, warming is late.

Case Reports in Anesthesiology
Tere are few publications about this anesthetic complication, but general information is common for location, time of diagnosis, and symptomatology.Posterior medical management includes several procedures.In Table 1, a compilation of papers is shown.

Conclusion
Fracture of the epidural catheter is an infrequent complication in regional anesthesia.Diferent brands have been associated with this side efect.A rare image in a golf club form is shown as chronically epidural catheter fractured, and the revision of the literature reported invasive and noninvasive managements.

Figure 1 :
Figure 1: Sagittal magnetic resonance image of the lumbar spine in T2 sequence showing a hyperintense image like a "golf club" (arrow) from subcutaneous tissue between the spinous processes of L2-L3 through the interspinous ligament.

Figure 2 :
Figure 2: Approach to the lumbar region where the catheter (arrow) is partially observed between the processes of L2 and L3.It appears to be directed along the midline but is lateralized to the left of the facets.

Figure 3 :
Figure 3: Photograph of the extracted catheter with an "S" shape and more than 12 cm in length.Te bar in the fgure has a length of 6 cm.

Table 1 :
A list of levels and symptoms involved in accidental fracture of epidural catheters and the ways of treating them.