Biportal endoscopic spinal surgery for removal of retained epidural catheter fragment: A case report

INTRODUCTION

Epidural catheter fracture is a rare but clinically significant complication of epidural anesthesia, with an incidence of 0.002–0.04%.^[1,2] Retained catheter fragments may cause dural adhesions, fibrosis, granuloma formation, hematoma, infection, radiculopathy, neurological symptoms, or considerable patient anxiety.^[3,4]

Management of retained fragments remains controversial, ranging from conservative observation in asymptomatic patients to surgical removal for symptomatic cases or longer fragments.^[3,4] However, a recent systematic review found that nearly 40% of patients initially managed conservatively ultimately required surgical removal.^[3] The optimal timing and surgical technique remain debated, particularly in younger patients who face a prolonged lifetime risk of delayed complications.

Advances in minimally invasive spinal surgery, particularly biportal endoscopic spinal surgery (BESS), have expanded surgical options for retained epidural catheter fractures. BESS provides direct visualization and safe extraction with minimal tissue trauma, shorter operative time, and faster recovery.^[5,6]

We report a case of a 7-cm retained epidural catheter fragment successfully retrieved with BESS after cesarean delivery, demonstrating the safety and efficacy of early minimally invasive intervention.

CASE REPORT

A 31-year-old woman at 36 weeks and 2 days of gestation was scheduled for cesarean delivery under epidural anesthesia. Epidural anesthesia was initiated at the L2–L3 interspace using an 18-gauge Tuohy needle. The epidural space was identified at 5 cm depth, and a multi-hole epidural catheter (Perifix^® Soft Type 700 filter set; B. Braun, Melsungen, Germany) was advanced to 15 cm at the needle hub.

Before test-dose administration, aspiration revealed blood. The catheter was withdrawn, the needle bevel rotated caudally, and the catheter was reinserted to 15 cm. When the catheter was retracted to adjust depth while the needle remained in place, a subtle scratching sensation was noted. With gentle traction, the catheter suddenly broke, leaving approximately 7 cm of the distal catheter tip in the epidural space. The cesarean section was completed uneventfully using spinal anesthesia.

Postoperatively, the patient had no neurological deficits or back pain. Plain lumbar radiographs failed to identify the catheter fragment. Lumbar computed tomography revealed the fractured catheter in the right posterolateral epidural space at the L2–L3 level [Figure 1]. After a multidisciplinary discussion, endoscopic removal was recommended due to the fragment’s length and the potential risk of delayed complications in this young patient.

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Figure 1:

Computed tomography images showing the retained epidural catheter fragment. (a) Coronal, (b) Sagittal, and (c) Axial views at the L2–L3 level. White arrows indicate the fractured catheter in the right posterolateral epidural space.

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After confirming hemodynamic stability and wound integrity, a pre-operative trial on a Wilson frame verified patient tolerance without discomfort. On post-operative day 2, under general anesthesia, the patient was positioned prone on the frame with abdominal decompression and padding to protect the surgical wound. BESS was performed, and the L2–L3 interlaminar space was identified fluoroscopically. Two 8 mm skin incisions were made, and a full endoscope (Arthrex, Inc., Naples, FL, USA) was introduced with continuous saline irrigation. After partial removal of the ligamentum flavum, the fractured catheter tip was immediately visualized [Figure 2a]. The fragment appeared intact, without adhesion to neural structures or compression of the dural sac. Using an endoscopic hook, the catheter was removed as a single unit without difficulty [Figure 2b]. The retrieved fragment measured approximately 7 cm and showed a sharply sheared edge [Figure 3]. No neural or dural injury occurred during the procedure. Total operative time was 41 min with estimated blood loss of 10 mL.

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Figure 2:

Intraoperative endoscopic views. (a) The fractured catheter tip identified in the epidural space. (b) Removal of the fractured catheter tip using an endoscopic hook under biportal endoscopic spinal surgery. Dark areas indicate caudal direction.

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Figure 3:

The retrieved epidural catheter fragment measuring approximately 7 cm in length. The white arrow indicates the sharply sheared end of the catheter, magnified in the inset. Epidural fat was found adherent to the retrieved catheter tip.

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There were no intraoperative or postoperative complications. The patient ambulated on post-operative day 1 after BESS and was discharged on post-operative day 4 without symptoms. At 6-month follow-up, the patient remained asymptomatic with no evidence of infection, radiculopathy, or other complications.

DISCUSSION

Epidural catheter breakage may occur through kinking, knotting, impingement against bony structures, or shearing at the Tuohy needle bevel.^[1,7] Manufacturing defects and material weakening from prolonged exposure to body temperature may also compromise catheter integrity.^[8] In this case, a fracture occurred during catheter retraction through the indwelling needle after bevel rotation, a well-recognized mechanism of shearing injury.^[1,7] The 7 cm fragment at L2– L3 showed no entrapment or knot formation, supporting a mechanical mechanism.

To reduce the risk of catheter fracture, catheter withdrawal or adjustment with the Tuohy needle in situ should be avoided, as bevel-catheter contact may cause shearing.^[1] If repositioning is needed, removing the needle and catheter together is recommended.^[1] During removal, resistance should prompt reassessment rather than the use of excessive traction.^[7]

The management of retained epidural catheter fragments has traditionally favored conservative observation in asymptomatic patients, based on the assumption that catheter materials are biologically inert.^[4] However, delayed complications such as chronic back pain, radiculopathy, infection, fragment migration, and adhesions have been reported even years after the initial injury.^[1,4,9]

For patients with a long expected lifespan, the risk-benefit balance may favor early surgical intervention as the cumulative lifetime risk of complications may exceed the short-term surgical risks. Intraspinal positioning significantly increases the risk of adhesion^[4] and longer fragments show a stronger association with the need for surgical intervention.^[9] In addition, prolonged observation entails repeated imaging and persistent anxiety, whereas progressive adhesion formation reduces the likelihood of safe removal. Early intervention may therefore be preferred in selected patients. Traditional open laminectomy requires extensive muscle dissection and bone removal with associated risks of postoperative pain, infection, and spinal instability.^[10] Minimally invasive options include uniportal full-endoscopic and biportal endoscopic techniques. BESS provides direct magnified visualization through small incisions, enabling precise fragment localization with minimal tissue disruption.^[5,6] We selected the biportal approach to facilitate instrument triangulation and bimanual manipulation near neural structures.^[5,6]

While lateral decubitus positioning was considered, we selected the prone position to optimize instrument triangulation and stability. Safety was ensured by the pre-operative tolerance trial, abdominal decompression using a Wilson frame, and minimizing operative duration. The absence of adhesions suggests removal before tissue attachment develops.^[4] Early endoscopic removal may facilitate rapid recovery and reduce the complexity of delayed surgery.

CONCLUSION

BESS provides a safe and minimally invasive option for removing retained epidural catheter fragments. Early surgical removal is recommended, particularly in patients with intraspinal fragments, longer catheter lengths, or long expected lifespan, to prevent adhesion-related complications and reduce the burden of long-term observation.