Management of a Broken Epidural Catheter
If an epidural catheter breaks during removal, immediately inform the patient and obtain imaging (CT with sagittal/coronal reconstruction or MRI) to localize the fragment, then pursue conservative management with close monitoring for asymptomatic patients, reserving surgical removal only for those who develop neurological symptoms or signs of infection. 1, 2
Immediate Actions When Breakage Occurs
Stop all attempts at further manipulation of the catheter once resistance is encountered or breakage is suspected, as continued traction can worsen the situation. 2, 3
Inform the patient immediately about the complication with transparent communication about the management plan and potential outcomes. 1, 2
Document thoroughly the imaging findings, clinical assessment, and rationale for your management decision in the medical record. 1
Diagnostic Imaging Protocol
Obtain CT scan with sagittal and coronal reconstruction as the primary imaging modality to visualize the retained catheter fragment and determine its precise location. 2
MRI can be used as an alternative or adjunct, though visualization of retained catheters remains difficult even with current radiological techniques. 2, 4
Determine whether the fragment is intrathecal, epidural, or outside the spinal canal, as this critically influences management decisions. 1
Risk Stratification and Management Algorithm
Conservative Management (Preferred for Most Cases)
Conservative management is appropriate when:
- The fragment is definitively outside the spinal canal on imaging 1
- No residual catheter breaches the skin 1
- The patient remains completely asymptomatic 1
- Close clinical follow-up can be ensured 1
The rationale for conservative management is that large retrospective reviews in obstetric patients have failed to identify cases of permanent neurological complications from retained intrathecal catheters, though the retained foreign body does create a potential nidus for infection. 1
Mandatory Daily Monitoring
Evaluate daily for signs of infectious or neurological complications, including:
- Fever, back pain, or worsening headache 1
- Erythema, tenderness, or drainage at the insertion site 1
- New radicular symptoms, motor weakness, or sensory changes 1
- Signs of meningitis (neck stiffness, photophobia, altered mental status) 1
If any signs of infection develop, immediately obtain blood tests and blood cultures, with consideration for CSF analysis if meningitis is suspected. 1
Surgical Intervention Indications
Surgery is reserved for:
- Patients who develop neurological symptoms or signs 2, 5, 3
- Fragments located in the subarachnoid (intrathecal) space 3
- Catheter tip emerging from the skin 3
- Signs of infection despite medical management 1
- Asymptomatic patients where removal is desired to prevent future complications (controversial) 2
Timing of surgical intervention matters: If surgery is indicated, it should be performed before significant adhesion develops, as adhesions make removal more difficult and increase complication risk. 4, 5
Minimally invasive spinal surgery (MISS) techniques can be employed by experienced surgeons, typically involving laminotomy at the appropriate level to retrieve the fragment. 4
Prevention Strategies (Critical for Future Cases)
Never insert the catheter more than 5 cm into the epidural space, as deeper insertion increases breakage risk during removal. 3
For intrathecal catheters specifically, advance only 2-4 cm into the subarachnoid space to minimize migration and dislodgement while reducing breakage risk. 6
Never withdraw the catheter through the Tuohy needle if resistance is encountered, as this is the most common mechanism of catheter shearing. 2, 3
If resistance is met during removal, withdraw both the catheter and needle together as a single unit. 2, 3
Use catheters with radiopaque materials to improve visualization on imaging if breakage occurs. 2, 3
Key Clinical Pitfalls to Avoid
Do not attempt repeated manipulation or traction once breakage is suspected, as this can fragment the catheter further or cause it to migrate. 2, 3
Do not reassure the patient that "follow-up is enough" without establishing a concrete monitoring plan with specific warning signs, as infections can develop and adhesions can complicate later removal if needed. 5
Do not delay imaging to confirm the location and extent of the retained fragment, as early localization guides all subsequent management decisions. 2, 4
Reinforced epidural catheters with coiled stainless steel wire are paradoxically more vulnerable to breakage compared to non-reinforced catheters, despite being marketed as more durable. 7