Case Presentation

30 year old G1P0 at 39w0d presenting for elective IOL requesting CLE

Medical history: Carrier of factor XI deficiency - factor levels 68% and no history of bleeding

Clinical course:

• Uneventful epidural placement with LOR at 5cm → catheter left at 10cm

• Epidural removal attempted 1hr postpartum by anesthesiologist, withdifficulty dislodging the catheter despite changing patient’s position

• Epidural catheter placed on traction overnight → attempts to remove it the following morning unsuccessful, but patient remained neurologically intact

• Neurosurgery consulted → recommended CT lumbar → L3-L4 midline catheter looping and possibly knotting in epidural space, distal tip intact

• Patient booked for microscopic foreign body removal under GA→noted with intact dura, lamina and ligaments → catheter removed in one piece albeit thinned, and patient had uneventful postoperative course

• Patient discharged home 2 days later and remained asymptomatic and neurologically intact at 1 month follow up

   

Teaching Points

• Prompt removal of a wholly entrapped epidural catheter is crucial to decrease the risk of infection or nerve injury

• Patient repositioning should initially be attempted, including lumbar flexion, extension and lateral flexion – ideally the same positioning as insertion

• Continuous, strong pulling should be avoided to protect catheter integrity

• If attempts are unsuccessful, the catheter should be placed on simple

  traction and secured to the skin under tension for several hours

• If difficulty removing the catheter persists, its anatomic location should be

  visualized with lumbar CT, alongside a neurosurgical evaluation

• MRI should be avoided if the catheter has metallic components, to avoid risk

  of thermal nerve damage

• For entrapped epidural fragments in asymptomatic patients, conservative management may be appropriate

• Care should be taken to counsel the patient throughout, providing updates and - when appropriate - reassurance and long-term follow up