Title:
Epidural catheter breakage during insertion; a cause of failed epidural?
Author(s):
Serchan P., Panteleou K., Tzima M., Zaimi D., Katsanoulas K., Katsika E.
Institute(s):
Hippokratio General Hospital of Thessaloniki, Dept of Anaesthesiology, Thessaloniki, Greece

Background: Epidural catheter breakage during insertion is a rare but worrisome complication. Guidelines for the prevention of the complication exist, but recommendations regarding whether or not a new epidural catheter should be placed are lacking. 
Case report: Epidural catheter placement was required for labor analgesia of a primigravid parturient 30-year-old, 1.73-cm and 86-kg. Loss of resistance with air technique was used at the L3-L4 space in the sitting position. The epidural space was identified at 4 cm from the skin with a 18-gauge Tuohy needle.The catheter was advanced up to 9 cm after which resistance was encountered. It was then decided to remove the catheter through the needle, when a tear of about 3mm X 0,4mm at the catheter's radio-opaque tip was noticed. The Tuohy needle was removed and the process stopped. Surgeon and patient were informed. Neurological examination was normal. After labor, X-rays of lumbar spine in antero-posterior and lateral position were unable to detect the retained catheter. Neurosurgeon suggested a CT and MRI scan, but the fragment was again not visualized. The patient remained asymptomatic and was informed to report any adverse symptoms in the future.
Discussion: In order to prevent epidural catheter breakage the equipment must be examined before placement for manufacturing defects. During placement, when resistance is encountered excessive force should be avoided, the catheter should be withdrawn along with the needle and the maximum length in the epidural space should be 5 cm. When the catheter breaks, imaging exams are not helpful in locating the catheter. The fragment remains in place as long as there are no neurological symptoms. Reviewing the literature epidural catheter placement has been performed after breakage, uneventfully, at another inter-vertebral space in awake, asymptomatic patients.
References: 
1. Üşar P, Kar AA, Çıtak G, Maral J, Canlı Ş. Breakage of an epidural catheter inserted for labor analgesia.Turk J Anaesthesiol Reanim.2015 Aug;3(4):282-4.
2. Ritu S, Zia Α, Ravi P, Karthik P,Brijbihari Κ. Broken epidural catheter; a rare complication. Journal of Case Reports in Practice(JCRP). 2014; 2(3): 72-73.
Learning Points: If the catheter breaks during placement, the patient should be informed. If asymptomatic, it is safe to leave the fragment in place. It seems that epidural anesthesia can be performed at another inter-space in awake, asymptomatic and well-informed patients after obtained consent.