Management of Retained Epidural Catheter Fragments: A Narrative Review of Individual Patient Data

Figures

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  Figure 1. PRISMA flow chart for the systematic review detailing the database searches, the number of records screened, and the studies included.

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  Figure 2. Illustration of mechanistic pathways of epidural catheter fragmentation. Anatomical resistance was reported as a cause of catheter breakage. Key sites included the following: (1) spinous processes (e.g., Baastrup disease), (2) facet joints, and (3) ligamentum flavum or dura (created with BioRender.com).

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  Figure 3. Comparative detection of retained epidural catheter fragments across imaging modalities: (A) Heatmap showing detection rates (%) of various catheter materials across imaging modalities. MRI and CT achieved full detection for Teflon, polyurethane, and stainless-steel fragments, while polyamide and polyethylene showed poor visibility, particularly on X-ray. (B) Receiver-operating characteristic (ROC) curves comparing diagnostic performance. MRI (green) demonstrated the highest diagnostic accuracy (AUC = 0.859, cutoff = 70 mm), outperforming CT (blue, AUC = 0.611) and X-ray (red, AUC = 0.533).

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  Figure 4. Sankey diagram illustrating patient flow between conservative management, surgical intervention, and cross-over (initially conservative patients who later underwent surgery). Final outcomes are classified using modified MacNab Criteria into “Excellent” and “Good” categories. Only patients with complete outcome data were included in the visualization. (Created with SankeyMatic).

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  Figure 5. Illustrative case of catheter looping and consecutive breakage. (A,B) Three-dimensional CT reconstructions demonstrating a retained epidural catheter fragment (white arrows and red dashed line) with looping and entrapment at the interlaminar space, contributing to failed removal and subsequent breakage. (C) Sagittal T2-weighted MRI revealing the retained catheter fragment (red arrow) within the posterior epidural space, without evidence of significant spinal cord compression. (D,E) Axial CT images illustrating the fragmented catheter segment (red arrows) embedded in the epidural space, extending into the right neuroforaminal area. (F,G) Coronal and sagittal CT reconstructions confirming the catheter’s intralaminar positioning (red arrows), demonstrating intersegmental looping. The catheter follows a bi-segmental aberrant trajectory, which likely contributed to retrieval resistance and mechanical failure.

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  Figure 6. Flow chart of clinical management of broken epidural catheters (created with Lucidchart).