Epidural catheter rupture is one of the complications of epidural block in clinical anesthesia. Its risk is accompanied by the implementation of clinical anesthesia. Most female patients have no obvious symptoms or signs in the early stage[1, 5, 13]. Epidural catheter materials are all biologically compatible materials that have been verified by clinical safety experiments. Generally, foreign materials, even biologically compatible materials, in the body can be recognized by the immune system. The long-term retention of foreign materials in the body will result in the formation of an immune complex or inflammatory granuloma around the foreign material[6, 14]. Those patients without clinical symptoms do not need special treatment and can be clinically observed. When the patient shows symptoms of nerve compression or irritation or a foreign body stress response, it is too late to consider surgical treatment, as the difficulty and risk of surgery are significantly increased; thus, it is recommended to remove the residual catheter as soon as possible[7, 8]. Early routine surgery requires removal of the lamina, spinous processes, and articular processes of the corresponding segment to remove the broken catheter, which destroys the stability of the spine and requires the assistance of the pedicle screw rod system to maintain spinal stability[9, 15]. Therefore, conventional surgery is traumatic and expensive, involves heavy bleeding, and results in slow postoperative recovery and obvious pain in the operation area[14, 15]. These factors will inevitably lead to complaints from the patients and their families, who may resort to law and initiate a medical dispute[16]. Such events also obviously affect the daily work of anesthesiologists, leading to anxiety and frustration, which are not conducive to the growth and development of young anesthesiologists. Some large hospitals no longer even perform epidural anesthesia, and all operations are performed under general anesthesia, which not only prevents young doctors from gaining the basic operation skills of epidural puncture but also greatly increases medical costs and wastes medical resources.
In recent years, due to the wide application of spinal endoscopy technology and the rapid development of minimally invasive spinal surgery and medical imaging, the level of percutaneous minimally invasive endoscopy technology in the diagnosis and treatment of spinal diseases has improved significantly[17, 18]. From the cases in this study, it can be seen that the percutaneous, fully endoscopic technique can be used to safely remove the residual epidural catheter, with significantly reduced iatrogenic injury and medical expenses compared with conventional surgery, and can even avoid the potential resulting medical disputes. Epidural catheter rupture has a very low incidence and mostly occurs at primary hospitals. Our hospital admitted a total of 7 cases in 4 years from 7 different hospitals; accidents are more common among young people who have been employed for approximately 2 years as anesthesiologists. During communication with the patient before the operation, inform the patient that the dural catheter may rupture during the anesthesia operation but that even in this case, it can be removed by a percutaneous endoscopic technique, which has no obvious impact on the patient's recovery. Patients and their families can generally recognize and understand the risk. The SAS scores of the patients and operating doctors show that with successful removal of the residual catheter by endoscopic surgery, the patient's recovery was smooth, the SAS scores of both the patient and doctor significantly decreased, and a positive and healthy outlook was obtained. At present, the commonly used epidural catheters are difficult to identify on imaging, which leads to a lack of objective imaging data for surgical judgment. Although there are epidural catheters containing steel wires for clinical use, which can reduce the probability of epidural catheter rupture and increase the recognition of the epidural catheter on imaging after rupture, due to the high cost, they have not been popularized in clinical practice[19, 20]. In anesthesia by epidural block, a channel is created for the bolus injection of local anesthetics. It can also be used for lumbar cistern drainage in neurosurgery patients. Epidural catheters are even used during the infusion of cryoprecipitate and platelets into the amniotic cavity to treat premature rupture of fetal membrane and oligohydramnios in pregnant women[21, 22]. This approach provides a new perspective on the use of epidural catheters, prompting clinicians to understand the application and clinical value of epidural catheters and better use this clinical device[22, 23, 24].
Clinical anesthesia complications and anesthesia practice go hand in hand. How to minimize the risks and complications of anesthesia is an eternal topic of clinical anesthesia safety and quality control[1, 4, 7, 8]. According to the relevant literature and subjective experience, the following points merit attention: First, when it is difficult to place the epidural puncture catheter, care should be taken to remove the epidural catheter together with the puncture needle and avoid withdrawal of the tube first and then the needle. Second, it is recommended to use a reinforced epidural catheter when inserting a catheter for epidural block. Third, the catheter and the puncture needle arc should be kept close during puncture of the epidural space to minimize the possibility of the puncture cannula damaging the catheter during tube placement[25]. Fourth, when removing the epidural catheter at the end of the operation, the applied force should be moderate and stable, and the catheter should not be forcibly removed[26]. Fifth, when catheter removal is difficult, the patient should be assisted in returning to the puncture position for trial removal, and a deep vein puncture needle should be used to remove the epidural catheter if necessary[27]. Sixth, the operator should not panic if the epidural catheter ruptures and partially remains in the body; the family of the patient should be informed in a timely manner, and the spine endoscopist should be contacted for the removal operation, or the operator should wait for the patient to stabilize and then perform endoscopic surgery to remove the broken catheter[28]. Seventh, it is necessary to grasp the relevant knowledge and the process of the diagnosis and treatment of foreign bodies in the spinal canal to minimize the medical risks, iatrogenic injuries and risks for complications to ensure the safety and normal practice of clinical medicine.
The percutaneous endoscopic removal of a residual epidural catheter is of great clinical significance. The following points should be grasped when implementing the percutaneous spinal endoscopic technique: 1. Localization of residual tube: Accurate localization is the basis of a successful operation. A detailed understanding of the previous operation and the length of the residual tube is essential for judging the location of the broken end of the catheter in the body. 2. CT and MRI examination of the lumbar spine: When using an ordinary epidural catheter, the remaining catheter is difficult to identify and can only be determined according to the specific conditions of the anesthesiologist's operation. If an enhanced epidural catheter is used, CT and MRI examinations can allow identification of the residual catheter. 3. Positioning of the surgical path based on the clear puncture gap, direction of the catheter, and length of the residual tube. Correctly determining the location of the residual broken tube in the body and applying the correct method to locate the residual tube are keys to the success of the operation. As shown in this study, the percutaneous endoscopic technique causes minimal trauma, has a high success rate, and is easy for patients and their families to accept. It can relieve patients' worries, improve patients' physical and mental health, and help prevent medical disputes. The shortcomings of this study are the small number of cases and the lack of cases involving the thoracic spinal canal, long-term residual catheterization and granuloma formation around residual catheters. More clinical studies are needed.