Partial displacement of epidural catheter after patient position change: A case report

Epidural catheter migration is a well-known cause of failed anesthesia and complications. One of the factors that affect catheter movement is when patients change their position after skin fixation. We report a case of an epidural catheter placed without evidence of intravascular or subdural insertion that produced an insufficient block. A 36-year-old woman presented for ankle surgery under epidural anesthesia. Epidural block was conducted at the L3-4 intervertebral space with a catheter threaded 3 cm into the epidural space with the patient in a back flexion and lateral position. The total volume of injected anesthetic was 28 mL, including a 3-mL test dose. The final anesthesia level was L1. The planned operation was completed without a pneumatic tourniquet. A postoperative C-arm fluoroscopic image revealed that 1 side hole of the catheter had moved out of the epidural space. We think that a positional change after catheter fixation was the reason for catheter outmigration leading to insufficient analgesia, which was incompatible with the amount of local anesthetic injected.