title: Repeated failure of epidural analgesia: an association with epidural fat?
abstract: OBJECTIVE
  To report the case of a patient who experienced repeated failed epidural analgesia associated with an unusual amount of fat in the epidural space (epidural lipomatosis).
  
  
  METHODS
  A 44-year-old female presented for an elective small bowel resection. An L(1-2) epidural catheter was placed for postoperative analgesia. The patient gave no indication of having pain at the time of emergence from general anesthesia or in the first 2 hours in the recovery room. Assessment of the level of hypoesthesia to ice while the patient was comfortable in the recovery room suggested a functional epidural catheter (cephalad level of T(10)). Two hours after admission to the recovery room the patient began to complain of increasing pain. Another 6 mL 0.25% bupivacaine was administered via the catheter. The patient's pain decreased, but remained substantial, and there was minimal evidence of sensory block above the T(10) level. Subsequently, a T(10) epidural catheter was placed. Testing confirmed proper placement of the catheter in the epidural space at the T(10) level. A test dose of 5 mL 0.25% bupivacaine resulted in prompt and complete relief of the patient's pain. However, the level of hypoesthesia to ice did not exceed the T(10) level. Approximately 1 hour later the patient complained of increasing discomfort again. There was no evidence of any sensory block, and there was no response to a bolus of 8 mL 1% lidocaine. A thorough examination of the patient did not suggest any cause for the pain other than a malfunctioning epidural catheter. A third epidural catheter was placed at the T(8-9) level. This catheter was again confirmed to be in the epidural space with a test dose of 10 mL 0.5% bupivacaine. The level of hypoesthesia to ice was restricted to a narrow bilateral band from T(7)-T(9). Analgesia failed 2 hours later. The epidural catheter was removed and the patient's pain was subsequently managed with intravenous patient-controlled analgesia (PCA) morphine. A magnetic resonance imaging (MRI) scan revealed extensive epidural fat dorsal to the spinal cord from C(5)-C(7) and from T(3)-T(9). An imaging diagnosis of asymptomatic epidural lipomatosis was established.
  
  
  CONCLUSIONS
  We have described a case of repeated failure of epidural analgesia in a patient with epidural lipomatosis.
authors.affiliation: Departments of Anesthesia, Foothills Hospital, University of Calgary, Calgary, Alberta, Canada. scottalang@shaw.ca
authors.forename: Scott A
authors.initials: SA
authors.lastname: Lang
authors.forename: Peter
authors.initials: P
authors.lastname: Korzeniewski
authors.forename: Donald
authors.initials: D
authors.lastname: Buie
authors.forename: Stephan
authors.initials: S
authors.lastname: Du Plessis
authors.forename: Kimiko
authors.initials: K
authors.lastname: Paterson
authors.forename: Gary
authors.initials: G
authors.lastname: Morris
mesh_terms: D000273:Adipose Tissue / Q000473:pathology*; D000328:Adult; D016058:Analgesia, Patient-Controlled; D000767:Anesthesia, Epidural; D003424:Crohn Disease / Q000601:surgery; D004824:Epidural Space / Q000473:pathology*; D005260:Female; D006801:Humans; D007421:Intestine, Small / Q000601:surgery; D008068:Lipomatosis / Q000150:complications* / Q000473:pathology*; D008279:Magnetic Resonance Imaging; D010149:Postoperative Pain / Q000473:pathology; D017211:Treatment Failure