Epidural catheter penetration of human dural tissue: in vitro investigation.
BACKGROUND
Factors contributing to subarachnoid catheter passage after epidural placement are not well understood. This study explored mechanisms that might explain its occurrence.


METHODS
Human cadaveric dura was mounted on a model and pressurized to physiologic levels. In a standardized fashion, a 20-gauge Portex three-port, closed end (nonflexible) tip catheter was passed through an epidural needle mounted on a micromanipulator at a 90 degree angle, attempting to penetrate dura with the catheter. Attempts then followed with a 19-gauge Arrow Flex Tip Plus single-port catheter. Subarachnoid catheter passage was compared in (1) intact dura, (2) clinically occult versus obvious epidural needle punctures, and (3) single 25-gauge Whitacre spinal needle punctures after combined spinal-epidural placement.


RESULTS
Neither catheter penetrated intact dura: Portex, 0 of 300 attempts (0.0000; 95% confidence interval [CI]: 0.0000, 0.0158); Arrow, 0 of 300 attempts (0.0000; 95% CI: 0.0000, 0.0158). In clinically occult epidural needle punctures, the 20-gauge Portex catheter penetrated 1 of 3 specimens in 1 of 14 attempts (0.0714; 95% CI: 0.0021, 0.3583). The 19-gauge Arrow did not pass (0 of 15 attempts, 0.0000; 95% CI: 0.0000, 0.2535). In clinically obvious epidural needle punctures, the Portex passed in 6 of 33 attempts (0.1818; 95% CI: 0.0760, 0.3608) and the Arrow passed in 1 of 35 attempts (0.0286; 95% CI: 0.0012, 0.1662). Neither catheter passed through a single 25-gauge spinal needle puncture after an uncomplicated combined spinal-epidural: Portex, 0 of 90 attempts (0.0000; 95% CI: 0.0000, 0.0510); Arrow, 0 of 90 attempts (0.0000; 95% CI: 0.0000, 0.0510).


CONCLUSIONS
Catheter passage is unlikely in the presence of intact dura or after an uncomplicated combined spinal-epidural. Unintentional subarachnoid passage suggests dural damage with the epidural needle.
Angle
Pamela J
PJ
Department of Anesthesia, Women's College Hospital Campus, Sunnybrook and Women's College Hospital, University of Toronto, Ontario, Canada. pamela.angle@sw.ca
Kronberg
Jean E
JE
Thompson
Dorothy E
DE
Duffin
James
J
Faure
Peter
P
Balasubramaniam
Shan
S
Szalai
John Paul
JP
Cromwell
Susan
S
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002404:Catheterization / Q000295:instrumentation* / Q000379:methods*; D004824:Epidural Space / Q000473:pathology / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013116:Spinal Cord / Q000473:pathology / Q000601:surgery; D013129:Spinal Puncture / Q000295:instrumentation / Q000379:methods; D013346:Subarachnoid Space / Q000473:pathology / Q000601:surgery