The patient gave written informed consent for publication of this case report and any accompanying images, and the presentation was approved by the institutional review board of Juntendo University (JHS 18-027).
A 67-year-old male, 170 cm tall, weighing 72 kg, was scheduled to undergo left lower lung lobectomy via open thoracotomy for non-small cell lung carcinoma. He had no relevant medical history, and his preoperative blood examination revealed no abnormal findings. We decided to preoperatively insert a thoracic epidural catheter for postoperative analgesia.
On the day of surgery, no premedication was administered. He was monitored by ECG, noninvasive blood pressure monitoring and pulse oximetry. Before general anesthesia induction, the patient was positioned in the right lateral position for catheter insertion. We initially attempted the epidural puncture at the thoracic (Th) 6–7 interspace, which we changed to the Th 5–6 interspace after 15 min due to difficulty in an epidural puncture at the original site. Using a right paramedian approach, an 18 G Tuohy needle (Perican® epidural needle, 18G × 80 mm, B. Braun, Hessen, Germany) was used for epidural puncture 1 cm caudal and 1 cm to the right of the spinous process. After confirming accurate placement of the needle tip in the epidural space by the loss of resistance to injection of normal saline, the epidural catheter (Perifix® epidural catheter, standard 1000 mm, B. Braun) was inserted via the Th 5–6 intervertebral space with no resistance. The final total insertion length was 13 cm: 6 cm through the skin and 7 cm placed in the epidural space. After the catheter was appropriately secured in place, the patient was turned to the supine position in preparation for general anesthesia. Before general anesthesia induction, we gave a test dose of 2 ml of 2% plain lidocaine via the epidural catheter, followed by administration of 50 μg fentanyl and 4 ml of 0.25% levobupivacaine. We were able to confirm the loss of cold sensation around the left T5 area 5 min after local anesthetic administration. After induction of general anesthesia, endotracheal intubation with a double-lumen tube was performed to enable single lung ventilation during surgery.
At the beginning of surgery, an approximately 12- cm posterolateral incision was made at the level of the fifth to sixth intercostal space. Blood pressure and heart rate remained stable, suggesting the adequacy of analgesia in the incision area. However, when the surgeon opened the thoracic cavity, he saw the epidural catheter below the fifth rib. The catheter seemed to follow the course of the intercostal nerve. The tip of the catheter could be seen 3 cm from the dorsal edge of the incision (Fig. 1a, b).
Fortunately, the catheter had not been severed during the surgical procedure. After discussion with the surgical team, we decided to withdraw the catheter via the skin of his back under direct observation by the surgeon in the surgical field. The catheter was successfully withdrawn and examined for intactness of the tip. Thereafter, intraoperative analgesia was achieved mainly by continuous intravenous infusion of remifentanil and intermittent administration of fentanyl. For postoperative analgesia, a continuous intravenous infusion of 1 mg (20 ml) fentanyl and 20 ml normal saline was administered as patient-controlled analgesia (PCA) at the rate of 1 ml/h, with bolus doses of 1 ml and a lockout time of 10 min, the infusion being commenced in the latter half of surgery. The scheduled surgery was completed uneventfully without any complications.
We also performed TPVB under ultrasound guidance, injecting 20 ml of 0.25% levobupivacaine in the paravertebral space, besides the Th5 transverse process, before the patient’s emergence from general anesthesia and while he was still in the lateral position.
Anesthesia emergence and his subsequent recovery from anesthesia were uneventful. During the postoperative period, his numerical rating scale score ranged from 0 to 1 and he required a single administration of supplemental analgesic (15 mg pentazocine) and six IV PCA boluses within 24 h. He did not complain of any paresthesia around the intercostal region. He was discharged from the hospital without any paresthesia or complications on the fifth day after surgery.
