The use of neuraxial blockade in patients with preexisting spinal stenosis, lumbar disk disease, or prior spinal surgery is controversial [1]. Furthermore, the efficacy of neuraxial analgesia with spinal canal pathology varies, with some reports showing a higher failure rate of analgesia and others showing comparable rates [1,2,3]. The spread of anesthetic solutions can be unpredictable in patients with lumbar epidural adhesions. Consequently, placing a second epidural catheter has been used to manage inadequate analgesia in women with spinal pathology [4, 5].

Therefore, we present a case in which catheter withdrawal played a critical role in achieving effective labor analgesia in a woman with epidural adhesions after lumbar discectomy who had inadequate analgesia with two epidural catheters.

A 29-year-old gravida 2 para 1 woman with a normal pregnancy presented for labor induction with neuraxial analgesia at 38 weeks and 4 days of gestation. She had not received epidural analgesia for her previous delivery. Her medical history included failed back surgery syndrome after L4/5 discectomy, with no neurologic deficits other than back pain. Epidurography conducted 1 year before the delivery showed an epidural adhesion cephalad to the upper one-third of the L5 vertebra (Fig. 1) and confirmed the absence of the sixth lumbar vertebra.

Epidurography 1 year before delivery. Epidurography showing a filling defect above the upper third of the L5 vertebra. The arrow shows a catheter inserted into the sacral hiatus for a contrast injection

We predicted that local anesthetic solutions administered from L3/4, where we usually place epidural catheters for labor analgesia, would not spread to the sacral epidural space; therefore, we planned to place two epidural catheters: one cephalad (L1/2) and another caudal (L5/S) to the epidural adhesion. Moreover, a dural puncture epidural technique was planned for caudal epidural catheter placement to accelerate sacral analgesia onset.

Labor was induced with oral prostaglandin E2 and intravenous oxytocin. After labor onset, two closed-end catheters with three lateral holes (Perifix™ SoftTip Catheter, B. Braun, Tokyo, Japan) were inserted 4 cm cephalad into the epidural space at the L1/2 and L5/S intervertebral spaces, respectively, while the patient was sitting. Intervertebral levels were identified using ultrasonography and counted from the sacrum. A dural puncture was performed at L5/S using a 27G pencil-point spinal needle (Portex™ Secure CSE needle, Smith Medical Japan, Tokyo, Japan). Figure 2 shows the labor progression, medication dosages, and cold sensitivity along dermatomes.

Labor and analgesic process

The patient reported mild pain (numerical rating scale (NRS): 3) 1 h and 20 min after labor onset. The patient did not request analgesics; however, we administered 8 mL of 0.2% and 0.1% levobupivacaine through the L1/2 catheter after confirming no blood or cerebrospinal fluid aspiration. Furthermore, 0.08% levobupivacaine with 2 µg/mL fentanyl was administered through programmed intermittent bolus (PIB) from the cephalic catheter after observing decreased cold sensitivity at the bilateral Th10 dermatome. Epidural infusion pump settings were 8-mL PIB every 60 min, starting 30 min after the initial epidural effect was confirmed, and 6 mL patient-controlled analgesic with a 10-min lockout interval.

The patient complained of moderate lower abdominal pain (NRS 4) 2 h after labor onset. Therefore, we administered 8 mL of 0.1% levobupivacaine via the L5/S catheter. As the pain increased (NRS 5) 2.5 h into labor, and the evaluation of cold discrimination revealed decreased cold sensitivity at Th10-L3 on the right and Th10–Th11 on the left dermatome, 6 mL of 0.2% levobupivacaine and 50-µg fentanyl were sequentially administered via the L5/S catheter.

However, she still complained of moderate pain (NRS 5) 3 h after labor onset. Evaluation of cold discrimination revealed cold sensitivity at Th10-L3 on the left and L1–L5 on the right dermatome (Fig. 3, 9:30). Cervical ripening and dilation suggested labor progression; therefore, 6 mL of 0.2% levobupivacaine was administered through the L5/S catheter. Rapid labor progression commenced after amniotic sac rupture and cervix dilation, and the patient reported severe pain (NRS 7). Therefore, we administered 5 mL of 0.3% lidocaine through the L5/S epidural catheter twice. Adrenaline and sodium bicarbonate were added to enhance the analgesic effect; however, no sensory blockade on the sacral segments was achieved (Fig. 3, 10:10). We retracted the L5/S catheter by 1 cm and administered 4 mL of 0.2% levobupivacaine, and this resulted in a marked improvement in analgesia (Fig. 3, 11:00).

Evaluation of cold discrimination by NRS. NRS, numerical rating scale

Notably, 4 h and 5 min after the onset of labor, an infant was delivered with Apgar scores of 8 and 9 at 1 and 5 min, respectively. The patient did not report pain at delivery (NRS 0) and was satisfied with the analgesia during labor. She was discharged 5 days after delivery, following the standard course in our hospital, without any anesthetic complications.