Successful lumbar epidural catheter placement through a lower back lipoma
A 67-year-old white male (106 kg, 173 cm) was admitted with peripheral vascular disease and gangrene of the right first and second metatarsal bones requiring vascular bypass surgery of the right lower extremity. His past medical history was significant for hypertension, coronary artery disease, and diabetes mellitus. Past surgical history was significant for orthotopic liver transplantation, coronary artery bypass surgery for three-vessel disease, and tracheostomy 7 years ago, which was closed subsequently. At that time, the patient was advised that his tracheal lumen was small and difficult to intubate and that if he is to undergo surgery, general anesthesia should be avoided if at all possible. The physical examination was unremarkable except for a lower back mass measuring 20 × 15 cm [] overlying the middle of his lower back. Neurological exam was unremarkable apart from diabetic neuropathy in both lower extremities. An X-ray of the spine showed no gross abnormalities. Work-up of the lower back mass at another hospital revealed a diagnosis of lipoma.\nConsidering the patient's refusal of general anesthesia, his request for an alternative technique, and given the duration of the procedure (5-7 h), an epidural anesthesia was chosen. The anesthetic options were discussed at length with the patient and the vascular surgeons, including the risk of the remote possibility of seeding the epidural space with lipomatous cells. After obtaining the informed consent, the area overlying the lower back, including the lipoma, was prepped and draped using sterile techniques. A 9-cm, 18-G Tuohy epidural needle (PERIFIX Epidural Anesthesia Tray, B. Braun Medical Inc., Bethlehem, PA, USA) was placed through the lipoma (midline approach) into the L2/3 intervertebral space. Loss of resistance was achieved at 8 cm. The epidural catheter was threaded and the needle was removed. The catheter length measured 14 cm at the skin. After administering a negative test dose of licocaine 1.5% with 1:200,000 epinephrine (3 ml), bupivacaine 0.5% (10 ml) was given through the epidural catheter. Right superficial femoral artery to popliteal artery bypass with amputation of first and second metatarsal bones was performed under epidural anesthesia and minimal sedation. Postoperatively, the epidural provided excellent pain relief and was discontinued on the 4th postoperative day. There were no complications and the patient was discharged home. Six months follow-up revealed unchanged neurological exam.