[The "walking" epidural catheter: one cause of failed epidural anesthesia].

We report a "walking" catheter resulted in failed epidural anesthesia. An 85-year-old woman was scheduled for insertion of a nail in the left humerus. At 10 a.m. on the day of surgery, a Tuohy needle was inserted into the epidural space between the C6 and C7 vertebrae, and then we inserted an epidural catheter for 5 cm. Epidurography revealed that the catheter was inserted between C5 and C6, and the tip of the catheter was positioned windingly at C4. The contrast medium was found spread bilaterally from the C2 level to the Th2 level. The patient entered the operating room at 3 p.m. We infused 10 milliliters of 1% mepivacaine through the epidural catheter. Hypesthesia was obtained on the right side of her neck, from the C2 to the C5 level, after 10 minutes. Epidurography after surgery showed that the coiled catheter was placed straight into the right side of the epidural space; contrast medium infused through the catheter was found spread only to the right side from the C2 to the C4 level.