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Tumour metastasis at the site of a previous epidural catheter.

Epidural analgesia can provide excellent pain relief but can cause a number of rare, serious complications. These complications include epidural abscess, epidural haematoma and permanent neurological injury. The patient in this case report developed a metastasis in the vertebra and epidural space at the site of recent epidural catheterisation. This was a debilitating, life-threatening complication which may or may not have been directly related to the use of the epidural catheter. To our knowledge a direct link between epidural catheterisation and tumour metastasis has not been reported previously.


A 62-year-old woman presented with a three-month history of haematuria. There were no documented abnormal neurological symptoms or signs on initial presentation. The patient's body mass index was 39. Cystoscopy revealed a large bladder tumour which was unable to be completely removed via the transurethral route. Histology indicated an invasive poorly-differentiated transitional cell carcinoma of the bladder.

Two weeks later the patient underwent a radical cystectomy. For this operation an epidural catheter was inserted at T9/10 level for intra- and postoperative analgesia. The patient had scoliosis but no specific problems were noted at insertion of the epidural catheter. The number of passes required to insert the epidural catheter was not documented. The epidural catheter was used for four days postoperatively.

Histology revealed a 7 cm small cell carcinoma of the bladder with areas of glandular differentiation invading through the muscularis propria. There were no metastases to the lymph nodes, ureters, vagina, uterus, cervix, fallopian tubes or ovaries evident on histopathology. Bone scan and computerised tomography (CT) scan of the head, chest, abdomen and pelvis were performed. This staging did not reveal any metastases. The patient was discharged from hospital nine days after the cystectomy.

Forty-seven days after the radical cystectomy the patient was readmitted with back pain and immobility. Neurological examination revealed marked loss of power in both legs. Sensation appeared normal in both legs. Plantar reflexes were upgoing bilaterally. Deep tendon reflexes were otherwise normal to examination. Magnetic resonance imaging (MRI) of the spine (Figure 1) revealed marked central canal stenosis at the T10 level caused by pathological crush fracture of the T10 vertebral body and by tumour encroachment posteriorly in the epidural space. Urgent debulking of the epidural tumour and a T9/10 laminectomy were performed. Histology of the epidural tumour showed a small cell carcinoma with evidence of glandular differentiation consistent with a metastasis from the previous primary bladder tumour.


The patient's neurologic deficit did not improve and she required a wheelchair to mobilise. Palliative chemo- and radiotherapy was administered and the patient died six months later.


This case report is the first to directly link a tumour metastasis to the prior use of an epidural catheter. The patient in this case study had an epidural inserted at the T9/10 level for radical cystectomy. Fifty-three days later the patient required emergency debulking of metastatic small cell carcinoma in the T10 epidural space.

Possible mechanisms for a metastasis in the epidural space include:

1. Tumour seeding of the epidural catheter site from an occult T10 metastasis. In this scenario, there would have been an occult metastasis in the T10 vertebra at the time of the cystectomy. The epidural spread would then have resulted from seeding of the epidural catheter.

2. Direct tumour spread into the epidural space via crush fracture of the vertebral body from an occult metastasis present at the time of epidural catheterisation. In this scenario the epidural catheter would not have played a significant role in the metastasis to the epidural space.

3. Direct haematogenous metastasis to the epidural catheter site. Insertion of the epidural may have resulted in local bony or soft tissue trauma. The tumour may have spread haematogenously to the site of tissue trauma via the craniospinal venous system. This would be the least likely proposed mechanism because one would expect the tumour to spread more extensively through the epidural space, rather than to directly invade the bony vertebra at a single level.

It is impossible to conclusively prove either of the first two proposed mechanisms. However, features of this case that suggest involvement of the epidural catheter in the development of a metastasis at the same location include:

1. The rapid progression of the patient's symptoms. The patient did not complain of back pain prior to the radical cystectomy. The patient was readmitted to hospital 47 days after the epidural catheter insertion with back pain and spinal cord compression from the epidural metastasis.

2. The metastasis occurred at the same site as the epidural catheter placement.

3. There was no evidence of metastatic disease on initial presentation. Initial bone scan and CT scan of the head/chest/abdomen/pelvis did not reveal any metastases.

4. Tumour metastasis was confined to the level at which the epidural was inserted. MRI of the patient's spine revealed metastatic disease at the T10 level only. CT scan of the chest/abdomen/pelvis/head following the emergency laminectomy and debulking of the epidural tumour did not reveal any further metastases.

5. Anatomical, pathological and local factors may theoretically have contributed to the development of the epidural metastasis.

Anatomical factors

Physicians performing procedures on the spine (for example, spinal surgery, prone positioning, spinal anaesthesia and epidural anaesthesia) should understand the anatomy of the cerebrospinal venous system. An excellent review of this system is provided by Tobinick (1). The intracranial venous system and the vertebral venous plexuses directly communicate and have been collectively termed the cerebrospinal venous system1. Another name proposed for this system is the craniospinal venous system2. For descriptive purposes, the vertebral venous plexus has been subdivided into three intercommunicating divisions (2) (Figure 2):

1. The internal venous plexuses (anterior and posterior).

2. The external vertebral venous plexuses (anterior and posterior).

3. The basivertebral veins.


The internal venous plexuses (anterior and posterior) lie within the spinal canal but external to the dura. The external vertebral venous plexuses (anterior and posterior) surround the vertebral column. The basivertebral veins run horizontally within the vertebrae.

The vertebral venous plexus is a valveless system which communicates directly with pelvic, sacral, intercostal, azygos, caval and intracranial veins (1). Bidirectional blood flow occurs in the vertebral venous plexus due to its lack of venous valves (1). Consequently, the vertebral venous plexus can act as an overflow system for venous drainage. For instance, if flow in the inferior vena cava is impeded, venous pressures elevate and increased flow occurs via the pelvic veins into the vertebral venous plexus, resulting in engorgement of this system.

The vertebral venous plexus, via its communication with pelvic veins, provides a direct route for haematogenous spread of cancer from the bladder to the epidural space or vertebral body (1). This is the proposed primary anatomical route for the metastasis of the bladder tumour in this case report.

Pathological factors

Small cell carcinoma is a neuroendocrine tumour which most commonly occurs in the lungs (3). Primary extrapulmonary small cell carcinoma has been reported in a number of organs (3). Small cell carcinoma of the bladder is an uncommon tumour which accounts for approximately 0.5% of primary bladder tumours (3). Small cell carcinomas are biologically aggressive tumours showing early vascular and muscle invasion and a tendency to rapidly metastasise (3). The commonest sites for metastases are lymph nodes, liver, bone, lung and brain (3). At initial diagnosis more than 20% of patients with small cell lung carcinoma have bone involvement evident on bone scan (4). A bone scan is essential when investigating patients with limited disease because it can show bony metastases in asymptomatic patients (4). The patient in this case report was at an increased risk of early bone metastases due to the aggressive nature of the tumour and its propensity to metastasise to bone.

Local factors

local factors that may predispose to tumour metastasis include tissue trauma, needle tract seeding, impaired immunity and the presence of a foreign body (5-8).

Tumour adherence may be enhanced by tissue trauma due to breakdown of endothelial barriers, exposing subendothelial tissue (5). Enhancement of tumour growth may occur because tissue trauma results in clot formation which provides nutrients and a protective barrier for tumour cells (5). Thus, trauma from epidural catheter insertion may result in a favourable environment for tumour adherence and growth.

Needle tract seeding has been reported in a number of clinical cases including lung cancer biopsies and percutaneous vertebroplasty (6,7). Needle tract seeding appears to depend upon the size of the needle (7). larger needles carry a higher risk of tract seeding (7). In this case report an 18 gauge needle was used to insert the epidural catheter. This needle could have caused direct bony trauma to the T10 vertebra. If the bone had an occult metastasis then it is feasible that needle tract-like seeding of the epidural catheter might have occurred.

Impaired immune function may be an important local factor in tumour growth. Tissue trauma can impair local immune function (5). Infusion of epidural solution may impair immune function by dilution of immune factors or by a direct drug effect. local anaesthetics have been shown to impair the immune response by decreasing leucocyte activity and reducing the release of leukotrienes, interleukins and histamine (8). The immune system's ability to restrict tumour growth may be affected by epidural analgesia, due to tissue trauma or the administration of epidural local anaesthetic solution.

There have been numerous reports of tumour metastases occurring at sites of foreign bodies. For example, metastases have been reported at laparoscopic port sites, Hickman's catheter sites and percutaneous gastrostomy sites (9-11). To our knowledge this is the first report of a tumour metastasis occurring at the site of a prior epidural catheter.

In conclusion, this case links the use of epidural analgesia with the subsequent presentation of a tumour metastasis. An epidural catheter was inserted for intra- and postoperative analgesia. Subsequently, the patient developed a metastasis in the epidural space at the same level as the epidural catheter. Anatomical, pathological and local factors may have contributed to this metastasis or it may have been coincidental. The patient's neurologic deficit did not improve and the patient died six months later.


(1.) Tobinick E, Vega CP. The cerebrospinal venous system: anatomy, physiology, and clinical implications. MedgenMed 2006; 8:53.

(2.) Pearce JMS. The craniospinal venous system. Eur Neurol 2006; 56:136-138.

(3.) Sved P, Gomez P, Manoharan M, Civantos F, Soloway MS. Small cell carcinoma of the bladder. BJU Int 2004; 94:12-17.

(4.) Ruckdeschel JC, Schwartz Ag, Bepler g, Cooppage L, Lonardo F, Kucuk O et al. Cancer of the lung: NSCLC and SCLC. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, Mckenna WG, eds. Clinical oncology, 3rd ed. Philadelphia, Pennsylvania: Elesevier Churchill Livingstone 2004.

(5.) Curet MJ. Port site metastases. Am J Surg 2004; 187:705-712.

(6.) Chen Y-J, Chang G-C, Chen W-H, Hsu H-C, Lee T-S. local metastases along the tract of needle: a rare complication of vertebroplasty in treating spinal metastases. Spine 2007; 32:E615-E618.

(7.) Kara M, Alver G, Sak S D, Kavukcu S. Implantation metastasis caused by fine needle aspiration biopsy following curative resection of stage IB non-small cell lung cancer. Eur J Cardiothorac Surg 2001; 20:868-870.

(8.) Homburger Jay A, Meiler Steffen E. Anesthesia drugs, immunity, and long-term outcome. Curr Opin Anaesthesiol 2006; 19:423-428.

(9.) Nguyen Ba D, Roarke Michael C. Postlaparoscopic abdominal port-site metastasis: F-18 FDG PET/CT demonstration. Clin Nucl Med 2007; 32:732-734.

(10.) Davidson NG. Tumour metastasis from multiple myeloma in Hickman catheter tract. Eur J Surg Oncol 1990; 16:170-171.

(11.) Douglas JG, Koh W, Laramore GE. Metastasis to a percutaneous gastrostomy site from head and neck cancer: radiobiologic considerations. Head Neck 2001; 22:826-830.

M.M. CHAPPELL *, H.A. SCHOENGEN [[dagger]]

Department of Anaesthetics, Princess Alexandra Hospital and Royal Brisbane Hospital, Brisbane, Queensland, Australia

* M.B., B.S., Anaesthetic Registrar, Department of Anaesthetics, Princess Alexandra Hospital.

[[dagger]] M.D., D.E.S.A., F.A.N.Z.C.A., Consultant Anaesthetist, Department of Anaesthetics, Royal Brisbane and Womens Hospital.

Address for reprints: Dr M. M. Chappell, Department of Anaesthetics, Princess Alexandra Hospital, Ipswich Road, Brisbane, Qld 4102.

Accepted for publication on July 10, 2008.
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Article Details
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Title Annotation:Case reports
Author:Chappell, M.M.; Schoengen, H.A.
Publication:Anaesthesia and Intensive Care
Article Type:Case study
Geographic Code:1USA
Date:Nov 1, 2008
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