Where is the Catheter? An Unexpected Complication from a Paravertebral Catheter Placement

Abstract

Background: Placement of a thoracic paravertebral nerve block catheter (PVBC) is a safe and effective method for providing postoperative analgesia for pediatric patients undergoing thoracotomy. The PVBC can be misplaced despite accurate needle placement. Case Presentation: An 8 year old girl with a history of right lower extremity osteosarcoma and a right lung nodule underwent thoracotomy and wedge resection of the right lung. A T7 paravertebral nerve block catheter (PVBC) was placed under ultrasound guidance for postoperative pain relief. The patient reported satisfactory analgesia at thoracic incision without side effects throughout postoperative anesthesia care unit stay and postoperative day 1 (POD1). On POD2, the patient reported a droopy left eyelid and disclosed blurry vision since POD1. The physical exam revealed left partial Horner’s syndrome and numbness along the left T5-7 dermatome. The PVBC insertion depth was unchanged. The ptosis and miosis resolved completely one hour after stopping the ropivacaine infusion. The infusion was restarted after the catheter was pulled back by 2 cm and bloused with 5 ml of ropivacaine 0.2%. Patient reported that her pain was relieved with no recurrence of her symptoms. Discussion: This is the first case report of a patient who developed contralateral Horner’s syndrome from the placement of a PVBC. The PVBC can reach the contralateral paravertebral space via inter vertebral foramina or prevertebral space. Conclusion: The paravertebral catheter depth in children may need to be individualized.