Authors: Lor K et al.
Cureus 18(2): e103832, February 18, 2026
Summary
This case report describes the combined use of a tunneled thoracic epidural catheter and a second non-tunneled lumbar epidural catheter to manage severe acute postoperative pain in a medically complex, highly opioid-tolerant patient undergoing thoracoabdominal surgery.
Clinical Scenario
The patient had a tunneled thoracic epidural (T7–T8) placed five weeks prior for chronic pain, infusing local anesthetic and opioid. Upon hospital admission and perioperative management, multimodal analgesia included:
-
Thoracic epidural infusion
-
High-dose systemic opioids (~5,500 MME total requirement)
-
Intravenous ketamine infusion
-
Methadone
-
Clonidine
-
Acetaminophen
-
Intermittent hydromorphone
Despite this extensive regimen, postoperative pain became severe following exploratory laparotomy and subsequently a defunctioning esophagectomy and jejunostomy.
Dual Epidural Strategy
Because pain remained uncontrolled, a second epidural catheter was placed at L3–L4.
The strategy:
-
Thoracic epidural: coverage of thoracic dermatomes
-
Lumbar epidural: coverage of abdominal dermatomes
This dual approach improved dermatomal distribution and significantly reduced pain scores post-extubation to 3–4/10.
The lumbar catheter was discontinued after transient lower-extremity weakness from bupivacaine, without precipitating a pain crisis.
Complication
After more than seven weeks of tunneled epidural infusion, the patient developed:
-
Low-grade fever
-
Leukocytosis
-
Erythema at the insertion site
The tunneled epidural was removed due to concern for localized infection. Pain remained stable (5–6/10) on multimodal therapy afterward.
Discussion
Key themes include:
-
Dermatomal Coverage in Thoracoabdominal Surgery
Esophagectomy and similar procedures span thoracic and abdominal regions. A single epidural catheter may not provide sufficient spread. Dual catheters can extend coverage and improve analgesia. -
Extreme Opioid Tolerance
Chronic high-dose opioid exposure complicates postoperative pain management due to tolerance and possible opioid-induced hyperalgesia. Neuraxial techniques reduce systemic opioid escalation and target segmental pain pathways. -
Tunneled Epidural Catheters
While uncommon in U.S. postoperative practice, tunneled epidurals are frequently used internationally—especially in palliative care. Published data suggest:
-
Reduced systemic opioid requirements
-
Generally low infection risk
-
Most common complication: superficial insertion-site infection
The prolonged dwell time (>7 weeks) in this case likely contributed to localized infection.
-
Infection Risk
Available literature suggests neuraxial infection rates are low overall, though risk increases with longer catheter duration. Strict aseptic technique remains critical.
Conclusion
This report supports dual epidural analgesia as a viable strategy in selected, highly opioid-tolerant patients undergoing complex thoracoabdominal surgery. It also highlights the balance between prolonged neuraxial benefit and infection risk, particularly with tunneled catheters.
What You Should Know
-
Dual epidurals can improve dermatomal pain coverage after thoracoabdominal procedures.
-
Tunneled epidurals can provide extended analgesia but require infection vigilance.
-
Profound opioid tolerance demands multimodal, neuraxial-inclusive strategies.
-
Infection risk appears time-dependent but remains relatively uncommon.
-
Individualized analgesia planning is essential in complex surgical patients.
Key Points
-
Case from Cureus describing tunneled + non-tunneled dual epidurals.
-
Severe opioid tolerance (~5,500 MME).
-
Improved pain control with dual catheter strategy.
-
Removal of tunneled epidural due to suspected skin infection.
-
Highlights benefits and risks of prolonged neuraxial therapy.
Thank you to Cureus for allowing us to summarize and share this instructive case highlighting advanced neuraxial pain management strategies.