Background Dual epidural catheters (DEC) were originally described in 1949 to alleviate labor pain (1). Although uncommon, the technique has been successfully used for complex surgical procedures including spine deformity surgery, esophagectomy, and abdominal perineal resections (2,3,4). DECs have not been shown to significantly increase adverse events and have been associated with a 50% reduction in the rate of major post-operative complications, including anastomotic leaks, pulmonary complications, atrial fibrillation, and sepsis (3). We present a patient who received DEC for a two-stage removal of a coccygeal tumor. Case Presentation A 62-year-old 60kg female with a history of sacral chondrosarcoma s/p multiple intralesional resections presented for a 2-stage surgical removal. The first procedure was an anterior discectomy of the lumbar sacral spine. The pain service placed a T8-T9 epidural and started an infusion of bupivacaine 0.075% with hydromorphone 2mcg/cc at 5cc/hr. Patient reported 0/10 post op pain. On POD 2, she underwent stage 2 (posterior approach) of her tumor resection, and the surgeon placed a Lumbar epidural. The lumbar epidural infusion started at the post-op at 3cc/hr of the same epidural solution while the thoracic epidural was continued at 3cc/hr. Notably, the first epidural was continued intraoperatively at a rate of 3cc/hr during the second stage. After her second procedure, the patient again reported 0-3/10 pain for the next 5 days with both epidurals in place. Hemodynamics remained stable throughout, and the patient quickly met postoperative milestones. Multimodal agents added to her pain regimen included acetaminophen 500 mg q6h IV, gabapentin 300mg BID, and methocarbamol 500mg q8h IV. For breakthrough pain, her regimen included epidural boluses of 3cc q3h, oxycodone 5mg q4h prn and hydromorphone 0.25mg q4h PRN. She seldom required any PRN medications. Both catheters were removed on POD 5 from the second surgery.

Discussion Overall, our patient tolerated the procedure and successfully transitioned to oral multimodals. The DEC technique has been reported to decrease opioid requirements and dependence on mechanical ventilation, which is increasingly important for today’s aging and sicker population. It allows for limited opioid use and its side effects such as respiratory depression, delirium, and ileus. The use of neuraxial can promote early recovery of bowel function, shortened hospital length of stay, decreased risk of perioperative complications such as immunosuppression and opioid induced endocrinopathy (4). While the DEC approach is promising, risks must be balanced with the benefit of the patients. Kinking, knotting, or looping of the catheter can cause it to break off and be left within the patient as seen in rare cases (5). However, complications of DEC are the same as single epidural catheters, and include infection, hematoma, and abscesses (6).