From the Guidelines
Performing a thoracic epidural in a patient with neurofibromas throughout the thoracic spine is not recommended due to significant safety concerns. The presence of multiple neurofibromas creates unpredictable anatomy and increases the risk of neurological complications during needle placement, as noted in the context of thoracic surgery and anesthesia management 1. These tumors can distort the epidural space, potentially leading to inadvertent tumor puncture, incomplete or patchy anesthesia, and possible permanent neurological injury.
Alternative pain management strategies should be considered instead, such as:
- Multimodal analgesia with intravenous opioids (like fentanyl 25-50 mcg IV every 1-2 hours or hydromorphone 0.2-0.4 mg IV every 2-3 hours)
- Scheduled acetaminophen (1 gram IV/PO every 6 hours)
- NSAIDs if not contraindicated, as suggested by guidelines for enhanced recovery after pulmonary lobectomy 1 Patient-controlled analgesia may also be appropriate. In some cases, paravertebral nerve blocks or intercostal nerve blocks might provide regional anesthesia without the risks of epidural placement, considering the better safety profile of continuous paravertebral block over thoracic epidural analgesia 1. If regional anesthesia is absolutely necessary, consultation with a neuroradiologist to review recent imaging and involvement of an experienced anesthesiologist with expertise in complex spine cases would be essential before attempting any neuraxial procedure.
From the Research
Safety of Thoracic Epidural in Patients with Neurofibromas
- The safety of performing a thoracic epidural in a patient with neurofibromas throughout the thoracic spine is a concern due to the potential for nerve damage or tumor compression 2, 3.
- Studies have shown that patients with neurofibromatosis type 1 (NF1) are at a higher risk for complications during spinal surgery, including nerve damage and tumor recurrence 2, 4.
- The presence of neurofibromas in the thoracic spine can make it challenging to perform a thoracic epidural, as the tumors can compress or infiltrate the spinal nerves and surrounding tissues 5, 6.
- However, there is no direct evidence to suggest that performing a thoracic epidural in a patient with neurofibromas throughout the thoracic spine is absolutely contraindicated 2, 3, 4, 5, 6.
Considerations for Thoracic Epidural in Patients with Neurofibromas
- Patients with NF1 and thoracic neurofibromas should be carefully evaluated before undergoing a thoracic epidural, taking into account the size and location of the tumors, as well as the patient's overall health status 2, 4.
- The use of imaging studies, such as MRI or CT scans, can help to identify the location and extent of the neurofibromas, and guide the placement of the epidural needle 5.
- The risk of complications, including nerve damage and tumor recurrence, should be carefully weighed against the potential benefits of the thoracic epidural 2, 3, 4.
- Alternative pain management strategies, such as systemic analgesics or regional anesthesia, may be considered in patients with neurofibromas throughout the thoracic spine 6.