23-year-old primip with incidental finding of Neurofibromatosis

Background

• MRI during pregnancy to assess potential foetal abnormality
• Noted lesions on maternal lumbar spine
• Maternal MRI performed showed ‘thoracic and lumbar spine lesions involving almost all the nerve roots…. Lesion at L3 extends into the spinal canal and deviates cauda equina to the left.’
• Differential diagnosis of Neurofibromatosis or schwannomas
• Asymptomatic, some intermittent back pain
• No skin lesions, vascular involvement, or hypertension

Issues

• Uncertain Diagnosis
• Reviewed by geneticist and awaiting phenotype results
• 37 weeks at time of review so may not have confirmed diagnosis by delivery
• Planned for vaginal delivery
• Patient keen for epidural anaesthesia

Discussion

Suitability for neuraxial anaesthesia

• Consensus opinion that neuraxial would be a safe option
• Epidural vs spinal – considering the lesion at L3 is causing significant compression of the dura, it may be difficult to feed an epidural catheter
• Likely that any neuraxial technique would have an increased likelihood of ineffective or patchy block
• Plan would be for an ultrasound-guided approach, performed early in labour, and a senior proceduralist.
• Space above L3 lesion recommended; L2/3
• See attached BJA article.

Neurosurgical opinion

• MRI reviewed, agree that neuraxial anaesthesia is safe.
• No brain lesions, therefore, no risk of herniation if Dural puncture
• Advice approach above or below L3