Ultrasound-guided thoracic paravertebral block in a case of carcinoma breast with neurofibromatosis type-1 for modified radical mastectomy: A case report

Dear Editor,

von Recklinghausen disease or neurofibromatosis type 1 (NF-1) is a genetic autosomal dominant disease that presents with café-au-lait spots, skin fold freckling, Lisch nodules and neurofibromas.[1] An association between the NF1 gene and the breast cancer susceptibility gene (BRCA1) has been noted as both are located on the long arm of chromosome 17.[2] Modified radical mastectomy (MRM) is the most common surgical technique for the management of carcinoma breast. We report a case of carcinoma left breast with NF-1 posted for MRM with left thoracic paravertebral block, with left superficial cervical plexus block as the primary anaesthetic technique under sedation.

A 51-year-old female, with American Society of Anesthesiologists (ASA) physical status II, was posted for left MRM with axillary lymph node dissection for carcinoma left breast (YcT4bN2aM0). The patient displayed a large number of café-au-lait spots and cutaneous neurofibromas all over her body [Figure 1]. The diagnosis of NF-1 was made clinically.[1] An intravenous (IV) cannula of 18 gauge was secured in the right arm and standard ASA monitors were applied. Under aseptic precautions, using a high-frequency linear ultrasound probe and a 22-gauge Quincke spinal needle, paravertebral space at T3–T4 level on the left side was identified. Intermittent hydro-location using sterile 5 ml of 0.9% normal saline was performed till displacement of pleura was noticed. After confirming negative aspiration, 10 ml of 0.5% bupivacaine mixed with 10 ml of 2% lignocaine with 1:200,000 adrenaline and 4 mg dexamethasone was given into the paravertebral space. Thereafter, a left superficial cervical plexus nerve block was performed using a linear ultrasound probe; 2.5 ml of 0.5% bupivacaine mixed with 2.5 ml of 2% lignocaine with 1:200,000 adrenaline was given for the block. Complete surgical anaesthesia occurred 30 min after the block, which was confirmed by a pin-prick test over C5–T5 dermatomes. Intraoperatively, 2 mg midazolam and 50 μg fentanyl were given IV along with dexmedetomidine infusion at a rate of 25 μg/h. The patient was comfortable during surgery which lasted for 90 min. Pain assessment, done 2 h after surgery, using the visual analogue scale (VAS) score was 0. The duration of analgesia lasted for 22 h.

Figure 1.

Patient of Neurofibromatosis type-1 showing café-au-lait spots and cutaneous neurofibromas

Patients with NF-1 could present with potential difficulties for general anaesthesia. The presence of neurofibromas in the airway can cause obstruction and tracheal deviation, which results in difficulty in intubation and placement of a supraglottic airway device. Chest wall deformities such as kyphoscoliosis can be associated with NF-1, which can lead to a decrease in lung volume, chest compliance and breathing capacity and can cause respiratory failure in extreme cases. Macroglossia, mandibular abnormalities and cervical spine dislocation have been reported with NF-1, which can further complicate airway management.[1] We, therefore, selected an ultrasound-guided thoracic paravertebral block to avoid complications related to general anaesthesia and preserve spontaneous ventilation by the use of dexmedetomidine for intraoperative sedation. The effectiveness of anaesthesia and analgesia by thoracic paravertebral block in breast surgeries has been reported in previous studies.[3,4] Advantages of paravertebral block include avoidance of intubation and mechanical ventilation, unilateral anaesthesia without bilateral sympathectomy, profound postoperative analgesia, reduced incidence of postoperative nausea and vomiting (PONV), rapid recovery and early mobilisation.[5]

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Conflicts of interest

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