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Regional anesthesia in Marfan syndrome: not all dural ectasias are the same.
Abstract Number: F-28
Abstract Type: Case Report/Case Series
Background: The anesthetic management of women with Marfan syndrome and associated dural ectasia (DE) undergoing cesarean section (CS) remains controversial. Spinal anesthesia may result in undesirable hemodynamic changes in patients with significant cardiovascular disease, and may fail as a result of an increased lumbar CSF volume (1). Epidural anesthesia has been used successfully, however while providing a more stable hemodynamics, may be difficult to perform due to scoliosis, and has been associated with failure and risk of accidental dural puncture due to DE (2). We present 2 cases with Marfan syndrome and DE, where neuraxial anesthesia was used successfully.
Case 1: A 31 year old, G1P0 female with Marfan syndrome presented for elective CS at 35 3/7 weeks of gestation. The MRI of the spine revealed significant DE in the lumbosacral area. A two-segment CSE with 9 mg of 0.75% hyperbaric bupivacaine injected intrathecally produced no sensory block. The epidural was then titrated, and 150 mg of 0.5% bupivaine was required to achieve a bilateral T4 sensory level. Patient delivered a healthy male infant. On the 5th postoperative day, she had a surgery for aortic root repair and was discharged home 12 days later.
Case 2: A 34 year old, G1P0 female, with Marfan syndrome presented for elective CS at 37 weeks of gestation. A two-segment was planned again, and 13.5 mg of 0.75% hyperbaric bupivacane injected intrathecally produced a bilateral T5 sensory level. She delivered a healthy female infant and was discharged home on the 4th postoperative day. An MRI of the spine prior to discharge confirmed diagnosis of moderate DE.
Dural sac dimensions at various lumbar levels are presented for both patients in Figure 1.
Discussion: We reported two cases of parturients with Marfan syndrome and DE, who responded differently to spinal anesthesia, most likely based on the severity of their DE. This finding may explain variability in cerebrospinal fluid volume and as a result, different response to neuraxial anesthesia. Greater than normal volume of lumbosacral CSF is postulated to restrict the spread of intrathecally injected local anesthetics and cause “failed” spinal. Although preoperative MRI may help to identify patients at risk for failed spinal, we suggest that a CSE technique should be used in cases of DE.
References: 1) BJA 2005; 94:500-4; 2) Korean J Anesthesiol 2011 ; 60 :214-6;