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Anesthesia for Cesarean Delivery in a Patient with Marfan Syndrome and Lumbar Tarlov Cyst
Abstract Number: S 52
Abstract Type: Case Report/Case Series
A 41-year-old patient, G2P1, at 38 weeks gestation presented for elective Cesarean delivery (C/D); she had a past medical history of Marfan syndrome with aortic root dilation, rheumatoid arthritis with atlanto-axial instability, and a large lumbar dural (Tarlov) cyst. During her pregnancy, she experienced new onset numbness and paresthesias in her right lateral thigh.
Preoperative MRI (attached) showed 4mm alanto-odontoid subluxation, a dural cyst (4.3cm x 6.5cm x 8.6cm) with sacral extension from its origin at L5-S1, and multiple nerve root cysts at L2 and L3. Notwithstanding her neurologic symptoms, a neuraxial anesthetic was chosen as the mode of anesthesia for overall patient safety.
For C/D, a thoracic epidural was placed at the T10/11 intervertebral space. A T4 surgical anesthesia level was attained via 3 mL boluses of 1.5% lidocaine for a total dose of 20mL. The patient remained stable throughout the procedure. She was discharged on postpartum day 3 without complication.
Dural ectasia, a major diagnostic criterion for Marfan Syndrome, occurs in 63-92% of Marfan patients. Tarlov cysts, a subset of dural ectasias, are perineural cysts occurring along the nerve roots, most commonly in the sacral region. They occur in 4.6-9% of the adult population. At least part of the lining contains nerve fibers; they vary widely in size and number, and can compress or even invade the nerve roots leading to paresthesias or other neurologic symptoms.
Neuraxial anesthesia was the safest course for delivery. General anesthesia would be suboptimal in this patient with an aortic root diameter of 4.3cm and concern for rupture. In addition, atlanto-axial instability would make airway management more dangerous.
Spinal anesthesia was also discounted as an option. Since Tarlov cysts contain an unknown and sometimes significant volume of CSF, appropriate dosing of a spinal block can be unpredictable and often inadequate for C/D. Her dural cyst contained a significant amount of CSF based on imaging, and was located such that a typical approach for neuraxial anesthesia could not be safely attempted. A low thoracic epidural provided adequate surgical anesthesia while avoiding the Tarlov cyst.
LaCassie HJ, et. al. Dural ectasia: a likely cause of inadequate spinal anaesthesia in two parturients with Marfan’s syndrome. Br. J. Anaesth 2005; 94: 500–4
Acosta FL, et. al. Diagnosis and Management of Sacral Tarlov Cysts. Neurosurg Focus 2003;15(2)