Inadequate spinal anesthesia in a parturient with Marfan's syndrome due to dural ectasia

provided the original work is properly cited. CC Marfan syndrome (MFS) is a rare hereditary connective tissue disorder that affects the cardiovascular, musculoskeletal, and ocular systems. Pregnancy further increases the potential for cardiovascular risks due to increases in blood volume, heart rate and stroke volume. The choice of anesthetic technique is very important in patients with MFS. Dural ectasia (DE) in MFS patients may result in failure of spinal anesthesia. We reported a patient without typical symptoms related to DE who experienced spinal anesthesia failure. A-29-year-old female (weight, 58 kg; height, 161 cm) with known MFS was admitted for cesarean delivery at 37 + 6 weeks of gestational age. She had valve sparing aortic root replacement surgery due to aortic root aneurysm and was diagnosed with MFS 6 years ago. Preoperative echocardiography revealed a left ventricular ejection fraction of 68% with moderate aortic regurgitation (G2-3), trivial tricuspid regurgitation and intact aortic root graft. Aortic regurgitation had increased since the previous study conducted 6 months earlier. The patient was medicated with atenolol during pregnancy. Elective cesarean section was scheduled and routine monitoring devices were applied in the operating room. The left radial artery was cannulated for continuous monitoring of arterial pressure. The initial blood pressure was 140/73 mmHg, heart rate was 74 beats /min, and peripheral oxygen saturation was 100% at room air. Combined spinal-epidural (CSE) anesthesia was administered. The epidural space was found using a loss of resistance technique at the first attempt. Clear cerebrospinal fluid (CSF) was obtained on spinal needle insertion. There was no paresthesia. Eight mg of 0.5% hyperbaric bupivacaine and 10 ug of fentanyl was injected intrathecally. An epidural catheter was inserted without resistance and advanced 5 cm upward. The levels of sensory block were tested by alcohol swabs and pinprick tests. Ten minutes following the intrathecal injection, the patient had only limited lower limb analgesia. The epidural injection was titrated over the next 20 min, and 8 ml of 2% lidocaine and 8 ml of 0.75% ropivacaine were required to achieve T4 sensory block. The remainder of the procedure was uneventful. Ephedrine 4 mg IV was administered twice to maintain systolic blood pressure above 100 mm Hg and the patient was sedated with midazolam after delivery. The patient’s postoperative vital signs were stable with a blood pressure of 111/54 mmHg, a heart rate of 68 beats/min, and an oxygen saturation of 98%. The postoperative pain was managed with patient-controlled epidural analgesia. She had an uneventful postoperative course and was discharged 4 days later. DE is defined as 1) an enlarged neural canal along the spinal column, usually in the lower lumbar and sacral regions; 2) a thinning of the cortex of the pedicles and lamina of the vertebra; 3) a widening of the neural foramina; or 4) an anterior meningocele [1]. A more recent definition of DE is a widening of the dural sac or spinal nerve root sleeves. The most common clinical symptoms include low backpain, headache, weakness, and loss of sensation above and below the affected limb, bowel and bladder dysfunction, occasional rectal pain and pain in the genital area [2]. The incidence of DE in MFS patients reportedly ranges from 63% to 92% [3]. The associated increase in CSF volume due to DE, and the