Thoracic spinal anesthesia for emergency derivative colostomy in a turner syndrome patient

Sir, We read with great interest the recent case report by Guillarducci et al., entitled “Anesthetic implications of elective cesarean section in a parturient with Noonan syndrome and complex cardiomyopathy: A case report,” which highlighted the importance of individualized anesthetic planning and demonstrated that neuraxial anesthesia can represent a safe and effective approach in selected high-risk patients.[1] Notably, Noonan syndrome is characterized by a Turner phenotype, reflecting the shared anatomical and cardiovascular features between these two conditions, which may significantly impact anesthetic management.[1] Turner syndrome (TS) is a genetic disorder caused by sex chromosomal abnormalities affecting women and is associated with a wide spectrum of anatomical and physiological alterations, particularly involving the airway and cardiovascular system.[2] Short webbed neck, maxillary and mandibular hypoplasia, reduced tracheal length, and altered tracheal anatomy may contribute to difficult airway management.[3,4] Additionally, congenital cardiovascular abnormalities and pulmonary arterial hypertension may significantly increase perioperative morbidity and mortality, particularly during general anesthesia.[5] Therefore, thorough understanding of these anatomo-physiological abnormalities is essential to ensure safe anesthetic care. Neuraxial anesthesia may represent a valuable alternative to general anesthesia in selected high-risk patients, allowing avoidance of airway manipulation and reduction of hemodynamic stress.[3,4] However, short stature requires careful individualization of local anesthetic dosing, and spinal deformities such as scoliosis may increase the technical difficulty of neuraxial block placement. We describe the case of a 62-year-old ASA IV woman with TS, who underwent emergency derivative colostomy for intestinal obstruction. The patient presented multiple severe comorbidities, including heart failure with moderate left ventricular dysfunction, moderate precapillary pulmonary arterial hypertension (PAP 65 mmHg), persistent atrial fibrillation on anticoagulation therapy, end-stage renal disease on hemodialysis, chronic obstructive pulmonary disease requiring oxygen therapy, hypothyroidism, neurogenic bladder, chronic iron-deficiency anemia due to colonic angiodysplasia, adrenal adenoma, and previous endometrial carcinoma. After obtaining informed consent, thoracic spinal anesthesia was performed in the sitting position using a 25 G Whitacre needle at the T9–T10 interspace, administering a low dose of bupivacaine 0.25% 8 mg with dexmedetomidine 5 mcg as adjuvant. Minimal sedation with midazolam 1 mg was provided. Hemodynamic stability was maintained using continuous norepinephrine infusion (0.05 µg/kg/min), guided by minimally invasive monitoring. The surgical procedure lasted approximately 70 min. The patient maintained spontaneous breathing and stable vital parameters throughout the operation. No intraoperative or postoperative complications occurred. Postoperative analgesia required only acetaminophen, without opioid administration. This case further supports the concept that neuraxial anesthesia, when carefully individualized, may represent a safe and effective anesthetic strategy in high-risk patients with TS, particularly in those presenting Turner phenotype features associated with increased risks of general anesthesia. Careful patient selection, dose adjustment, and experienced anesthetic management remain essential to optimize perioperative safety in this challenging population. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.