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Object. The authors conducted a study to determine how to avoid emergency postoperative reintubation and its associated morbidity in patients who have undergone multilevel anterior—posterior cervical spine surgery. Methods. In a group effort between the departments of anesthesia and neurosurgery, a protocol was developed to avoid having to reintubate patients postoperatively. As a preventative measure, patients remained intubated overnight; on the 1st postoperative day or thereafter, based on direct fiberoptic visualization of reactive tracheal swelling, an anesthesiologist extubated the patients. Fifty-eight patients underwent multilevel anterior corpectomy with fusion (ACF; with 41 receiving plates and 17 not receiving plates), posterior wiring and fusion (PWF), and application of a halo. On average, ACF involved three levels, whereas PWF included 6.5 levels. Surgery typically lasted 10 hours, and an average 2.6 U of blood was required. Forty patients were successfully extubated on the 1st, five on the 2nd, three on the 3rd, two on the 4th, two on the 5th, and three on the 7th postoperative day. Three elective tracheostomies were performed on the 7th postoperative day. Risk factors associated with delayed extubation or tracheostomy in 18 patients included: operative time longer than 10 hours (12 patients), obesity greater than 220 lbs (12 patients), transfusion of more than 4 U of blood (10 patients), ACF reoperations (nine patients), ACF including C-2 (seven patients), four-level ACF (five patients), and asthma (five patients). In the only case in which emergency reintubation was required, three risk factors were present. Conclusions. Emergency reintubation following anterior—posterior cervical surgery and fusion can be avoided by maintaining intubation overnight and subsequently having an anesthesiologist remove the tube after healing is fiberoptically confirmed. Familiarity with major risk factors contributing to airway compromise, combined with this protocol, should minimize the significant morbidity associated with reintubation following multilevel anterior—posterior cervical fusion.

This article starts with two empirical observations from Organisation for Economic Co-operation and Development countries about longer constitutions: (1) they are more rigid (that is, more difficult to amend) and (2) they are in practice more frequently amended. The study presents models of the frequently adopted rules for constitutional revision (for example, qualified majorities in one or two chambers, referendums) and demonstrates that, if longer constitutions are more frequently revised, it is because they must impose actual harm on overwhelming majorities. In trying to explain this finding, the article demonstrates that longer constitutions tend to contain more substantive restrictions. Countries with longer constitutions also tend to have lower levels of GDP per capita and higher corruption. Finally, the negative effect of constitutional length on GDP per capita is shown to persist even if corruption is controlled for.While few could doubt the influence of the US constitution in the history of constitutional democracy, 225 years after its enactment we still have not solved a fundamental question of constitutional design: are shorter constitutions better? The US constitution is famous for its brevity; for years, American lawyers have praised this feature as the secret to its endurance and durability. Globally, however, the US constitution has been a model more in the abstract; relatively few countries have directly copied it. In fact, over time, constitutions have grown longer as they have begun to cover more topics. 1 But the question remains: is this trend more likely to produce better governance outcomes?In this article, we take a new approach to this question. First, we note the paucity of previous research on the relationship between constitutional length and governance outcomes. Then, we justify our decision to focus on Organisation for Economic Co-operation and Development (OECD) countries. In the subsequent section, we present two puzzling empirical observations. First, 'locking' constitutions does not work, since it is not the case that more rigid constitutions are less frequently amended. Secondly, if we control for length, there is a positive correlation between constitutional rigidity and frequency of amendments. In other words, longer constitutions are more difficult to amend and are also more frequently amended than shorter ones.The next section of the article explains why. We present a model explaining what it means to 'lock' a constitution, and how a 'locked' constitution requires an overwhelming majority of the relevant constitutional authority -and/or the voting public -to change it. If, despite 'locking', interesting discussions, as well as three anonymous reviewers for their thoughtful comments. Data replication sets and online appendices are available at http://dx.doi.org/

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