Airway management pearls in cervical spine disorders

Abstract

Cervical spine (C-spine) pathologies that can cause compression on the spinal cord include acute trauma, congenital, and inflammatory disorders. The most important goal in managing a patient with C-spine pathology is to prevent further insult or aggravation of spinal cord injury. Even though the evidence is weak, manipulations of the head and neck during airway management of patients with C-spine pathology have been implicated in neurological deterioration. [1][2][3][4][5][6][7][8][9] The "sniffing position," used during intubation with direct laryngoscopy (DL), aligns the oral, oropharyngeal, and laryngeal axis. To attain this position, the lower C-spine is flexed, and extension occurs at the occipitalatlantoaxial (OAA) complex. In unstable C-spine pathology, such manipulations may result in displacement or subluxation of the bony elements, which may aggravate spinal cord compression and injuries.Neurological deterioration may occur due to the natural course of C-spine disease, surgical manipulation, and hemodynamic derangements. When managing the airway, the anesthesiologist's role is mostly to limit C-spine movements during intubation. The recent literature shows that using modern intubation equipment and techniques makes it easy and safe to intubate patients with C-spine pathology.Knowledge of the relevant anatomy, biomechanics, various pathologies affecting the C-spine, and the assessment of C-spine stability is important for anesthesia providers. This review covers, in brief, all these relevant aspects and focuses on current literature on various intubation techniques. Clinical anatomy of the C-spineBoth bony and ligamentous structures contribute to the stability of the spine. Perioperative physicians should know about these elements to identify the unstable C-spine. The foramina transversaria, through which the vertebral arteries pass, is a core structure of the cervical vertebra. Of 7 cervical vertebrae, the first, second, and seventh vertebrae are atypical, while the third to sixth are typical vertebrae. The upper 2 cervical vertebrae are anatomically and functionally different from the lower 5. These structures will be discussed separately.