Management of the Airway in Patients Undergoing Cervical Spine Surgery

Abstract

The perioperative management of the airway in patients with cervical spine disease requires careful consideration. In an observational prospective cohort study, we assessed the preoperative factors that may have influenced the anesthesiologists' choice for the technique of intubation and the incidence of postoperative airway complications. We recorded information from 327 patients: mean (+/-SD) age 51+/-15 year, 138 females and 189 males, for anterior surgical approach (n=195) and posterior (n=132). The technique of intubation used was awake fiberoptic bronchoscopy (FOB) in 39% (n=128), asleep FOB 32% (n=103), asleep laryngoscopy 22% (n=72), and other asleep 7% (n=24). Awake FOB was predominately chosen for intubating patients with myelopathy (45%), unstable/fractured spine (73%), and spinal stenosis (55%) but patients with radiculopathy had more asleep FOB (49%) (P<0.001). There was no association between method of intubation and postoperative airway complications. Acute postoperative airway obstruction occurred in 4 (1.2%) patients requiring reintubation. The technique of management of the airway for cervical spine surgery varied considerably among the anesthesiologists, although the choice was not associated with postoperative airway complications.

Awake fibreoptic intubation in neurosurgery

“…28 Laryngeal reflexes are maintained during the procedure, which allows for continuous spontaneous ventilation in patients where airway obstruction would be particularly difficult to manage. Normal cervical muscle tone can splint the damaged spine to provide additional protection, 29 although there is little evidence to support this. Once the airway has been secured, a neurological assessment can ensure there has been no secondary injury.…”

“…In an observational study of 327 patients with cervical spine disease, 39% were intubated using an awake fibreoptic approach. 29 Anaesthetists were more likely to use this technique if patients had myelopathy, unstable or fractured vertebrae or spinal canal stenosis. The authors consider these criteria suitable for the use of awake fibreoptic intubation.…”

Neuroanesthesiology Review—2007

“…In an observational prospective cohort study, Manninen et al 175 documented the approach to airway management in 327 patients presenting for cervical spine surgery. The tracheas of 39% of patients were intubated fiberoptically before induction of general anesthesia and 61% were intubated after induction.…”

Effects of propofol or sevoflurane anesthesia induction on hemodynamics in patients undergoing fiberoptic intubation for cervical spine surgery: A randomized, controlled, clinical trial

“…[1] Several intubating devices have been proposed for the management of airways in patients with neurological conditions to minimize spinal cord compression and distortion due to mechanical effects of intubation,[2] and many anesthesiological approaches have been proposed to minimize the hemodynamic instability after anesthesia induction. [3] Among these, fiberoptic intubation (FOI) with topical anesthesia and mild systemic sedation are the preferred intubating techniques[4] as they guarantee minimal neck motion and adequate conditions for endotracheal tube positioning as well as hemodynamic stability.…”