Can airway complications following multilevel anterior cervical surgery be avoided?

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> 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.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> 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.</jats:p> <jats:p content-type="fine-print">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.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> 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.</jats:p>

Effect of steroid use in anterior cervical discectomy and fusion: a randomized controlled trial

“…In addition, the more life-threatening complication of postoperative airway problems may occur in up to 6% of patients. 4,9,11,29 Kepler et al 16 also found significantly increased dysphagia and soft-tissue shadowing on postoperative radiographs after 1-and 2-level ACDFs. The swelling decreased by 6 weeks but remained significant.…”

“…The severity and potential life-threatening nature of these complications from anterior cervical spinal surgery have prompted more thorough evaluations of their incidence and associated risk factors. 3,6,9,11,13,19,24,[27][28][29]33 The reported rates of dysphagia after anterior cervical surgery have varied widely, from 1% to 79%. 9 In a prospective study, Lee et al 19 found the prevalence of postoperative dysphagia at 1, 2, 6, 12, and 24 months to be 54%, 34%, 19%, 15%, and 14%, respectively.…”

“…4,9,11,29 Three patients who had significant symptoms of respiratory difficulty required intubation; all of them had been randomly assigned to the placebo group and ultimately required intravenous dexamethasone for control of airway edema. Airway issues and need for intubation trended toward significance (p = 0.057 and 0.083, respectively) and may prove significant with repeated studies in larger populations.…”

“…It has been reported that more concerning, potentially life-threatening complications of airway compromise can occur in up to 6% of patients and that 2% require intubation. 4,9,11,29 Believed to be related to the retraction of midline structures during surgery, edema has obJect Anterior cervical discectomy and fusion (ACDF) is an effective procedure for the treatment of cervical radiculopathy and/or myelopathy; however, postoperative dysphagia is a significant concern. Dexamethasone, although potentially protective against perioperative dysphagia and airway compromise, could inhibit fusion, a generally proinflammatory process.…”

Cervical Decompression and Unexpected Soft Tissue Oedema: Case Report

“…All were present in the case reported here. Epstein et al also noted asthma, age > 65 year, obesity (> 100kgs) and severe postoperative neurological deficit (8). Prolonged and excessive deep tissue retraction can be a predisposing factor in the development of UAO.…”