Cervical Injury after Videolaryngoscopy in Patient with Ankylosing Spondylitis: Comment

Abstract

T he recent article by Epaud et al. 1 reinforces the need for anesthesiologists to be comfortable with the flexible fiberoptic intubation technique. I read with great concern that a neurologic injury occurred because of the choice of videolaryngoscopy as the intubation approach because the operator was more familiar with that technique. Was the decision to use videolaryngoscopy a result of our anesthesiology training programs shifting the focus of difficult airway training to videolaryngoscopy because this technique is readily available and relatively easy to use compared to flexible fiberoptic intubation? It has been demonstrated that videolaryngoscopy does not significantly reduce cervical spine movement compared to direct laryngoscopy 2 and, unfortunately, patient harm occurred in the authors' case presentation.The authors endorse that flexible fiberoptic intubation could have been used to avoid injury; the use of fiberoptic intubation mitigates cervical spine movement because it is flexible and can be manipulated in difficult anatomy presentations. A randomized clinical trial showed that there was no difference in intubation time and success rate 3 between videolaryngoscopy and flexible fiberoptic intubation in experienced hands. That is the key: experience! Anesthesiology residency programs should not compromise training in flexible fiberoptic intubation because of the relative ease of use and convenience of videolaryngoscopy, and American Board of Anesthesiology/Accreditation Council for Graduate Medical Education requirements should reflect this.

Relationship Between Glottic View and Intubation Force During Macintosh and Airtraq Laryngoscopy and Intubation

“…For example, a recent case report describes a cervical spine fracture occurring in a patient with ankylosing spondylitis in whom the glottis could not be visualized with a videolaryngoscope. 2,15 In addition, there are case reports of videolaryngoscope blade fractures, which require hundreds of Newtons of applied force. 16…”

“…For example, a recent case report describes a cervical spine fracture occurring in a patient with ankylosing spondylitis in whom the glottis could not be visualized with a videolaryngoscope. 2,15 In addition, there are case reports of videolaryngoscope blade fractures, which require hundreds of Newtons of applied force. 16 Another limitation of our study was that anesthesiologists were tasked to achieve the best possible glottic view whereas, in clinical practice, a glottic view sufficient only to place the endotracheal tube in the glottis may more often be the goal.…”

Cervical Injury after Videolaryngoscopy in Patient with Ankylosing Spondylitis: Comment

“…W e express our condolences to Epaud et al and to their patient with ankylosing spondylitis who experienced a C5-C6 cervical spine fracture in association with a difficult videolaryngoscopic intubation. 1 Their image report adds to existing reports of intubation-mediated cervical spine injury in patients with ankylosing spondylitis and conveys several important clinical messages.…”

“…In their report, Epaud et al state that there were "difficulties in exposing the epiglottis" and a bougie was utilized. 1 Therefore, because of impaired glottic visualization, it is likely Epaud et al applied a greater amount of force with the videoscope than they would have normally, causing the fracture.…”

Cervical Injury after Videolaryngoscopy in Patient with Ankylosing Spondylitis: Reply

“…We thank Drs. Hindman and Dexter 1 and Dr. Cometa 2 for their interest in our image in clinical medicine relaying a cervical spine injury secondary to videolaryngoscopy. 3…”