Neurological deterioration during intubation in cervical spine disorders

Abstract

Anaesthesiologists are often involved in the management of patients with cervical spine disorders. Airway management is often implicated in the deterioration of spinal cord function. Most evidence on neurological deterioration resulting from intubation is from case reports which suggest only association, but not causation. Most anaesthesiologists and surgeons probably believe that the risk of spinal cord injury (SCI) during intubation is largely due to mechanical compression produced by movement of the cervical spine. But it is questionable that the small and brief deformations produced during intubation can produce SCI. Difficult intubation, more frequently encountered in patients with cervical spine disorders, is likely to produce greater movement of spine. Several alternative intubation techniques are shown to improve ease and success, and reduce cervical spine movement but their role in limiting SCI is not studied. The current opinion is that most neurological injuries during anaesthesia are the result of prolonged deformation, impaired perfusion of the cord, or both. To prevent further neurological injury to the spinal cord and preserve spinal cord function, minimizing movement during intubation and positioning for surgery are essential. The features that diagnose laryngoscopy induced SCI are myelopathy present on recovery, short period of unconsciousness, autonomic disturbances following laryngoscopy, cranio-cervical junction disease or gross instability below C3. It is difficult to accept or refute the claim that neurological deterioration was induced by intubation. Hence, a record of adequate care at laryngoscopy and also perioperative period are important in the event of later medico-legal proceedings.

Airway management in the presence of cervical spine instability: A cross-sectional survey of the members of the Indian Society of Neuroanaesthesiology and Critical Care

“…Despite the lack of evidence demonstrating benefit with indirect intubation techniques on patient-important outcome (post-intubation new-onset neurological injury),[ 2 ] and the lack of evidence for harms with direct techniques,[ 14 15 16 17 18 19 ] indirect techniques of intubation continue to be widely used in patients with CSI. [ 20 ] Recently, two indirect intubation techniques (fibreoptic and intubating LMA) were found to be similar with respect to new-onset motor deficit (a patient-important outcome measure) and cervical spine movement.…”

Neurological complications in adult spinal deformity surgery

“…Nerve root injury, as confirmed by electromyography (EMG) monitoring, occurred in 1 % of cases and was due to improper lateral mass screw placement. SCI has also been reported as a sequelae of cervical hyperextension during intubation [29]. Alternative intubation techniques should be performed in patients with cervical myelopathy, posttraumatic deformities, instability, or other risk factors for SCI.…”

Airway management in a patient of ankylosing spondylitis with traumatic cervical spine injury

“…[ 5 ] While it is hard to accuse intubation as a sole donor to spinal cord injury in such cases but one should not underscore the need to exert caution while intubating these patients. [ 6 ] In our case, the patient was in severe pain, lying in left lateral position and was unable to lie supine. He was supported with pillows for comfort, airway blocks were done with great difficulty in the lateral position due to distorted anatomy and difficult access.…”