Upper Airway Obstruction After Cervical Spine Fusion Surgery: Role of Cervical Fixation Angle

Lee, Yi-Hui; Hsieh, Pei-Fang; Huang, Hurng‐Wern; Chan, Kuang-Cheng

doi:10.1016/s1875-4597(08)60008-9

Cited by 23 publications

(13 citation statements)

References 11 publications

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“…To the best of our knowledge, there have been only two reports in the international literature addressing this issue [1,2]. Potential causes of airway obstruction in cervical spine surgery or injury include pharyngeal edema [1][2][3][4][5][6], hematoma [7,8], cerebrospinal fluid leak [4,9], angioedema [10], graft or plate dislodgement [11,12], recurrent laryngeal nerve injury [13], and overflexion fixation of the cervical spine [1,2,14]. The most common cause is pharyngeal edema [15].…”

Section: Discussionmentioning

confidence: 99%

“…However, it is not widely known that a cervical fusion in a flexed position may cause upper airway obstruction. There are only a limited number of reports describing the issue [1,2]. This is a case report of upper airway obstruction after posterior occipitocervical fusion in a patient with rheumatoid arthritis.…”

Section: Introductionmentioning

confidence: 99%

“…The most common cause of this complication is pharyngeal edema [1][2][3][4][5][6]. However, it is not widely known that a cervical fusion in a flexed position may cause upper airway obstruction.…”

Section: Introductionmentioning

confidence: 99%

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Upper airway obstruction associated with flexed cervical position after posterior occipitocervical fusion

et al. 2010

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Upper airway obstruction resulting from overflexion fixation of the cervical spine is a rare but life-threatening complication after cervical spine surgery. There are few reports of dyspnea after a posterior cervical fusion. We present the case of a 63-year-old woman with rheumatoid arthritis who developed an upper airway obstruction immediately after an O-C4 fusion. She was reintubated with a fiberoptic scope. Revision surgery allowing the angle to return to the neutral position was performed to ameliorate the overflexion of the cervical spine fixation and the consequent upper airway obstruction. After revision surgery, the upper airway obstruction disappeared. Our experience suggests that intraoperative use of fluoroscopy and extubation with a tube exchanger are recommended to avoid this complication, especially in patients at high risk of upper airway obstruction.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Upper airway obstruction associated with flexed cervical position after posterior occipitocervical fusion

et al. 2010

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“…Numerous case reports of fixed flexion of the cervical spine have described postoperative airway obstruction as a result of overflexion of the cervical spine. [1][2][3] Although the application of halo immobilization in cervical spine fractures has been shown to result in acute airway compromise, 4 these patients are usually immediately symptomatic. In this case report, we describe a patient who did not experience respiratory distress immediately following placement of a halo orthosis; rather, she developed almost complete airway obstruction during topicalization of her airway in preparation for awake intubation.…”

Section: Résumémentioning

confidence: 99%

Cervical spine overflexion in a halo orthosis contributes to complete upper airway obstruction during awake bronchoscopic intubation: a case report

White

Wong

Goldstein

et al. 2014

Can J Anesth/J Can Anesth

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Purpose We present a case of upper airway obstruction in a patient with an unstable cervical spine fracture in a halo orthosis. We also describe the mechanism by which the obstruction occurred and identify features that predispose patients in a halo orthosis to upper airway obstruction. Case An 81-yr-old female presenting to hospital with an unstable cervical spine fracture was scheduled for spinal fusion. She was fitted with a halo traction device in a flexed position, and an awake tracheal intubation was planned. The patient's airway was topicalized and 1 mg of midazolam was administered. Her oxygen saturation dropped, and mask ventilation was difficult and insufficient. She then became unresponsive and pulseless.

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“…Although, the true cause of D/D has not been elucidated, cervical flexed alignment has been thought to be a major factor, in addition to pharyngeal edema or a postoperatively enlarged tongue [5][6][7].…”

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confidence: 99%

The O-C2 angle established at occipito-cervical fusion dictates the patient’s destiny in terms of postoperative dyspnea and/or dysphagia

et al. 2013

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Purpose We have revealed that the cause of postoperative dyspnea and/or dysphagia after occipito-cervical (O-C) fusion is mechanical stenosis of the oropharyngeal space and the O-C2 alignment, rather than total or subaxial alignment, is the key to the development of dyspnea and/or dysphagia. The purpose of this study was to confirm the impact of occipito-C2 angle (O-C2A) on the oropharyngeal space and to investigate the chronological impact of a fixed O-C2A on the oropharyngeal space and dyspnea and/or dysphagia after O-C fusion. Materials and methods We reviewed 13 patients who had undergone O-C2 fusion, while retaining subaxial segmental motion (OC2 group) and 20 who had subaxial fusion without O-C2 fusion (SA group). The O-C2A, C2-C6 angle and the narrowest oropharyngeal airway space were measured on lateral dynamic X-rays preoperatively, when dynamic X-rays were taken for the first time postoperatively, and at the final follow-up. We also recorded the current dyspnea and/or dysphagia status at the final followup of patients who presented with it immediately after the O-C2 fusion.Results There was no significant difference in the mean preoperative values of the O-C2A (13.0 ± 7.5 in group OC2 and 20.1 ± 10.5 in group SA, Unpaired t test, P = 0.051) and the narrowest oropharyngeal airway space (17.8 ± 6.0 in group OC2 and 14.9 ± 3.9 in group SA, Unpaired t test, P = 0.105). In the OC2 group, the narrowest oropharyngeal airway space changed according to the cervical position preoperatively, but became constant postoperatively. In contrast, in the SA group, the narrowest oropharyngeal airway space changed according to the cervical position at any time point. Three patients who presented with dyspnea and/or dysphagia immediately after O-C2 fusion had not resolved completely at the final follow-up. The narrowest oropharyngeal airway space and postoperative dyspnea and/or dysphagia did not change with time once the O-C2A had been established at O-C fusion. Conclusions The O-C2A established at O-C fusion dictates the patient's destiny in terms of postoperative dyspnea and/or dysphagia. Surgeons should pay maximal attention when establishing the O-C2A during surgery, because their careless decision for the O-C2A may cause persistent dysphagia or a life-threatening consequence. We recommend that the O-C2A in O-C fusion should be kept at least at more than the preoperative O-C2A in the neutral position.

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Upper Airway Obstruction After Cervical Spine Fusion Surgery: Role of Cervical Fixation Angle

Cited by 23 publications

References 11 publications

Upper airway obstruction associated with flexed cervical position after posterior occipitocervical fusion

Upper airway obstruction associated with flexed cervical position after posterior occipitocervical fusion

Cervical spine overflexion in a halo orthosis contributes to complete upper airway obstruction during awake bronchoscopic intubation: a case report

The O-C2 angle established at occipito-cervical fusion dictates the patient’s destiny in terms of postoperative dyspnea and/or dysphagia

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