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Spinal Cord Injury As a Result of Endotracheal Intubation in Patients with Undiagnosed Cervical Spine Fractures

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(1)

Spinal cord injury as a result of endot

racheal intubation in patients with und

iagnosed cervical spine fractures

National Taiwan University Depart

ment of Anesthesiology

(2)

Case 1

A 45-yr-old unrestrained man

suffered bilateral femoral shaft

fractures and a closed bead injury

resulting from a motor vehicle

collision in which he was the driver.

On admission to a peripheral

hospital. His Glasgow Coma Scale

was 15, although he was reported

by the paramedical staff to have

(3)

No cervical spine radiographs were

obtained; and the patient was transferred

to King Edward VIII Hospital for operative

fixation of the fractures. On repeated

examination by the orthopedic registrar,

the patient was fully conscious with

normal power and sensation in the upper

limbs. No sensory deficit was detected in

the lower limbs; power was not assessed

because of the femoral fractures.

(4)

Although he complained of neck pain, cer

vical spine radiographs were again omitte

d. The induction of general anesthesia w

as comlicated by aspiration of gastric con

tents during tracheal intubation, which wa

s achieved rapidly but without any effort t

o immobilize the cervical spine. On emer

gence after operation, the patient could n

ot breathe spontaneously, and he was tra

nsferred to the surgical intensive care uni

(5)

Neurologic examination revealed complet

e quadriplegia.

A lateral cervical spine rad

iograph showed a fracture of the pedicle

of C2 with anterior subluxation of C2 on

C3. Results of computed tomographs of t

he lower cervical and upper thoracic spin

e were normal. Halter neck traction was a

pplied. The SICU course was complicate

d by nosocomial pneumonia and acute re

nal failure, but the patient was discharged

after 36 days. Complete neurologic recov

ery occurred within a further 5 weeks.

(6)

Case 2

A 22-yr-old man was admitted after multiple

low-velocity gunshot wounds of the neck (through an

d through zone II-the area between the crcoid ca

rtilage and angle of the mandible), abdomen (ent

rance-only subumbilical), and leg (through and th

rough calf). On examination by the surgical regist

rar, he was found to be fully conscious, in no res

piratory distress, and hemodynamically stable.

(7)

There were no motor or sensory deficits in the

limbs, and rectal examination revealed norma

l sphincter tone. Tenderness and guarding wa

s found on abdominal examination. A lateral c

ervical spine radiograph showed the upper fiv

e cervical vertebrae only, of which no abnorm

ality was evident. The film was not repeated n

or were any other views obtained. The patient

was transferred to the operating theater for la

parotomy. Before induction of anesthesia, no

neurologic deficits were evident.

(8)

Anesthesia was induced, and tracheal intubation

was performed without any effort to immobilize th

e cervical spine. At laparotomy, multiple small int

estinal perforations were repaired. At the end of t

he procedure, neuromuscular blockade was reve

rsed, and the trachea was extubated, but respirat

ory distress was noted, and the neck appeared to

be swollen. The trachea was reintubated, again

without cervical spine stabilization. Bilateral neck

exploration was undertaken, but no reason for re

spiratory distress was found. The bullet track was

described to pass toward the vertebral bodies, bu

t no fracture was documented.

(9)

Reversal of intramuscular blockade was again complicated by severe respiratory distress, and thus the patient was tra nsferred to the SICU with the trachea intubated. Neurologi c examination revealed an incomplete deficit. Ventilation w as by diaphragmatic movement alone. Sensation was inta ct, but motor function was absent in both upper limbs, trun k and right lower limb. The left lower limb showed grade 1/ 5 power. Sphincter tone was normal. A computed tomogra phy (CT) scan showed a burst fracture of the body of C6 w ith retropulsion of a large fragment with narrowing of the di ameter of the spinal canal. Initial treatment was by cones calipers with 2 pounds of traction for spinal immobilization. Later the patient had spinal fusion. The patient regained fu ll mobility and function and was discharged from our care 7 months later.

(10)

Case 3

A 64-yr-old man admitted for elective laparoscopic ch olecystectomy for gallstones, having had the operatio n postoned on two previous occasions for non-medic al reasons. He noted a history of pain in the region of

his right shoulder, which his general practicitioner had ascribed to referred pain from his gall bladder exacer bated by stress. He admitted to occasional pain in his neck, which he said caused him no problems. His me

dical history included an appendicectomy complicate d by peritonitis, diet-controlled diabetes mellitus, and

osteoarthritis for which he had undergone knee arthro scopy. He denied any other medical problems.

(11)

At induction he was given midazolam, propofol, fe ntanyl and atracrium and a size 5 LMA was inserted. The insertion of the LMA was described as straightfor

ward by the anaesthetist and did not involve any unto ward movements of the neck or jaw thrust. The ultima

tely successful surgery was complicated by the prese nce of adhesions and lasted for 75 min. The lowest n

on-invasive systolic blood pressure recorded during t he anaesthetic was 100 Hg. The LMA was removed

with jaw opening but without head movement in recov ery. The patient complained of abdominal pain, for wh ich he was treated with opiate and a non-steroidal ant i-inflammatory drug. He was transferred to the ward a

(12)

Approximately 1 h after the patient had been returned to the ward it was noted that he had difficulty in movin g his legs and there was no sensation to pain or touc h in his abdomen. A weak cough was noted but there was good air entry into the lungs bilaterally. Shortly th

ereafter he was seen by a consultant neurologist, wh o noted no movement in the legs and weakness of el bow extension together with weakness of the left arm distally. The level of sensation to pinprick was C5/6 o n both sides with poor joint position sense in his left lit

tle finger. Joint position and vibration sense was abse nt in both legs. The patient was managed with a cervi cal collar and urinary catheterization, and an MRI sca n was performed. A consultant neuroadiologist report ed these images as showing a rupture of the posterio

(13)

The patient was admitted to ITU where methyl

prednisolone 3 g was given over 15 min. He

was then transferred to the regional neurologi

cal centre, where he underwent C5/6 discecto

my with insertion of a wedge of bone. At oper

ation, a completely ruptured and very oedema

tous posterior spinal ligament was found at th

e site. Since that time the patient has made lit

tle recovery and he remains effectively tetrapl

egic. He has undergone further uncomplicate

d surgery for small bowel obstruction due to h

erniation of bowel through a hole in the mese

(14)

After the laparoscopic cholecystectomy, th

e patient’s wife admitted that the patient had v

isted his general practitioner on the day befor

e surgery as he was experiencing weakness i

n his legs and had had some difficulty in walki

ng. He was also suffering from severe neck p

ain, necessitating him sleeping upright on the

night before surgery in a chair. However, ther

e was no history of trauma to the neck. He ha

d failed to inform the anaesthetist of these fac

ts, as he was worried that his surgery would a

gain be cancelled.

(15)

Cervical spine motion with direct Laryngos

copy and orotracbeal intubation

Methods: Ten patients without clinical or radiographi

c evidence of cervical spine abnormaility underwent l aryngoscopy using a #3 Macintosh blade while under general anesthesia and neuromuscular blockade. Cer

vical motion was recorded with continuous lateral fluoroscopy. The intubation sequence was divided in

to distinct stages and the corresponding fluoroscopic images were digitized. Segmental motion, occiput thr ough C5, was calculated for each stage using the digi

(16)

Results: During exposure and laryngoscope blade ins

ertion, minimal displacement of the skull base and ro

stral cervical vertebral bodies was observed. Visua

lization of the larynx created superior rotation of the

occiput and C1 in the sagittal plane, and mild inferi or rotation of C3-C5. C2 maintained nearneutral po sture. This pattern of displacement resulted in extensi

on at each motion segment, with the most significant motion produced at the occipitoatlantal and atlantoaxia l joints (mean=6.8 and 4.7 , respectively). Intubation cr eated slight additional superior rotation at the occiput a nd C1, without substantial alteration in the posture of C2-C5. After laryngoscope removal, position trended t oward baseline at all levels, although exact neutral pos

(17)

Conclusions: This investigation quanti

fies the behavior of the normal cervical

spine during direct laryngoscopy with

a Macintosh blade. With this maneuver

, the vast majority of cervical motion i

s produced at the occipitoatlantal and

atlantoaxial joints. The subaxial cervical

segments (C2-C5) are displaced only mini

mally. This study establishes a highly relia

ble and reproducible method for analyzing

cervical motion in real time.

(18)
(19)
(20)

The intubating laryngeal mask (Fastrach TM) caused l

ess extension (at C1-2 and C2-3) than intubation by d irect laryngoscopy. Direct laryngoscopy is still the fast

est method to secure an airway provided no intubatin g difficulties are present. However, in trauma patients requiring rapid sequence induction and in whom cervi cal spine movement is limited or undersirable, the int ubating laryngeal mask (Fastrach TM) is a safe and f ast method by which to secure the airway.

Tracheal intubation and cervical spine excursio

n: direct laryngoscopy vs. intubating laryngeal

mask

(21)

Fluoroscopic comparison during intubatio

n with lighted stylet, GlideScope, and m

acintosh laryngoscope

C-spine movement was reduced 57% using the

Lightwand versus direct Macintosh Laryngosco

py.

C-spine motion was reduced by 50% at the

C2-5 segment for GlideScope versus Macintosh lar

yngoscopy.

There was no significant difference in duration

(22)

The etiology of missed

cervical spine injuries

Injuries to the cervical spine are not

uncommon.

incidence: 1.5~5 per 100000 population.

Up to 10% of these patients arrive

neurologically intact at the trauma

center or emergency department, but

(23)

Reid et al. noted the emergence of seco

ndary neurologic deficits in 10.5% of pat

ients with delays in diagnosis. (J Traum

a 1987)

The cause of missed cervical injuries ha

s been suggested as being due to (1) la

ck of an appropriate index of suspicion

(2)inadequate testing.

(24)

Recommendations for reducing delayed diag

nosis of these injuries have included adoption

of the five-view cervical spine roentgenogram

series. (AP odontoid, lateral and oblique) and

CT scans. (J trauma 1987)

Misinterpretation of the roentgenograms that

were obtained ranked as the second most im

portant cause of missed C-spine injures. This

error was responsible for 47% of the missed d

iagnoses.

(25)

Patients with neck pain and “normal” cervical

roentgenograms should be presumed to have

an occult cervical spine injury and be maintai

ned with cervical precautions in place until the

diagnosis can be made.

In conclusion, most errors (94%) leading to th

e missed/delayed diagnosis of C-spine injurie

s were fundamental (failure to obtain a techni

cally adequate three-view C-spine injuries, mi

sinterpretation of roentgenograms) and did no

t require sophisticated interpretive skills or ad

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