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
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
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.
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
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.
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.
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.
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.
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.
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.
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
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
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
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.
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
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
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.
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.