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Journal of Clinical Anesthesia (2013) 25, 6672

Special Article

Airway compromise due to laryngopharyngeal edema after


anterior cervical spine surgery,
Mark A. Palumbo MD (Chief, Division of Spine Surgery),
Jessica Pelow Aidlen MD (Spine Fellow), Alan H. Daniels MD (Resident),
Aaron Bianco MD (Spine Fellow),
Joseph M. Caiati MD [Clinical Assistant Professor of Surgery (Anesthesiology)]
Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI 02905, USA

Received 17 February 2012; revised 29 May 2012; accepted 2 June 2012

Keywords:
Abstract Postoperative airway compromise due to laryngopharyngeal edema is a potentially serious
Adverse event;
adverse event associated with anterior cervical spine surgery. The reported incidence of this
Postoperative airway
complication has varied from 1.2% to 6.1%, with a higher incidence following multi-level surgery. The
compromise;
relevant literature on airway compromise following anterior cervical spine surgery is reviewed.
Cervical spine surgery;
2013 Elsevier Inc. All rights reserved.
Laryngopharyngeal edema

1. Introduction Sagi et al documented a 6.1% incidence of airway


complications, with 1.9% of patients requiring reintubation
Cervical spine surgery is commonly performed by [2]. Manninen et al reported acute postoperative airway
orthopedic and neurological surgeons. These procedures obstruction requiring intubation in 1.2% of patients under-
generally involve decompression of the neural elements by going cervical spine procedures [3]. Investigations of
discectomy or corpectomy in combination with reconstruc- combined anterior and posterior cervical fusion by Hart
tion of the spinal column at one or more levels. One of the et al [4] and Terao et al [5] showed a high incidence of
most serious adverse events associated with anterior cervical airway edema requiring delayed extubation or emergent
spine surgery is postoperative airway compromise due to reintubation in 5 of 13 and 7 of 10 patients, respectively.
edema of the laryngopharynx and prevertebral soft tissues. Postoperative airway compromise due to soft tissue edema
Emery et al. reported significant postoperative airway presents a challenging clinical scenario. The primary objective
obstruction in 2.8% of 108 patients following anterior of this review is to describe a systematic approach to
decompression and noninstrumented fusion [1]. In a maintenance of an airway after anterior cervical spine surgery.
retrospective review of 311 anterior cervical procedures,

No outside funding was obtained for this study.
2. Anatomy

The authors have no conflicts of interest or other relevant relevant
financial disclosures to report. Effective management of airway compromise after cervical
Correspondence: Mark A. Palumbo MD, Chief, Division of Spine
spine surgery requires an understanding of the anatomy of the
Surgery, Department of Orthopaedic Surgery, Alpert Medical School of
Brown University, 2 Dudley St., Providence, Rhode Island 02905, USA.
upper respiratory tract and the surgical approach. In the adult
Tel.: +1 401 457 1595; fax: +1 401 457 2141. upper airway, the epiglottis separates the oropharynx from the
E-mail address: mpalmd@aol.com (M.A. Palumbo). laryngopharynx at approximately the level of the fourth

0952-8180/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jclinane.2012.06.008
Airway edema after cervical spine surgery 67

cervical vertebra (Fig. 1). The larynx, extending from the collection, and construct failure. In some patients, vocal
lower pharynx to the trachea, is composed of a cartilaginous cord dysfunction from intraoperative recurrent laryngeal
skeleton, which includes the thyroid and cricoid cartilage and nerve trauma may coexist with laryngopharyngeal edema.
the intervening cricothyroid membrane. Direct trauma to the pharyngeal mucosa during a difficult
The surgical approach for anterior cervical spine surgery intubation may contribute to the development of edema.
may be performed from either the right or left side of the Swelling of the prevertebral soft tissues related to surgical
anterior neck via a transverse or longitudinal incision. Access manipulation also compromises the airway lumen [6,7]. Suk
to the vertebral column is achieved by dissection in the plane et al found that prevertebral tissue edema in cases of one or
between the carotid sheath and the midline viscera (Fig. 2). two-level anterior cervical discectomy and fusion (ACDF)
During surgery, the upper airway structures and esophagus peaked on the second and third days after surgery, with
are retracted in a medial direction. The longus colli swelling noted to be predominant at the C2-C4 levels [6]. In
musculature is elevated off the ventral surface of the spine the case of anterior-posterior surgery, surgical manipulation
to expose the vertebral bodies and disc spaces. of the ventral soft tissues combined with the dependent
position of the upper respiratory tract in a prone patient may
3. Etiology potentiate both laryngopharyngeal and prevertebral edema.

Airway compromise after cervical spine surgery is most 4. Diagnostic considerations


commonly produced by edema of the laryngopharynx and
prevertebral soft tissues [1,2]. Other less common causes The underlying cause of airway compromise is suggested
include wound hematoma, abscess, cerebrospinal fluid by the elapsed time to symptom onset after the operation

Fig. 1 Midsagittal section of the upper respiratory tract. Path for direct laryngoscopic orotracheal intubation (arrow A). Path for surgical
cricothyrotomy (arrow B). Path for high surgical tracheostomy (arrow C). OP = oropharynx, LP = laryngopharynx, TR = trachea, ES =
esophagus, EP = epiglottis, TC = thyroid cartilage, CC = cricoid cartilage. Reproduced with permission from: Palumbo MA, Aidlen JP,
Daniels AH, Thakur NA, Caiati J. Airway compromise due to wound hematoma following anterior cervical spine surgery. Open Orthop J
2012;6:10813.
68 M.A. Palumbo et al.

Fig. 2 Anterior cervical approach to the spine (cross-sectional view). Note the potential space created by dissection in the plane between the
carotid sheath and the midline viscera. The carotid sheath structures are retracted laterally, and the esophagus and trachea are retracted medially
to expose the ventral surface of the spine. Reproduced with permission from: Albert T, Balderston R, Northrup B. Surgical Approaches to the
Spine. Philadelphia: W.B. Saunders; 1997. p. 10.

(Table 1). Airway compromise due to pharyngeal/prevertebral compromise, dyspnea, inspiratory stridor, and cyanosis
edema most typically occurs during the early postoperative develop and may progress to respiratory failure/arrest.
period (1272 hrs after completion of surgery). In certain cases of delayed airway compromise, laboratory
Upper airway edema may produce a spectrum of and radiologic data may be available. Arterial blood gas
clinical findings. The patient may progress at a variable analysis generally indicates some degree of hypercarbia and
rate from being asymptomatic to exhibiting signs of partial hypoxia. Lateral radiography and computed tomography of
occlusion and then complete obstruction. In the early the cervical spine may identify prevertebral soft tissue
stages of airway compromise, complaints of difficulty swelling (Fig. 3A-E). From the standpoint of diagnosis, it
breathing and talking predominate. Breathing problems should be emphasized that postoperative airway compromise
may be exacerbated by the supine position. Subtle changes requires immediate attention to prevent a poor outcome. The
in voice quality may be evident. Oxygen saturation is often essential diagnostic tool is bedside evaluation by an
normal at this point but this does not rule out an experienced provider who understands the range of contrib-
impending airway problem. As the process evolves, the uting factors and the importance of timely intervention.
patient may become restless and agitated due to hypercar- Definitive action should not be delayed for the purpose of
bia (with or without hypoxia). In the later stages of airway obtaining other types of data.

Table 1 Probable etiology of airway compromise after 5. Prevention


anterior cervical spine surgery
Postoperative Time elapsed Probable causative factor The effective prevention of postoperative airway compli-
period from surgery cations after anterior cervical spine surgery requires
cooperation and communication among the anesthesiologist,
Immediate b 12 hours Wound hematoma
the surgeon, and the clinicians responsible for postoperative
Early 1272 hours Pharyngeal/prevertebral edema
Late N 72 hours Abscess, CSF accumulation, care. The primary objective of the airway management plan
construct failure is to allow recovery to proceed with minimal risk of airway
loss. In this regard, the probability of postoperative airway
CSF = cerebrospinal fluid.
compromise may be reduced by attention to certain
Airway edema after cervical spine surgery 69

Fig. 3 Prevertebral edema after anterior-posterior decompression and fusion from C3-T1. A. Lateral radiograph. B, C, D, E. Sequential
axial computed tomography sections. Note the increased thickness of the prevertebral soft tissues (*) and constriction of the airway lumen
ventral to the C3-C5 vertebrae (arrow).
70 M.A. Palumbo et al.

Table 2 Risk factors for postoperative airway compromise


Primary Secondary
Surgical Patient Anesthetic Institutional
Exposure of N 3 vertebral bodies Morbid obesity Grade 3 or 4 view No 24-hour inhouse anesthesia care
Exposure of C2-C4 levels Obstructive sleep pnea Multiple intubation attempts No 24-hour inhouse surgical staff
Blood loss Pulmonary disease
N 300 mL
Operative time Cervical myelopathy
N 5 hours
Dual approach operations Previous anterior cervical surgery
Swelling secondary to BMP use
BMP = bone morphogenetic protein.

anesthetic and surgical principles during the procedure and edema and postoperative airway complications [10-12].
adherence to a patient-specific protocol for airway protection Anesthetic factors that warrant consideration include sub-
after the operation. optimal visualization of the glottis (Grade 3 or 4 view,
according to the Cormack & Lehane Grading System) [13])
6. Anesthetic and surgical principles or a problematic intubation process (multiple attempts).
While the patient profile and anesthetic variables are
relevant, recent data implicate intraoperative surgical factors
There are a number of basic anesthesia and intraoperative
as the more important determinants of risk [2,4]. Variables
surgical tactics that may potentially reduce the risk of
found to be statistically associated with airway compromise
postoperative airway complications. Irrespective of the
include exposure of more than three vertebral bodies,
intubation technique employed, atraumatic placement of
exposures involving the C2-C4 levels, blood loss exceeding
the endotracheal tube (ETT) on the first attempt is optimal.
300 mL, and surgical time of more than 5 hours, or
Multiple attempts to secure the airway may traumatize the
preexisting spinal cord dysfunction (myelopathy). Surpris-
mucosa and lead to intrinsic edema of the laryngopharynx.
ingly, pulmonary problems, smoking, anesthetic risk factors,
Likewise, the surgical team should make every effort to
and absence of a drain did not correlate with airway
avoid excessive soft tissue trauma. Handheld and self-
compromise [2]. In addition, patients undergoing combined
retaining retractors must be carefully deployed, especially at
anterior-posterior cervical procedures are at increased risk of
the upper cervical levels.
airway complications compared with single-approach oper-
Perioperative corticosteroids have been used as a means
ations [5,14,15].
of reducing edema of the upper airway and prevertebral soft
tissues following anterior cervical spine surgery. The
efficacy of a steroid regimen in reducing the rate of 8. Airway protection protocol
postoperative airway compromise remains unproven [8,9].
In a recent prospective randomized study, the use of
Safe postoperative care after anterior cervical spine
dexamethasone did not result in a lower incidence of delayed
surgery requires identification of those patients who are at
extubation after multiple-level anterior cervical corpectomy
increased risk of airway complications due to laryngophar-
and fusion [9]. For the surgeon who elects to administer
yngeal edema. At the conclusion of surgery, risk factors
perioperative steroids, the regimen described by Emery et al
specific to the case must be identified (Table 2). The primary
is a reasonable method [9]. Dexamethasone is infused just
determinants of risk relate to the surgical procedure [2,5,16].
prior to incision at a dosage of 0.3 mg/kg (approximately 20
Secondary risk factors consist of patient characteristics,
mg). A dose of 0.15 mg/kg (approximately 10 mg) is
anesthetic considerations, and institutional resources.
delivered at 8 and 16 hours after the index dose.
A proven formula for quantifying the risk of airway
obstruction after cervical spine surgery does not exist.
7. Risk factor analysis Nevertheless, the probability of an airway complication due
to laryngopharyngeal edema must be estimated in each case.
Patient characteristics that potentially influence the risk of In this regard, the number of primary (ie, surgical) risk
airway problems include morbid obesity, obstructive sleep factors allows for stratification of patients into low,
apnea, chronic obstructive pulmonary disease, cervical intermediate, or high-risk categories. This classification
myelopathy, and previous anterior cervical surgery. The scheme, along with consideration of secondary risk factors
off-label use of recombinant bone morphogenic protein-2 for for airway compromise, provides a rational basis for
anterior cervical fusion correlates with increased prevertebral selection of a plan for postoperative airway management.
Airway edema after cervical spine surgery 71

The low-risk category for postoperative airway compli- verified and optimal clinical expertise is available in the
cations includes those patients who undergo a limited event of a failed extubation. As such, the intubated patient
anterior cervical procedure associated with no primary (ie, may be considered for extubation at 24 to 36 hours after the
surgical) risk factors. Airway compromise due to the conclusion of surgery. The specific time point to assess the
operation is unlikely and the risk of extubation is minimal. patient for extubation should be chosen to coincide with a
An example of such a procedure is a one or two-level anterior period of maximal clinical support.
cervical decompression and reconstruction caudal to C4. In With respect to the method of verifying airway patency,
general, these individuals may be safely extubated in the the cuff leak test may be used [1,3,11,17]. The technique is
operating room and then transferred to a surgical ward after performed on the awake patient by deflating the ETT cuff
recovery in the Postanesthesia Care Unit. and occluding the end of the ETT. If air flows around the
Patients are assigned to the intermediate-risk category plugged tube on inspiration and expiration, the airway is
based on the presence of a single primary (surgical) risk considered patent and extubation is deemed safe. If there is
factor. A relevant example consists of a three-level anterior no air flow around the ETT at the time of the cuff leak
discectomy and fusion from C4-C7 executed in b 5 hours test, the patient should remain intubated for an additional
with minimal blood loss. Selection of the appropriate airway 12 to 24 hours and then retested. Fiberoptic bronchoscopy
protection protocol requires considerable judgment and represents an alternative means of assessing airway
necessitates analysis of the secondary (patient and anesthet- patency that allows for direct visualization of the
ic) risk factors. An isolated primary risk factor combined laryngopharynx. For difficult cases, an ETT exchanger
with one or more secondary risk factors may warrant a may be placed at the time of extubation as a measure to
postoperative protocol that incorporates delayed extubation. facilitate reintubation (if necessary).
In the absence of secondary risk factors, it is reasonable to Following extubation, the patient should be monitored in
extubate the intermediate-risk patient immediately after the ICU for a minimum of 4 to 6 hours before transfer to an
surgery. Given the increased vulnerability to postoperative inpatient ward. For patients who have required a more
airway compromise, consideration should be given to prolonged period of postoperative intubation, there can be a
monitoring the extubated patient in an intensive care setting temporary stenting effect on the airway after removal of the
for 24 to 36 hours, with the head of the bed elevated and a ETT. Progressive obstruction may result as the airway
surgical airway set immediately available. becomes more flexible in response to negative inspiratory
Patients in the high-risk category for postoperative pressure. In these cases, a longer period of observation is
airway complications include those who have undergone necessary following extubation.
an operation associated with multiple primary surgical risk
factors (or a single-stage, dual approach cervical proce-
dure). A multiple-level corpectomy combined with arthrod-
esis and instrumentation from C3-C6 is a representative
9. Summary
operation. For patients assigned to this category, a
postoperative protocol incorporating delayed extubation is Postoperative airway compromise due to laryngophar-
indicated. Monitoring in an intensive care unit (ICU) yngeal edema is a serious adverse event associated with
setting is mandatory. The head of the bed should be anterior cervical spine operations. A plan for prevention of
elevated approximately 30. this complication based on an analysis of risk factors related
Controversy exists over the minimum elapsed time to the surgical procedure, anesthesia variables, and patient
before extubation is considered reasonable and safe. The characteristics is valuable. When preventive measures fail,
practice of many spine surgeons is to maintain overnight multispecialty input should be recruited to establish and
intubation and consider removal of the ETT on the maintain patency of the airway. A systematic approach to
morning of the first postoperative day within 12 to 18 postoperative airway compromise is necessary to optimize
hours of the surgical end time. However, the reported the outcome of anterior cervical spine surgery.
average time to development of airway complications after
anterior cervical spine surgery has ranged from 23 to 37
hours [1,2]. Based on these data, consideration should be References
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