Airway Complications After Anterior Cervical Diskectomy and Fusion/Cricothyrotomy
Andrew H. Milby
David A. Reeder
John M. Rhee
Illustrative Case
A 64-year-old female underwent C4-6 anterior cervical diskectomy and fusion (ACDF) for spondylotic radiculopathy refractory to conservative treatment, which was complicated by incidental durotomy during uncovertebral osteophyte resection (Figure 40-1). There was no apparent cerebrospinal fluid (CSF) egress intraoperatively following application of fibrin sealant. Her initial postoperative course was uncomplicated, drain output was minimal, and the patient was discharged home after 48 hours of bed rest. The day following discharge, the patient called reporting progressive neck swelling, difficulty breathing, and positional headache. She urgently returned to the hospital for evaluation.
 Figure 40-1 ▪ Lateral x-ray of cervical spine, demonstrating C4-6 anterior cervical diskectomy and fusion, as well as significant prevertebral soft-tissue density concerning for cerebrospinal fluid leak. |
Radiologic Assessment
In the subacute setting, initial evaluation may commence with a lateral plain x-ray of the cervical spine.
The prevertebral soft-tissue contours should be carefully evaluated for a substantial increase in prevertebral soft tissue swelling when compared to imaging obtained prior to symptom onset, if available.
Prevertebral soft tissue is highly variable between individuals and dependent on surgical levels, but an appropriate contour should be evident with a thinner shadow cranially from C1-4 and a thicker shadow distally beyond the level of the thyroid cartilage and trachea.
Special Equipment
If available, a percutaneous cricothyrotomy kit offers a less traumatic alternative to open cricothyrotomy in the inpatient setting.
In a field or prehospital setting, a temporizing emergent cricothyrotomy may be accomplished with only a scalpel and handle, or equivalent sharp implement.
Indications
The first sign of airway compromise may be a patient reporting increased anxiety due to perceived difficulty breathing, well before any objective change in oxygen saturation or other vital signs.
All such reports must be taken seriously and promptly evaluated to prevent potentially catastrophic airway obstruction.
The time course of presentation is typically 24 to 36 hours postoperatively.
Differential diagnosis
Pharyngeal edema
Hematoma
CSF leak
Angioedema
Graft and/or plate dislodgment
Risk factors for airway complications after anterior cervical surgery
The overall incidence of airway compromise following anterior cervical surgery has been reported to be from 1.2% to 6.1% of cases.
The following factors have been associated with increased risk:
Age
Male gender
History of chronic obstructive pulmonary disease
History of bleeding disorder
Longer operative time
Larger blood loss
American Society of Anesthesiology class >2
Other factors, such as multilevel and corpectomy procedures, have demonstrated inconsistent associations with airway complications, but may be correlated with the variables above.
Treatment Algorithm
At the first suspicion of impending airway compromise, efforts to proceed with reintubation should commence.
In a patient with early symptoms but not in extremis, semielective reintubation may be the best precautionary approach.
Grossly apparent swelling at the surgical site and/or tracheal deviation suggests the presence of an expanding hematoma or fluid collection. The first step in these emergent situations is to open the incision at the bedside. If this evacuates a hematoma or fluid collection and resolves the airway symptoms, then intubation may be deferred or performed semielectively under more controlled circumstances in consultation with anesthesia or ENT, but the patient should be
closely monitored. If opening the incision at the bedside fails to resolve the airway issue, then proceed immediately to an emergency surgical airway.Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
