Medically Challenging Cases

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Morbidly Obese Patient with Cervical Spine Ankylosing Spondylitis Presenting with Acute Spinal Shock and Complex Airway Management

Authors: Ulrike Berth MD, Shaheen Shaikh MD, Bronwyn Cooper MD, Stephen O. Heard, MD
Department of Anesthesiology, University of Massachusetts

Introduction

 

A 67 year old morbidly obese male presented to the emergency department (ED) with weakness in both lower extremities after a fall at home. The patient sustained an unstable T12-L1 vertebral fracture with cord compression at the thoracolumbar junction and acute traumatic paraplegia.

Preoperative Evaluation

 

The patient arrived in the PACU directly from the ED with a cervical collar and on backboard. The review of the patient’s chart revealed that he had a history of hypertension, a pulmonary embolus for which he took warfarin, hypothyroidism, Type 2 diabetes mellitus, bipolar disorder and ankylosing spondylitis of his cervical spine. On physical exam the patient was sleepy but arousable and unable to move his lower extremities, with loss of bladder and bowel control. His airway exam revealed that he was Mallampati class 3.The patient was hemodynamically unstable with a blood pressure of 80/40, a heart rate in the 70’s, and an oxygen saturation of 86-88%. The patient was in acute spinal shock and his low oxygen saturation was likely due to atelectasis. His INR was 2.4. The patient was given oxygen by face mask and a fluid bolus of 1 L normal saline was administered to attempt to increase his blood pressure. The fluid bolus had a minimal effect and an infusion of phenylephrine was started. The blood pressure improved to a systolic value in the 120’s that we felt was necessary for adequate spinal cord perfusion. The oxygen saturation improved to 95%. Methylprednisone at a dose of 30 mg/kg was given as a bolus to decrease expected spinal cord edema.Two units of fresh frozen plasma were given in an attempt to normalize the INR value. A right radial arterial catheter was inserted. A three-port central venous catheter was inserted into the right internal jugular vein under ultrasound guidance. This procedure was difficult secondary to the patient’s body habitus and the underlying ankylosing spondylitis, that both greatly reduced the patient’s neck mobility.

Airway Management

 

This patient presented with multiple factors that would influence our airway management. The patient had longstanding history of ankylosis spondylitis of the cervical spine. The CT scan obtained in the ED showed ankylosis of C2-C7 with dextroscoliosis and ostephytes impinging on the cervical spinal cord (Figure 1). There was a hyperextension injury of the spinal cord at T12-L1. The patient was morbidly obese and we anticipated both difficult mask ventilation and a difficult intubation (Figures 2 and 3). Hence we decided that the safest way to manage this patient’s airway was via an awake fiberoptic intubation that was accomplished on the first attempt. A 7.5 ETT was inserted orally, end-tidal carbon dioxide and bilateral breath sounds were confirmed, and general anesthesia was induced uneventfully. Figure 1. CT of the cervical spine showing ankylosis of C2-C7 with dextroskoliosis, and large posterior body osteophytes (arrow) impinging on the spinal cord. Figure 2. Anterior CT view of the patient’s body habitus. Figure 3. Lateral CT view of the patient’s body habitus.

Discussion

 

Ankylosing spondylitis leads to fibrosis, ossification, and ankylosis along the spinal column that can have a significant impact on airway management. Reduction in atlantooccipital articulation mobility, fixation of cervical vertebrae, and temporomandibular joint involvement can complicate airway management further. The cervical spine is also the most susceptible to fractures, particularly in hyperextension, that can lead to damage to the cervical spinal cord during intubation.This case illustrates the challenges posed by a morbidly obese patient in spinal shock with a stiff and unstable neck. The patient needed emergency surgery for traumatic paraplegia, but it was vital to stabilize the patient first. To ensure the most optimum outcome for this patient it was very important to have monitoring in place to be able to treat both anticipated and unforeseen events that might emerge during surgery. The entire anesthetic management of this patient was extremely formidable for many reasons. His morbid obesity caused challenging intravenous catheter placement, with additional concerns about securing the airway, high airway pressures and difficult ventilation intraoperatively in the prone position. Preoperative spinal shock, likely caused by shearing forces during the patient’s fall causing spinal cord injury well above the anatomical fracture site, resulted in hemodynamic instability. Type 2 diabetes mellitus and anticoagulation (warfarin therapy) were added concerns. The patient was stabilized in the PACU with a phenylephrine infusion, oxygen therapy, and fresh frozen plasma transfusions. Longstanding ankylosing spondylitis left the patient with a stiff neck with virtually no movement. Despite no acute fracture in his cervical spine, the cervical CT results showed osteophytes pressing against his spinal cord causing spinal cord compression. After considering all factors we felt the safest possible option to secure the airway was an awake fiberoptic intubation.Studies have shown that the Bullard laryngoscope, Glidescope, and Fastrack LMA can be safely used for the management of a difficult airway in patients with an unstable cervical spine. Further studies are needed to demonstrate their benefit versus the standard of awake fiberoptic intubation. Trauma patients often have unstable cervical spine injuries and the airway in the ED is often secured by rapid sequence intubation with manual inline stabilization. Our patient however not only had an unstable cervical spine but superimposed ankylosing spondylitis resulting in difficult airway management that was worsened by his morbid obesity.

References

 

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