Atlantoaxial Subluxation in Different Intraoperative Head Positions in Patients with Rheumatoid Arthritis

Fiberoptic bronchoscopy versus video laryngoscopy guided intubation in patients with craniovertebral junction instability: A cinefluroscopic comparison

Background:

Manipulation during endotracheal intubation in patients with craniovertebral junction (CVJ) anomalies may cause neurological deterioration due to underlying instability. Fiberoptic-bronchoscopy (FOB) is better than video laryngoscope (VL) for minimizing cervical spine movement during intubation. However, evidence suggesting superiority of FOB in patients with CVJ instability is lacking. We prospectively compared dynamic movements of the upper cervical spine during intubation using FOB with VL in patients with CVJ anomalies.

Methods:

A prospective, randomized, and clinical trial was conducted in 62 patients of American Society of Anaesthesiologist Grade I-II aged between 12 and 65 years with CVJ anomalies. Patients were randomized for intubation under general anesthesia with either VL or FOB. The intubation process was done with application of skeletal traction and recorded cinefluroscopically. The dynamic interrelationship of bony landmarks (horizontal, vertical, and diagonal distances between fixed points on posterior C1 and C2) was analyzed to indirectly calculate alteration of the upper cervical spinal canal diameter (at CVJ). Atlanto-dental interval (ADI) was calculated wherever possible.

Results:

The alteration in canal diameter (using bony landmarks) at CVJ during intubation was not significant with the use of either VL or FOB (P > 0.05). In 41 patients, where ADI could be measured, ADI was reduced (increased spinal canal diameter) in a greater number of patients in VL group when compared to FOB group (P < 0.05).

Conclusion:

Using rigid skull traction, intubation under general anesthesia with VL offers similar advantage as FOB in terms of the spinal kinematics in patients with CVJ anomalies/instability. Nevertheless, greater number of patients intubated with VL may have an advantage of increased cervical spinal canal diameter when compared to FOB.

Shoulder arthroplasty for juvenile idiopathic arthritis

There is limited literature to guide shoulder surgeons in the management of juvenile idiopathic arthritis (JIA). We aim to help clinicians to formulate an approach to the surgical management of the condition through a review of the available literature on arthroplasty in JIA, general considerations when operating on patients with inflammatory arthropathy and recommendations based on the authors' experience. Four articles report formal data on arthroplasty in JIA with favourable improvements in post-operative pain and function scores after the long-term follow-up. Significant heterogeneity in treatment and a lack of standardisation in quantitative outcomes highlights the need for further larger scale and higher quality research. The aim of this study is to review the evidence and provide information on preoperative evaluation of surgical candidates, operative techniques, choice of implant design and to evaluate functional outcomes in patients who undergo shoulder arthroplasty.

[Cervical spine involvement in rheumatoid arthritis : Diagnostics and treatment of instability due to rheumatism]

In addition to involvement of small peripheral joints, the cervical spine is the second most affected body region in rheumatoid arthritis (RA). Due to improvement of pharmaceutical treatment in recent years, new data show that there is a decreasing prevalence of cervical involvement; however, depending on the severity of cervical lesions surgical treatment still plays an important role. The sequelae of involvement of the cervical spine are craniocervical and atlantoaxial instability, which can cause severe pain, neural deficits and even death. Multimodal conservative treatment can lead to an alleviation of pain but in cases of therapy-resistant pain or neural deficits surgical treatment alone is essential to improve patient outcome. For isolated atlantoaxial instability (AAS), atlantoaxial fusion by posterior C1-2 fixation according to Harms and Goel is the method of choice. Posterior stabilization including C0 should be avoided whenever possible due to substantial limitations in range of movement.

Cervical instability in patients with Trisomy 21: The eternal gamble

Patients with Trisomy 21 are particularly at risk of cervical instability due to ligamentous laxity and osseous abnormalities. Up to 30% of Trisomy 21 patients are affected by atlanto-axial or atlanto-occipital instability, but only 1%-2% of cases are symptomatic. The radiologic assessment of cervical instability is not unanimously considered mandatory. The dynamic cervical spine radiograph is the most common screening tool for ruling out cervical spine instability in patients with Trisomy 21, and it is often requested before surgery. Several measurements have been investigated to assess the presence and degree of cervical instability; however, no conclusive recommendations have been forthcoming. In daily practice, many anesthesiologists may provide anesthesia via such means as laryngoscopy and tracheal intubation during surgery, without any radiological investigations before surgery. This review focuses on the diagnostic and prognostic measures available to evaluate the presence and degree of cervical instability in patients with Trisomy 21 and to propose practical recommendations to be applied in clinical practice.

Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation in Cadavers-Cadavers versus Patients, the Effect of Repeated Intubations, and the Effect of Type II Odontoid Fracture on C1-C2 Motion

BACKGROUND

The aims of this study are to characterize (1) the cadaver intubation biomechanics, including the effect of repeated intubations, and (2) the relation between intubation force and the motion of an injured cervical segment.

METHODS

Fourteen cadavers were serially intubated using force-sensing Macintosh and Airtraq laryngoscopes in random order, with simultaneous cervical spine motion recorded with lateral fluoroscopy. Motion of the C1-C2 segment was measured in the intact and injured state (type II odontoid fracture). Injured C1-C2 motion was proportionately corrected for changes in intubation forces that occurred with repeated intubations.

RESULTS

Cadaver intubation biomechanics were comparable with those of patients in all parameters other than C2-C5 extension. In cadavers, intubation force (set 2/set 1 force ratio = 0.61; 95% CI, 0.46 to 0.81; P = 0.002) and Oc-C5 extension (set 2 - set 1 difference = -6.1 degrees; 95% CI, -11.4 to -0.9; P = 0.025) decreased with repeated intubations. In cadavers, C1-C2 extension did not differ (1) between intact and injured states; or (2) in the injured state, between laryngoscopes (with and without force correction). With force correction, in the injured state, C1-C2 subluxation was greater with the Airtraq (mean difference 2.8 mm; 95% CI, 0.7 to 4.9 mm; P = 0.004).

CONCLUSIONS

With limitations, cadavers may be clinically relevant models of intubation biomechanics and cervical spine motion. In the setting of a type II odontoid fracture, C1-C2 motion during intubation with either the Macintosh or the Airtraq does not appear to greatly exceed physiologic values or to have a high likelihood of hyperextension or direct cord compression.

Airway management in neuroanesthesiology

Airway management for neuroanesthesiology brings together some key principles that are shared throughout neuroanesthesiology. This article appropriately targets the cervical spine with associated injury and the challenges surrounding airway management. The primary focus of this article is on the unique airway management obstacles encountered with cervical spine injury or cervical spine surgery, and unique considerations regarding functional neurosurgery are addressed. Furthermore, topics related to difficult airway management for those with rheumatoid arthritis or pituitary surgery are reviewed.

Cervical spine radiographs in patients with rheumatoid arthritis undergoing anesthesia

BACKGROUND

There is no consensus on the role of preoperative cervical spine radiographs to screen for instability in patients with rheumatoid arthritis (RA).

OBJECTIVES

This study aimed to evaluate the preoperative use of cervical spine radiographs in patients with RA undergoing preoperative anesthesia assessment and to determine whether preoperative radiographic findings influenced anesthesia delivery techniques.

METHODS

We reviewed all medical records of RA patients who underwent surgical procedures requiring general anesthesia with airway intubation or monitored anesthesia care without airway intubation. We examined cervical spine radiographs obtained up to 2 years before surgery and determined airway management techniques used during surgery.

RESULTS

Overall, 215 patients with RA underwent 217 individual surgeries requiring anesthesia; of these, 176 (82%) underwent general anesthesia with airway management with direct laryngoscopy in 83%, fiber-optic intubation in 10%, and laryngeal mask in 7%. Ninety-two (52%) of the patients receiving airway management had radiographs available for cervical spine evaluation; of these, only 7 (8%) had complete radiographic examinations with which to evaluate possible atlantoaxial subluxation. Eighteen (20%) of the 92 patients receiving airway management had radiographic evidence of cervical spine abnormality. Multiple regression models were conducted to evaluate the association of patient demographics and airway management technique used and showed that the use of fiber-optic intubation or laryngeal mask was not influenced by radiographic results. A difficult oropharyngeal class/glottic visualization grade (3 or 4) as determined by the anesthesiologist was the only statistically significant predictor of fiber-optic intubation or laryngeal mask use.

CONCLUSIONS

Cervical spine abnormalities were frequently noted in patients who underwent general surgery but did not influence the choice of airway management. Future prospective studies evaluating the utility of cervical spine radiographs in patients with RA and practice guidelines are needed to ensure appropriate and cost-effective perioperative cervical evaluation and management of patients with RA.

Rheumatoid arthritis and anaesthesia

There has been a great deal of progress in our understanding and management of rheumatoid arthritis in recent years. The peri-operative management of rheumatoid arthritis patients can be challenging and anaesthetists need to be familiar with recent developments and potential risks of this multi system disease.

[Anesthesia and rheumatoid arthritis]

BACKGROUND AND OBJECTIVES

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown etiology. It is known that RA patients have a reduced life expectancy when compared with the general population. Rheumatic diseases are numerous and occur with high variability; some of them develop very rapidly while others occur chronically provoking disability throughout life. Anesthetic risks in osteoarticular disorders involve not only the mechanical deformations caused by the disease, but also the cardiovascular, respiratory, renal, and digestive systems.

CONTENTS

The purpose of this review was to stress the importance of stages in disease process that may affect anesthesia control before, during, and after surgery, highlighting the authors' experience in a retrospective review of patients with juvenile rheumatoid arthritis (JRA) undergoing placement of orthopedic prosthesis with emphasis on intubation techniques.

CONCLUSIONS

Rheumatoid arthritis patients can present a number of complex problems for the anesthesiologist. This requires careful preoperative evaluation; anesthesia requires experience with the technique; and postoperative care should be judiciously chosen to meet the specific needs of the patient. The procedure requires effective communication among surgeon, rheumatologist and anesthesiologist so each member of the multidisciplinary team can contribute with his/her expertise in order to better benefit the patient.

Considerations for airway management for cervical spine surgery in adults

Surgery on the cervical spine runs the gamut from minor interventions done in a minimally invasive fashion on a short-stay or ambulatory basis, to major surgical undertakings of a high-risk, high-threat nature done to stabilize a degraded skeletal structure to preserve and protect neural elements. Planning for optimum airway management and anesthesia care is facilitated by an appreciation of the disease processes that affect the cervical spine and their biomechanical implications and an understanding of the imaging and operative techniques used to evaluate and treat these conditions. This article provides background information and evidence to allow the anesthesia practitioner to develop a conceptual framework within which to develop strategies for care when a patient is presented for surgery on the cervical spine.