Risk factors for airway-related complications after surgery, specific to this surgery type / population

• Patient factors
  • Pre-existing myelopathy
  • Pre-existing pulmonary disease
  • Rheumatoid arthritis
  • Predictors of difficult intubation (LEMON etc)
• Surgical factors
  • Combined anterior-posterior approach
  • Operative time >5 hours
  • Estimated blood loss >300mL
  • ≥3 cervical levels involved
  • C1 or C2 involved

Causes of upper airway obstruction specific to this type of surgery

• Haematoma
• CSF leak & accumulation
• Upper airway oedema / angioedema
• Infection & abscess formation
• Recurrent laryngeal nerve injury –> vocal cord paralysis

Signs of post-operative airway obstruction post cervical spine surgery

• Agitation / restlessness
• Dysphonia
• Dysphagia
• Stridor
• Respiratory distress
• Low oxygen saturations
• Increasing neck swelling

Specific airway management strategies after cervical spine surgery (starting PRIOR to extubation)

• PRIOR to extubation
  • Assess for risk factors suggesting increased likelihood of airway complications
  • Check pharyngeal / glottic swelling with cuff leak / fibreoptic visualisation
  • IF oedema is present or suspected
    • Delay extubation
    • Steroids
    • Elevate head of bed (>30 degrees)
  • Establish airway management plan if patient requires reintubation (eg AFOI, VAFI, etc)
    • During daylight hours
    • In theatre
    • With senior staff present
    • Notify surgical team early if required to facilitate immediate surgical cric as needed
• DURING extubation
  • Consider extubation over Aintree airway exchange catheter (facilitates reintubation & oxygenation)
  • Have advanced airway devices immediately available
  • Low threshold for reintubation if any signs/symptoms of respiratory compromise
  • cough prevention (eg remifentanyl)
• POST extubation
  • close monitoring
  • head up
  • adequate analgesia