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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.

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Preoperative Evaluation

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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.

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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.

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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.

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Airway Management

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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.

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Figure 1.
Graphic Jump Location

CT of the cervical spine showing ankylosis of C2-C7 with dextroskoliosis, and large posterior body osteophytes (arrow) impinging on the spinal cord.

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