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