Review Question - QID 218237

The patient underwent a prolonged anterior cervical approach (>5 hours) with high blood loss and upper subaxial spine exposure which places the patient at increased risk of post-operative airway complications (Answer 2).

The anterior approach to the cervical spine is a workhorse for the treatment of cervical myelopathy. Decompression of the spinal cord can be accomplished through discectomy or corpectomy. Fusion with interbody grafts or strut grafts can correct sagittal plane kyphosis to restore normal lordosis and stabilize spondylotic segments. Due to the inherent anatomy of the anterior neck, several potentially catastrophic complications exist. Post-op airway complications are one of the most feared due to the potentially rapid decompensation and high mortality. Airway complications have been associated with prolonged procedures (>5 hours), high blood loss, and upper subaxial spine exposure.

Sagi et al. conducted a retrospective review of 311 anterior cervical procedures in order to identify potential risk factors for airway complications. Variables that were found to be statistically associated with an airway complication (p < 0.05) were exposing more than three vertebral bodies, a blood loss greater than 300 mL, exposures involving C2, C3, or C4, and an operative time longer than 5 hours. A history of myelopathy, spinal cord injury, pulmonary problems, smoking, anesthetic risk factors, and the absence of a drain did not correlate with an airway complication.

Kim et al. retrospectively analyzed the effect of a postoperative airway management protocol (AEP) on airway complications in patients undergoing anterior cervical spine surgery (ACSS). The authors based the AEP on clinical risk factors, aimed to guide postoperative extubation decisions. The study found that implementing the AEP significantly reduced the incidence of airway complications compared to the non-protocol group, highlighting the importance of identifying risk factors and following standardized protocols to minimize postoperative airway compromise in ACSS patients.

Figure A depicts a sagittal T2 cervical spine MRI with spinal cord compression C3-6 with myelomalacia.

Incorrect Answers:
Answer 1: Pseudoarthrosis can occur after multilevel anterior cervical fusion. Fusion rates with 3-level ACDF with plate fixation is 80% with a small subset of nonunions being symptomatic.
Answer 3: Surgical site infections are very rare after anterior cervical fusions.
Answer 4: Esophageal injuries are rare complications and are associated with anterior cervical trauma, previous anterior cervical surgery, and diverticula.
Answer 5: Superior laryngeal nerve palsy is an exceedingly rare complication following anterior cervical spine surgery and is associated with corpectomies at C4 and above. Patients often present with dysphonia, dysphagia, and absent cough reflex.