Analysis of the Risk Factors Associated with Prolonged Intubation or Reintubation after Anterior Cervical Spine Surgery

Abstract

Background: Standardized postoperative airway management is essential for patients undergoing anterior cervical spine surgery (ACSS). The paucity of clinical series evaluating these airway complications after ACSS has been resulted in a significant limitation in statistical analyses.

Methods: A retrospective cohort study was performed regarding airway distress (intubation for more than 24 hours or unplanned reintubation within 7 days of operation) developed after ACSS. If prevertebral soft tissue swelling was evident after the operation, patients were managed with prolonged intubation (longer than 24 hours). Preoperative and intraoperative patient data, and postoperative outcome (time to extubation and reintubation) were analyzed.

Results: Between 2008 and 2016, a total of 400 ACSS were performed. Of them, 389 patients (97.25%) extubated within 24 hours of surgery without airway complication, but 11 patients (2.75%) showed postoperative airway compromise; 7 patients (1.75%) needed prolonged intubation, while 4 patients (1.00%) required unplanned reintubation. The mean time for extubation were 2.75 hours (range: 0-23 hours) and 50.55 hours (range: 0-250 hours), respectively. Age (P = 0.015), diabetes mellitus (P = 0.003), operative time longer than 5 hours (P = 0.048), and estimated blood loss (EBL) greater than 300 mL (P = 0.042) were associated with prolonged intubation or reintubation. In prolonged intubation group, all patients showed no airway distress after extubation.

Conclusion: In ACSS, postoperative airway compromise is related to both patients and operative factors. We recommend a prolonged intubation for patients who are exposed to these risk factors to perform a safe and effective extubation.

Keywords: Airway Management; Anterior Cervical Spine Surgery; Extubation; Intubation; Reintubation.

Fig. 1. Radiological features of the patient with reintubation after ACSS. (A) A 73-year-old male patient (case No. 9) showing herniated intervertebral disc C3–C4 with severe spinal cord compression on sagittal MR imaging. Anterior cervical discectomy C3–C4 and fusion using iliac bone graft was performed. Extubation was conducted on the day of operation as the patient has no respiratory distress and immediate postoperative plain lateral X-ray revealed (B) only mild prevertebral soft tissue swelling compared to (C) preoperative film. (D) On postoperative day 4, the patient began complaining of difficult breathing and plain lateral X-ray showed markedly increased prevertebral soft tissue swelling. (E) We decided to reintubate the patient to protect the airway patency. (F) The patient was intubated for 4 days and extubated on postoperative day 8. The patient was discharged from hospital on postoperative day 14 without any further respiratory distress.

ACSS = anterior cervical spine surgery, MR = magnetic resonance.

Fig. 2. Radiological features of the patient with prolonged intubation due to cervical hematoma after ACSS. (A) A 52-year-old female patient (case No. 4) showing herniated intervertebral disc C5–C6, C6–C7 right on sagittal MR imaging. Anterior cervical discectomy C5–C6, C6–C7 and fusion using Solis cage with polybone were performed. Immediate postoperative plain lateral X-ray showed (B) mild prevertebral soft tissue swelling compared to (C) preoperative film. Prolonged intubation was decided to protect airway patency. (D) On postoperative day 1, the patient showed desaturation with severe anterior neck swelling and increased soft tissue swelling at the operation level on plain lateral X-ray. (E) Contrast enhanced neck CT scan revealed hematoma (marked in yellow circle) compressing trachea to the left side. Emergent hematoma evacuation was followed and injured right thyroid artery was noted. (F) Immediate postoperative plain lateral X-ray showed much decreased prevertebral soft tissue swelling. Extubation was conducted 4 days after hematoma evacuation. The patient was discharged from hospital on postoperative day 10 without any respiratory complication.

ACSS = anterior cervical spine surgery, MR = magnetic resonance, CT = computed tomography.