A Retrospective Pilot Study for Preoperative Screening to Prevent Iatrogenic Cervical Spinal Cord Injury

Abstract

Purpose: The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series.

Methods: Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure.

Results: There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman's and Spurling's sign, independently, were significantly associated with a positive neck extension exam (p<0.05). Fourteen patients were recommended for cervical decompression prior to planned procedure.

Conclusions: Our preoperative cervical spine clearance protocol is safe and may aid in identifying patients susceptible to iatrogenic cervical spine injury.

Keywords: central cord syndrome; cervical hyperextension; cervical spine injury; iatrogenic; preoperative clearance.

Figure 1. Cervical Clearance Protocol

Flow chart illustrating decision making at each stage of the preoperative cervical clearance evaluation.

Figure 2. Patient 1 CT and MRI of the Neck

A: Patient 1 CT Neck Sagittal View B: Patient 1 CT Neck Axial View C: Patient 1 MRI Neck Sagittal View D: Patient 1 MRI Neck Axial View Evidence of cervical stenosis is seen at C6-C7 (Cervical Vertebrae 6-7).

Figure 3. Patient 2 CT and MRI of the Neck

A: Patient 2 CT Neck Sagittal View B: Patient 2 CT Neck Axial View C: Patient 2 MRI Neck Sagittal View D: Patient 2 MRI Neck Axial View A disc osteophyte complex with narrowing of the spinal canal is seen at C5-6 (Cervical Vertebrae 5-6).

Figure 4. Patient 3 CT and MRI of the Neck

A: Patient 3 CT Neck Sagittal View B: Patient 3 CT Neck Axial View C: Patient 3 MRI Neck Sagittal View D: Patient 3 MRI Neck Axial View Multilevel cervical stenosis can be seen in A and C.