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Comparative Study
. 2025 Jul 7;15(1):24325.
doi: 10.1038/s41598-025-09724-2.

Comparison of different tracheal intubation methods for unstable upper cervical spine injuries in a human cadaver model

Davut Deniz Uzun  1 , Niko R E Schneider  2   3 , Shiyao Liao  4 , Felix C F Schmitt  2 , Markus A Weigand  2 , Michael Kreinest  5 , Erik Popp  2 , Frank Weilbacher  2
Affiliations
Comparative Study

Comparison of different tracheal intubation methods for unstable upper cervical spine injuries in a human cadaver model

Davut Deniz Uzun et al. Sci Rep. .

Abstract

In severe trauma, it is estimated that approximately 2% of patients will sustain a spinal cord injury. The optimal method for advanced airway management that will minimize any associated cervical spine movement remains a topic of debate. Therefore, the aim of this study is to compare the effects of different tracheal intubation techniques in unstable injuries of the cervical spine. Tracheal intubation using conventional laryngoscopy (CL), video laryngoscopy (VL) or flexible bronchoscopic intubation (FO) was performed in six fresh human cadavers. Compression of the dural sac as well as angulation, distraction and intubation time were assessed by myelography in the presence of isolated atlanto-occipital dislocation (AOD) and of combined atlanto-occipital dislocation with atlanto-axial instability (AAI). In case of an isolated AOD, FO intubation resulted in significantly less compression of the dural sac at both levels compared to CL (- 0.46 mm vs. - 1.31 mm; p < 0.001, r = .66) for C0/C1 and (- 0.09 mm vs. - 0.19 mm; p = < 0.05, r = .36) for C1/C2 and VL (- 0.46 mm vs. - 0.64 mm; p = < 0.05, r = .42 for C0/C1 and (- 0.09 mm vs. - 0.22 mm; p = < 0.01, r = .52) for C1/C2. Atlanto-axial Angulation in simultaneous AOD and AAI, the differences between CL and VL were significantly in favor of VL (4.1° vs. 3.2°; p = < 0.05, r = .39), and using FO resulted in less angulation than CL (2.5° vs. 4.1°; p = < 0.001, r = .60) and VL (2.5° vs. 3.2°; p = < 0.05). FO required longer in the case of combined AOD and AAI (FO 16.6 s vs. CL 9.8 s; p = < 0.001, r = .56), (FO 16.6 s vs. VL 9.7 s; p = < 0.001, r = .56). The study demonstrated that tracheal intubation using VL caused significant less compression of the dural sac than the CL. FO showed the lowest compression at all measuring points, but took almost twice as long. For elective or stable patients, where time to airway management is not a relevant factor, FO appears to be the safest method. However, FO is not available everywhere, and in urgent emergency situations, the longer duration may not be acceptable. In such cases, video laryngoscopy can represent a compromise between duration and patient safety, and most physicians have more clinical experience with VL than with FO.

Keywords: Cervical spine; Direct laryngoscopy; Flexible bronchoscopic intubation; Tracheal intubation; Video laryngoscopy.

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Conflict of interest statement

Declarations. Competing interests: The authors declare no competing interests. Ethical approval and consent to participate: The protocol for this study was approved and had provided permission by the ethics committee of the Rhineland-Palatinate Medical Association (Registration No. 837.156.16) and registered in the German Clinical Trials Register (DRKS00010499). The body donors have given their written informed consent to medical and scientific use in accordance with the regulations of the state of Baden-Wuerttemberg.

Figures

Fig. 1
Fig. 1
The figure (a) shows an example of a measurement of the myelography with the width of the dural sac (WDS) drawn in during tracheal intubation using direct laryngoscopy (DL). Section (b) showed the relevant anatomical landmarks for the measurements.
Fig. 2
Fig. 2
Anatomy of the upper cervical spine with important landmarks. The parameters measured in our study are marked (A0 and A1: Angulation; D: Distraction; WDS1 and WDS2: width of dural sac).
Fig. 3
Fig. 3
Changes in width of dural sac at the C0/C1-level (WDS1) in the intact and injured upper cervical spine during different tracheal intubation techniques.
Fig. 4
Fig. 4
Changes in width of dural sac at the C1/C2-level (WDS2) in intact and injured upper cervical spine during different intubation techniques.
Fig. 5
Fig. 5
Changes in angulation at the C0/C1-level (A0) in intact and injured cervical spine during different intubation techniques.
Fig. 6
Fig. 6
Changes in angulation at the C1/C2-level (A1) in intact and injured cervical spine during different intubation techniques.
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