Upper airway obstruction after cervical spine fusion surgery: role of cervical fixation angle

Upper airway obstruction is one of the life-threatening events in cervical spine surgery. The risk is particularly great during the period immediately after operation. We present the case of a 56-year-old female with breast cancer and metastasis to the cervical spine. The surgical procedure involved C2-C3 laminectomy, posterior fixation (C0-C5), and C2 neurectomy. Tracheal extubation was carried out in the intensive care unit, and upper airway obstruction immediately followed. Emergency cricothyrotomy was performed under well-managed ventilation with a laryngeal mask after several failed intubation attempts. Over-flexion of the cervical spine fixation and severe prevertebral soft tissue swelling were the most probable causes of upper airway obstruction. With a well-adjusted angle for fixation of the cervical spine under fluoroscopic guidance before the procedure, such a surgical mishap could be avoided. Reintubation with a fiberscope might be considered first, and sustaining intubation for 2-3 days postoperatively could be safer in such high risk patients.