Risk Factors for Delayed Extubation Following High Posterior Cervical and Occipital Fusion

Much has been written on initial airway management in patients undergoing cervical spine procedures, but comparatively less is known about extubation criteria. High cervical and occipital fusion procedures pose a particular risk for extubation given the potential for a reduced range of motion at the occiput-C1 and C1-C2 joints should reintubation be necessary.

We performed a retrospective cohort analysis of posterior high cervical and occipital fusion cases to identify factors related to delayed extubation and postoperative airway and pulmonary complications. Using a convenience sample of all cases operated between January 2009 and April 2018, we reviewed anesthesia records and discharge summaries to compare patient characteristics, airway management, surgical factors, and postoperative complications between patients who underwent delayed extubation and those who did not.

A total of 135 patients met our inclusion criteria. Overall, 92 (68.1%) patients were extubated in the operating room (OR), and 43 (31.9%) underwent delayed extubation. Multivariate logistic regression analysis identified age, procedure length, C2 as the highest level fused, and percentage colloid administered as predictors of delayed extubation. We did not find a difference in the rate of postoperative pulmonary complications between groups (6/92 [6.5%] for OR extubation; 2/43 [4.7%] for delayed extubation). Two patients had serious airway complications, and both were extubated in the OR (2/92, 2.2%).

The decision to extubate immediately postoperatively after high cervical and occipital fusion should be considered carefully as the morbidity associated with airway obstruction can be severe in this population, while negative effects of delayed extubation were not evident in our analysis.