Occipitocervical fusion and serious airway adverse events: A systematic review

Occipitocervical fusion (OCF) is a critical surgical intervention for conditions affecting the craniovertebral junction, but it poses a risk for postoperative respiratory adverse events (RAEs), including reintubation failure, upper airway obstruction, and delayed extubation. This systematic review evaluates the incidence, severity, and risk factors associated with RAEs following OCF.

A comprehensive literature search was conducted across PubMed, Embase, Scopus, Cochrane Library, and Web of Science in accordance with PRISMA guidelines. Studies reporting RAEs in OCF patients were included. Extracted data included patient demographics, perioperative variables, radiographic parameters, and airway-related outcomes.

A total of 28 studies encompassing 429 patients were included. RAEs were observed in 11.7 % (n = 50) of cases, with respiratory failure (44 %), delayed extubation (28 %), and upper airway obstruction (10 %) being the most common. Failed extubation occurred in 58 % of RAE patients, with a higher rate in pediatric (78 %) compared to adult patients (52 %). Reintubation failure occurred in 61 % of cases. Among serious RAEs, emergent events were most frequent (53 %), followed by persistent (16 %) and lethal (13 %) complications. Tracheostomy was required in 32 % (n = 16) of RAE cases, primarily for respiratory failure and airway obstruction. Congenital conditions were the most common indication for OCF in RAE patients (42 %), with inflammatory (24 %) and neoplastic (22 %) etiologies also contributing. Age-related differences were evident, with pediatric patients experiencing more persistent RAEs, while adults had higher rates of emergent and lethal events.

Although RAEs following OCF are rare, they carry significant morbidity, with a high incidence of failed extubation and reintubation failure. Congenital abnormalities and inflammatory conditions may increase the risk, and age-related differences in airway compromise highlight the need for tailored perioperative management strategies. Standardized airway protocols may improve outcomes in high-risk populations.