9.1 Acute Cervical Subluxation

Question 1

65–year-old male awaiting a lobectomy for lung malignancy
presents with acute neck pain following a fall.

His past medical history consists of diet-controlled diabetes mellitus, hypertension, and a hiatus hernia.

His medications include candesartan, bendroflumethiazide, enoxaparin, simvastatin,
and lansoprazole.

on examination
Heart rate 80/min
BP 140/80 mmHg
Saturation 95% on room air
on auscultation he has some rhonchi at the right lower base and a harsh
ejection systolic murmur loudest at the left sternal edge in the second
intercostal space.

Blood Results Awaited

Arterial blood gas
Fio2 0.21
pH 7.32
pCo2 5.1 kPa
po2 9.5 kPa
HCo3 23
BE 1.2
Hb 9.8 g/dL

echocardiogram
LA: dilated
LV: thickened
RA: normal size and function
RV: normal size and function
Aortic valve: thickened and calcified
Valve area: 1.7 cm2
Peak gradient: 27 mmHg
Mitral valve: minimal mitral regurgitation
Tricuspid valve/Pulmonary valve: normal
Ejection fraction: 70%

CXR + PFTS

summarise the case.

Answer 1

This 65-year-old patient presents with an acute neck pain due to cervical
spine subluxation. He has multiple comorbidities including diet-controlled
diabetes, hypertension on dual therapy, lung cancer awaiting resection,
aortic stenosis, and a hiatus hernia for which he is on PPI therapy. He is also
anticoagulated.

Following anaesthetic and surgical assessment, he may need urgent
surgery requiring optimisation of comorbidities where possible and plans for
managing his difficult airway and anaesthesia with experienced personnel.
A cardiology assessment is important as his ECG shows a trifascicular
heart block.

Question 2

What is the significance of the aortic stenosis?

Answer 2

My concerns relate to the possibility of a fixed cardiac output and inability
to compensate for hypotension with increased contractility.

I would ask about symptoms of angina, syncope and breathlessness, palpitations and
peripheral oedema, and an idea of his exercise tolerance.

According to the information given, he has mild-moderate aortic stenosis without any
evidence of LV dysfunction.

Under Goldman’s risk criteria, it marks a risk factor for perioperative cardiac
complications.

Severity depends on presence of symptoms, development
of conduction abnormalities, and presence of left ventricular dysfunction
although these are difficult to correlate.

Question 3

What are your concerns for anaesthetising him?

Answer 3

Invasive monitoring is recommended for aortic valve area < 1 cm2 and mean
gradient > 30 mmHg.

When anaesthetising him, I would take care to treat hypotension,
arrhythmias, and electrolyte imbalances early, place invasive monitoring
with arterial line for continuous monitoring of BP and central line so that
vasoconstrictors can be given if needed.

In this way I hope to prevent both spinal cord and myocardial hypoperfusion in the first instance.

Question 4

What abnormalities does the ECG show?

Answer 4

Trifascicular block (incomplete)

1. • Right bundle branch block
2. • Left axis deviation (= left anterior fascicular block)
3. • First-degree AV block

Question 5

What are the causes of trifascicular block?

Answer 5

• Ischaemic heart disease
• Hypertension
• Aortic stenosis
• Congenital heart disease
• Hyperkalaemia (resolves with treatment)
• Digoxin toxicity

Question 6

Why is it a concern?

Answer 6

Incomplete trifascicular block may progress to complete heart block,

although the overall risk is low.

Patients who present with syncope and have an
ECG showing trifascicular block

usually need to be admitted for a cardiology workup,
and these patients will require insertion of a permanent pacemaker.

Asymptomatic bifascicular block with first-degree AV block is not an indication for pacing.

Question 7

comment on the radiographs

Answer 7

Chest X-ray done 1 week ago
Mass in the left lung in the perihilar region. This patient is known to have and
is awaiting lung resection for cancer. The current chest signs indicate the
presence of chest infection, and I would like to repeat the chest X-ray.

C spine—lateral radiograph
The X-ray is not labeled. It shows bilateral facet fracture-dislocation at C4-C5

Question 8

How can you interpret the lung function tests?

Answer 8

The FEV1/FVC ratio is normal, leaving us with either a restrictive or a normal
pattern.

As both the FVC and total lung capacity are normal,

we conclude that the spirometry and lung volumes are normal.

This suggests that the airways and lung parenchyma are functioning normally.

But the diffusing capacity is significantly reduced and
remains low even when corrected for lung volumes.

Question 9

Differential diagnosis for these PFTs

Answer 9

• Anaemia—
  the number of haemoglobin molecules to which carbon
  monoxide can bind is reduced, decreasing the ability of the lungs
  to transfer carbon monoxide to the blood, thus lowering the diffusing
  capacity without affecting any of the lung volumes or capacities.
• Pulmonary arterial hypertension.

Question 10

Tell me about lung cancer, some types,

Answer 10

Lung cancer can be subdivided into

1. non-small cell lung cancer (NSCLC—85%)
2. small cell lung cancer (SCLC—15%).

NSCLC is further subdivided into
adenocarcinoma,
squamous cell carcinoma,
large cell carcinoma.

Question 11

Lung Ca systemic complications

Answer 11

SCLC often presents late and is more rapid in progression.

I would take a history and note any weight loss/cachexia.

I would be interested in any investigations
he may have had to date,
any imaging/ mass effects of the tumour itself,
any metastasis,
evidence of paraneoplastic syndromes (Cushing’s, SIADH, Eaton-Lambert),

Any related medications including chemotherapy or radiotherapy.

I would also note any anaemia and
that he has increased thrombotic risk,
which may be why he is anticoagulated.

Question 12

What is your initial management of the patient?

Answer 12

I would take an ABC approach to managing this patient and would ensure
his airway is patent and his C spine stabilised and that his breathing and
circulation are not compromised.

My history would concentrate on the duration of symptoms and any
associated trauma or injuries. My concerns relate to a pathological fracture/
degenerative disease or trauma, and management should ensure that a full
primary and secondary survey have been completed via ATLS protocols if
appropriate.

More extensive history would include a full anaesthetic assessment including
airway, fasting status, social history, allergies, and previous anaesthetics.
Specific to him I would like to know about any active reflux, reasons for
and timing of anticoagulation, and steroid therapy.

I would be interested in breathlessness/cough/signs of heart failure/palpitations/syncope/angina and,
most importantly, acute or chronic neurology.

A full and complete examination and documentation should occur.

Question 13

Additional investigations would include

Answer 13

Blood tests
* Full blood count to exclude any anaemia/thrombocytopenia/infection
* Coagulation screen
* Renal function (as a baseline in view of diabetes)
* Electrolytes including Ca/Mg/PO4/Na/K
* HbA1C and glucose
* Liver function tests
* Group and screen should also be sent.

CXR
A recent Chest radiograph to exclude chest infection in view of findings on
auscultation.

CT / MRI

It is likely to be indicated and beneficial presurgery,
and if associated trauma,
a full body CT may be indicated.

Question 14

He is listed for urgent cervical spine fixation. How would you manage his airway?

Answer 14

Manipulation of his airway could result in significant cord compromise;
hence, due care should be given to technique.

I feel the most stable way to manage would be via an awake fibreoptic
intubation (AFOI).

I would like to do this in a safe environment with other
experienced personnel and senior support.

Alternatives would be to perform an asleep FoI or to do standard laryngoscopy with a manual in-line stabilisation technique.

AFoI will mean there is less neck movement,
will require less mouth opening on the part of the patient,
and allows a continuous monitor of neurology even after the endotracheal tube has been placed.

Asleep methods can be considered with fasted patients with good airway assessment.

Question 15

Talk me through your technique for an AFOI

Answer 15

In order to perform the AFoI,

1. I would need to explain the procedure to the patient,
   alleviating any anxiety, and
   assess suitability and prepare medication and equipment.
2. I would ensure good intravenous access and supplementary
   oxygen via nasal sponge and establish full monitoring.
3. I would treat with an antisialogogue such as glycopyrrolate and low-dose midazolam.
4. Procedure
   Sedation:
   Remifentanil target-controlled infusion and/or midazolam to obtund anxiety.
5. Nose and throat:
   Check nostril patency and choose best side. Apply topical
   vasoconstrictors and local anaesthetic in the form of 10% lignocaine to the
   chosen nostril and back of throat.
6. Larynx and trachea:
   Various methods have been followed in anaesthetising the larynx and trachea such as the cricothyroid puncture, internal laryngeal nerve block at the hyoid bone, etc.

I am used to the spraying of the local anaesthetic using an epidural catheter via the side port of the fibreoptic scope.

7. Prepare the tube:
   Railroad the reinforced nasal tube on the fibreoptic scope with copious lubricant.
8. Intubation: once position is confirmed (auscultation/EtCo2 trace), check
   neurology once more and then anaesthetise with either propofol or volatile
   agent.
9. I would have the difficult airway trolley to hand with a laryngeal mask
   available for rescue.
   I would secure with tape, avoiding ties (and also
   compression of neck veins), and recheck tube position with fibreoptic scope
   once secured

The surgeon tells you that the cervical spine fixation is done with the patient
in the prone position.

Question 16

What are the implications of the prone position?

Answer 16

These relate to personnel required, monitoring and line displacement,
pressure-related problems, and physiological implications. In this case it
should be discussed whether the surgeons would be using Mayfield pins as
an alternative for head placement.

Appropriate numbers of trained staff should be available in theatre
for both proning and reversal at the end of the procedure.

Lines and monitoring should be rationalised for transfer of patient
and should be well secured to avoid displacement.

Care should be taken to use special mattresses and head supports
to avoid pressure to
organs, abdomen, and nerves overlying joints (e.g. hips, elbows, and thighs).

Whilst rotating arms during positioning,
care should be taken to prevent brachial plexus injuries.

Eyes should be lubricated, taped, and padded and
checked at regular intervals to avoid complications
of abrasions and ischaemic retinopathy.

Abdominal pressure may cause IVC compression,
reduced venous return,
poor cardiac output,
regurgitation of stomach contents,
and reduced thoracic compliance.

Oxygenation may, however, improve in the prone position due to improved ventilation/perfusion matching.

Question 17

Do you have a checklist for when a patient is placed prone

Answer 17

Once patient is in position,

a systematic final check should occur from head to toe to ensure the following are checked: tube not kinked, air
entry adequate, no pressure on face/eyes/brachial plexus/breasts/abdomen/
anterior superior iliac spines/genitalia/knees and feet.

Question 18

What are the main principles for perioperative management of this patient aside from those mentioned already?

Answer 18

These relate to the surgery itself and the patient’s comorbidities and prevention
of complications.

Through use of invasive monitoring and perhaps cardiac output monitoring if available,

I would aim for optimal cardiac output and avoid excessive fluids;
this may require the use of low-dose infusion of vasopressors.

A remifentanil-based technique with volatile agent
will help control tachycardia and hypertension
through easy adjustment for periods of higher stimulation
(placement of pins/bony manipulation).

Care should be taken with assessing blood loss and
use of cell salvage if considered appropriate.

This patient will require regular assessment of blood sugars and may require
a sliding scale perioperatively.

Normal care with temperature,
warming measures,
prevention of thromboembolism should be taken
(e.g. TED stockings and intermittent pneumatic compression devices).

Question 19

Will you extubate this patient?

When will you decide that it is safe to do so?

Answer 19

I would ideally like to wake and extubate this patient early
for prompt assessment of their neurology

but in a careful and controlled manner to avoid coughing.

Use of lignocaine spray on cuff and using a remifentanil based
technique can aid a smooth extubation.

I would ensure that temperature, po2, EtCo2, and
reversal of neuromuscular blockade have been corrected.

I would ensure that the patient has adequate pain relief with
possible long-acting local anaesthetic infiltrated by the surgeon at the end,
a multimodal technique, and avoidance of large doses of opiates that may
compromise wakefulness at the end.

A guedel may be helpful to prevent biting on the tube.

After a period in recovery, a high-dependency bed should be made available.

In this patient my concerns are of a superadded chest infection,

making laryngospasm and coughing more likely; hence, the importance of adequate
suctioning and use of adjuncts such as remifentanil/pre-intubation lignocaine
spray.