Cervical Spinal Surgery

Surgery on the cervical spine for trauma, tumor, arthritis, spinal stenosis, or instability is associated with several complications.^{[122] [123]} Posterior cervical decompression may be performed in the sitting position, increasing the risk of air embolism, or in the prone position, increasing the risk from external pressure on the eyes.^[28] Intubation may be difficult because of instability of the spine (as in neck fracture or C1-2 instability) or a complex airway due to neck deformity, as in rheumatoid arthritis.^{[8] [11]} If any question exists, these patients are best intubated with the aid of a flexible fiberoptic bronchoscope and positioned while they are "awake" (i.e., sedated and amnesic) to be certain that the anesthetic maneuvers have not compromised the spinal cord. Once positioned, the patient's anesthetic may be lightened, and the patient is instructed to move the toes and open and close the hands. The ability to follow these commands, along with spontaneous breathing, ensures the cervical spinal cord is still intact. An armored endotracheal tube is often preferable to minimize kinking caused by retractors or movement during surgery.

Cervical spinal surgery may be complicated by injury to the spinal cord during surgery, leading to postoperative quadriplegia with respiratory impairment. ^[8] For this reason, somatosensory evoked potentials (SSEPs) are often used during these procedures to monitor surgical manipulations. Patients with rheumatoid arthritis undergoing cervical spinal surgery in the prone position should receive minimal intraoperative fluid, be intubated with the aid of a fiberoptic bronchoscope, and have the neck maintained in a neutral position; after surgery, they should be kept head up for 3 to 5 hours to minimize the risk of upper airway obstruction after extubation.^{[124] [125]} The potential respiratory difficulty is presumably from upper airway edema caused by trauma during intubation, excessive fluid, and prolonged dependency.^[125] Patients with rheumatoid arthritis should also have a full set of cervical spine radiographs, including odontoid views before elective surgery that may involve airway manipulation.^[126] Cervical spinal surgery can be performed using local anesthesia to avoid some of these problems.^{[19] [127]}