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GENERAL ARTICLES

Cervical Spine Motion During Airway Management: A Cinefluoroscopic Study of the Posteriorly Destabilized Third Cervical Vertebrae in Human Cadavers

Joseph Brimacombe, MB, ChB, FRCA, MD^*, Christian Keller, MD, Karl H. Künzel, MD, Othmar Gaber, MD, Michael Boehler, MD, and Fredrich Pühringer, MD

*University of Queensland, Department of Anesthesia and Intensive Care, Cairns Base Hospital, Australia; and Department of Anesthesia and Intensive Care Medicine, and Institute of Anatomy, Leopold-Franzens University, Innsbruck, Austria

Address correspondence and reprint requests to Joseph Brimacombe, MB, ChB, FRCA, MD, Department of Anaesthesia and Intensive Care Medicine, University of Queensland, Cairns Base Hospital, Cairns 4870, Australia. Address e-mail to jbrimacombe @north.net.au.

We conducted a randomized, controlled, crossover study to determine cervical spine motion for six airway management techniques in human cadavers with a posteriorly destabilized third cervical (C-3) vertebra. A destabilized C-3 segment was created in 10 cadavers (6–24 h postmortem). Cervical motion was recorded by continuous lateral fluoroscopy. The following airway management techniques were performed in random order on each cadaver with manual in-line stabilization applied: face mask ventilation (FM), laryngoscope-guided orotracheal intubation (OETT), fiberscope-guided nasal intubation (FOS-NETT), esophageal tracheal Combitube^® (Kendall-Sheridan, Neustadt, Germany) insertion (ETC), intubating laryngeal mask insertion with fiberscope-guided tracheal intubation (ILM-OETT), and laryngeal mask airway insertion (LMA). Afterward, maximum head-neck flexion (FLEX-MAX) and maximum head-neck extension (EXT-MAX) without manual in-line stabilization was performed to determine maximum motion. The maximum posterior displacement of C-3 and the maximum segmental sagittal motion of C2-3 were determined. There was a significant increase in posterior displacement for the FM (1.9 ± 1.2 mm, P < 0.01), OETT (2.6 ± 1.6 mm, P < 0.0001), ETC (3.2 ± 1.6 mm, P < 0.0001), ILM-OETT (1.7 ± 1.3 mm, P < 0.01), LMA (1.7 ± 1.3 mm, P < 0.01), FLEX-MAX (3.7 ± 1.9 mm, P < 0.0001), EXT-MAX (1.8 ± 1.7, P < 0.01), however, not for FOS-NETT (0.1 ± 0.7 mm). Posterior displacement was less for the ILM-OETT and LMA than for the ETC (both P < 0.04). There were no significant increases in segmental sagittal motion with any airway manipulation other than with FLEX-MAX (-4.5 ± 4.0°, P < 0.01). Posterior displacement was similar to FLEX-MAX for the OETT and ETC; however, it was less for the FM, FOS-NETT, ILM-OETT, and LMA (all P < 0.01). Posterior displacement was similar to EXT-MAX for all airway manipulations other than for FOS-NETT (P < 0.001). For cervical motion and the techniques tested, the safest method of airway management in a patient with a posteriorly destabilized C-3 segment is FOS-NETT. LMA devices may be preferable to the ETC.

Implications: In the cadaver model of a destabilized third cervical vertebrae, significant displacement of the injured segment occurs during airway management with the face mask, laryngoscope-guided oral intubation, the esophageal tracheal Combitube^® (Kendall-Sheridan, Neustadt, Germany), the intubating and standard laryngeal mask airway; but not with fiberscope-guided nasal intubation. For cervical motion and the techniques tested, the safest airway technique with this injury is fiberscope-guided nasotracheal intubation. Laryngeal mask devices are preferable to the esophageal tracheal Combitube^®.

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