Abstract
Purpose
Survival after atlanto-axial-occipital ligamentous injury is uncommon and experience with the immediate clinical management of these patients is similarly low. There has been considerable work published recently with respect to airway management in similar patients and a review of this material was undertaken.
Methods
Medline searches were performed to seek out the English language literature using the key words and phrases:cervical spinal injury; atlanto-occipital dislocation; atlanto-occipital disarticulation; andairway management after spinal injury. The titles were culled for materials relevant particularly to upper cervical spinal injury, these were obtained and reviewed. The bibliographies of these articles were searched to ensure that the review would be complete.
Relevant findings
The majority of cervical spinal movement occurring during direct laryngoscopy is concentrated in the upper cervical spine. The magnitude of movement during airway management rarely exceeds the physiological limits of the spine. Movement is reduced by in-line immobilization but traction forces cause clinically important distraction and should be avoided. Indirect techniques for tracheal intubation cause less cervical movement than does the direct laryngoscope. Survival after severe upper ligamentous injury is uncommon but intact survival occurs. Missed diagnosis is common and associated with a high incidence of severe secondary injury. Failure to immobilize the spine is deemed to be the most relevant factor in secondary injury.
Conclusions
Patients who survive severe upper cervical ligamentous injury and present to hospital are uncommon. However, of those who do, both intact survival and survival with limited neurological sequelae do occur. Meticulous airway care with maintenance of alignment and provision of continuous cervical immobilization are an integral component of care in these patients.
Résumé
Objectif
Il est rare qu’on survive à une blessure ligamentaire atlanto-axoïdienne-occipitale et le traitement clinique immédiat des patients qui en sont victimes est peu connu. De nombreuses publications récentes traitent de la prise en charge des voies aériennes dans des cas semblables. Une revue de ce matériel a donc été entreprise.
Méthode
Une recherche d’articles de langue anglaise a été faite dans Medline à partir des mots clefs et expressions: cervical spinal injury; atlanto-occipital dislocation; atlanto-occipital disarticulation et airway management after spinal injury. Les articles retenus et revus traitaient particulièrement de lésions de la colonne cervicale supérieure. La revue a été complétée par l’examen des bibliographies de ces articles.
Constatations pertinentes
La majorité des mouvements de la colonne cervicale qui se produisent pendant la laryngoscope directe mettent en jeu la colonne cervicale supérieure. L’amplitude du mouvement pendant la prise en charge des voies aériennes dépasse rarement les limites physiologiques de la colonne. Le mouvement est réduit par l’immobilisation synchronisée, mais les forces de traction causent d’importantes distractions cliniques et devraient être évitées. Les techniques indirectes d’intubation trachéale causent moins de mouvements cervicaux que la laryngoscope directe. La survie à la suite d’une sévère lésion ligamentaire supérieure est rare, mais possible sans séquelle. Il est fréquent de manquer le diagnostic, ce qui est associé à une incidence élevée de blessure secondaire sérieuse. Le défaut d’immobiliser la colonne est considéré comme le facteur le plus significatif de blessure secondaire.
Conclusion
Peu de patients survivent à une importante lésion ligamentaire cervicale supérieure. Cependant, parmi ceux qui se présentent avec cette blessure, certains survivent sans séquelles et d’autres subissent des limitations neurologiques. La prise en charge des voies aériennes de ces patients doit être minutieuse et comporter le maintien de l’alignement de la colonne cervicale par une immobilisation continue.
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References
Hensinger RN. Congenital anomalies of the atlantoaxial joint.In: The Cervical Spine Research Society Editorial Committee (Eds.). The Cervical Spine, 2nd ed. Philadelphia: JB Lippincott, 1989: 236–43.
Steel HH. Anatomical and mechanical considerations of the atlanto-axial articulations. J Bone Joint Surg 1968; 50: 1481–90.
Jofe MH, White AA, Punjabi MM. Clinically relevant kinematics of the cervical spine.In: The Cervical Spine Research Society Editorial Committee (Eds.). The Cervical Spine, 2nd ed. Philadelphia: JB Lippincott, 1989: 57–69.
White AA III, Johnson RM, Panjabi MM, Southwick WO. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop 1975; 109: 85–95.
White AA III, Punjabi MM. Clinical Biomechanics of the Spine, 2nd ed. Philadelphia: JB Lippincott, 1990: 314–7.
Sawin PD, Todd MM, Traynelis VC, et al. Cervical spine motion with direct laryngoscopy and orotracheal intubation. An in vivo cinefluoroscopic study of subjects without cervical abnormality. Anesthesiology 1996; 85: 26–36.
Horton WA, Fahy L, Charters P. Disposition of the cervical vertebrae, atlanto-axial joint, hyoid and mandible during x-ray laryngoscopy. Br J Anaesth 1989; 63: 435–8.
Donaldson WF III, Heil BV, Donaldson VP, Silvaggio VJ. The effect of airway maneuvers on the unstable C1–C2 segment. A cadaver study. Spine 1997; 22: 1215–8.
Aprahamian C, Thompson BM, Finger WA, Darin JC. Experimental cervical spine injury model: evaluation of airway management and splinting techniques. Ann Emerg Med 1984; 13: 584–7.
Lennarson PJ, Smith D, Todd MM, et al. Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg (Spine 2) 2000; 92: 201–6.
Lennarson PJ, Smith DW, Sawin PD, et al. Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. J Neurosurg (Spine 2) 2001; 94: 265–70.
Kihara S, Watanabe S, Brimacombe J, Taguchi N, Yaguchi Y, Yamasaki Y. Segmental cervical spine movement with the intubating laryngeal mask during manual in-line stabilization in patients with cervical pathology undergoing cervical spine surgery. Anesth Analg 2000; 91: 195–200.
Keller C, Brimacombe J, Keller K. Pressures exerted against the cervical vertebrae by the standard and intubating laryngeal mask airways: a randomized, controlled, cross-over study in fresh cadavers. Anesth Analg 1999; 89: 1296–1300.
Lee C, Woodring JH, Walsh JW. Carotid and vertebral artery injury in survivors of atlanto-occipital dislocation: case reports and literature review. J Trauma 1991; 31: 401–7.
Alker GJ Jr, Oh YS, Leslie EV, Lehotay J, Panaro VA, Eschner EG. Postmortem radiology of head and neck injuries in fatal traffic accidents. Radiology 1975; 114: 611–7.
Bucholz RW, Burkhead WZ, Graham W, Petty C. Occult cervical spine injuries in fatal traffic accidents. J Trauma 1979; 19: 768–71.
Davis D, Bohlman H, Walker AE, Fisher R, Robinson R. The pathological findings in fatal craniospinal injuries. J Neurosurg 1971; 34: 603–13.
Chiu WC, Haan JM, Cushing BM, Kramer ME, Scalea TM. Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: incidence, evaluation, and outcome. J Trauma 2001; 50: 457–64.
Werne S. Studies in spontaneous atlas dislocation. Acta Orthop Scand 1957; 23(suppl): 1–150.
Bailey H, Perez N, Blank-Reid C, Kaplan LJ. Atlantooccipital dislocation: an unusual lethal airbag injury. J Emerg Med 2000; 18: 215–9.
Gabrielsen TO, Maxwell JA. Traumatic atlanto-occipital dislocation with case report of a patient who survived. Radiology 1966; 97: 624–9.
Evarts CM. Traumatic occipito-atlantal dislocation. Report of a case with survival. J Bone Joint Surg 1970; 52-A: 1653–60.
Powers B, Miller MD, Kramer RS, Martinez S, Gehweiler JA Jr. Traumatic anterior atlanto-occipital dislocation. Neurosurgery 1979; 4: 12–7.
Przybylski GJ, Clyde BL, Fitz CR. Craniocervical junction subarachnoid hemorrhage associated with atlantooccipital dislocation. Spine 1996: 21: 1761–8.
Ferrera PC, Bartfield JM. Traumatic atlanto-occipital dislocation: a potentially survivable injury. Am J Emerg Med 1996; 14: 291–6.
Reid DC, Henderson R, Saboe L, Miller JDR. Etiology and clinical course of missed spine fractures. J Trauma 1987; 27: 980–6.
Davis JW, Phreaner DL, Hoyt DB, Mackersie RC The etiology of missed cervical spine injuries. J Trauma 1993; 34: 342–6.
Traynelis VC, Marano GD, Dunker RO, Kaufman HH. Traumatic atlanto-occipital dislocation. Case report. J Neurosurg 1986; 65: 863–70.
Dickman CA, Papadopoulos SM, Sonntag VKH, Spetzler RF, Rekate HL, Drabier J. Traumatic occipitoatlantal dislocations. J Spinal Disord 1993; 6: 300–13.
Wholey MH, Bruwer AJ, Baker HL Jr. The lateral roentgenogram of the neck (with comments on the atlanto-odontoid-basion relationship). Radiology 1958; 71: 350–6.
Dublin AB, Marks WM, Weinstock D, Newton TH. Traumatic dislocation of the atlanto-occipital articulation (AOA) with short-term survival. With a radiographic method of measuring the AOA. J Neurosurg 1980; 52: 541–6.
Kaufman RA, Dunbar JS, Botsford JA, McLaurin RL. Traumatic longitudinal atlanto-occipital distraction injuries in children. AJNR 1982; 3: 415–9.
Majernick TG, Bieniek R, Houston JB, Hughes HG. Cervical spine movement during orotracheal intubation. Ann Emerg Med 1986; 15: 417–20.
Kaufman HH, Harris JH Jr, Spencer JA, Kopanisky DR. Danger of traction during radiography for cervical trauma (Letter). JAMA 1982; 247: 2369.
Bivins HG, Ford S, Bezmalinovic Z, Price HM, Williams JL. The effect of axial traction during orotracheal intubation of the trauma victim with an unstable cervical spine. Ann Emerg Med 1988; 17: 25–9.
Heath KJ. The effect on laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia 1994; 49: 843–5.
Getting MC, Davis DP, Hamilton RS, et al. Effects of cervical spine immobilization technique and laryngoscope blade selection on an unstable cervical spine in a cadaver model of intubation. Ann Emerg Med 2000; 36: 293–300.
Hastings RH, Wood PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology 1994; 80: 825–31.
Wood PR, Dresner M, Hayden Smith J, Kumar CM, Lawler PGP. Direct laryngoscopy and cervical spine stabilisation (Letter). Anaesthesia 1994; 49: 77–8.
Fitzgerald RD, Krafft P, Skrbensky G, et al. Excursions of the cervical spine during tracheal intubation: blind oral intubation compared with direct laryngoscopy. Anaesthesia 1994; 49: 111–5.
McLeod AD, Calder I. Spinal cord injury and direct laryngoscopy — the legend lives on (Editorial I). Br J Anaesth 2000; 84: 705–8.
Hastings RH, Kelley SD. Neurologic deterioration associated with airway management in a cervical spineinjured patient. Anesthesiology 1993; 78: 580–3.
Liang BA, Cheng MA, Tempelhoff R. Efforts at intubation: cervical injury in an emergency circumstance? J Clin Anesth 1999; 11: 349–52.
Gerling MC, Davis, DP, Hamilton RS, et al. Effect of surgical cricothyrotomy on the unstable cervical spine in a cadaver model of intubation. J Emerg Med 2001; 20: 1–5.
Palmer MT, Turney SZ. Tracheal rupture and atlantooccipital dislocation: case report. J Trauma 1994; 37: 314–7.
Ahuja A, Glasauer FE, Alker GJ Jr, Klein DM. Radiology in survivors of traumatic atlanto-occipital dislocation. Surg Neurol 1994; 41: 112–8.
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Crosby, E. Airway management after upper cervical spine injury: what have we learned?. Can J Anesth 49, 733–744 (2002). https://doi.org/10.1007/BF03017455
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DOI: https://doi.org/10.1007/BF03017455