Patients requiring cervical spine stabilization for surgery present a significant challenge for anesthesiologists, as ensuring spinal integrity must be carefully balanced with securing the airway and maintaining hemodynamic stability during anesthesia. These challenges are heightened in cases of traumatic injury, degenerative disease, or congenital anomalies. Anesthetic management should aim to prevent further spinal injury while ensuring optimal oxygenation, ventilation, and neuroprotection.
Preoperative preparation is essential and begins with a thorough history and physical examination. Imaging, including computed tomography (CT) or magnetic resonance imaging (MRI), is often needed to confirm the extent of cervical instability and to identify potential complications, such as spinal cord compression. A detailed neurological evaluation should also assess any pre-existing deficits that may affect perioperative care. For example, high cervical spine injuries involving the phrenic nerve may impair diaphragmatic function, increasing the risk of respiratory compromise (1).
Airway management in patients requiring cervical stabilization involves careful planning, as conventional intubation techniques used in anesthesia may exacerbate spinal instability. Techniques such as video laryngoscopy are preferred because of their ability to reduce cervical spine motion. In situations where securing the airway is expected to be particularly difficult, awake fiberoptic intubation may be the safest approach. This technique allows the patient to maintain spontaneous breathing during intubation, reducing the risk of hypoxia. Close collaboration with surgical and critical care teams ensures that airway management strategies are aligned with the overall clinical needs of the patient (2).
During induction of anesthesia, agents are carefully selected to minimize blood pressure fluctuations that can affect spinal cord perfusion. Rapid sequence induction (RSI), a technique designed to minimize aspiration risk, may need to be modified or avoided in these patients if there is a risk of cervical spine movement. Neuromuscular blockade must be precisely titrated to ensure complete immobility during intubation and surgery. Maintaining oxygenation and stable blood pressure throughout this phase is critical to avoid secondary spinal cord injury that may result from ischemia or hypoperfusion (3).
Intraoperatively, the anesthetic plan must balance the goals of spinal immobilization and neuroprotection. Neuromonitoring techniques, such as somatosensory and motor evoked potentials, are often used during cervical spine surgery to provide continuous feedback on spinal cord integrity. Total intravenous anesthesia (TIVA), typically using agents such as propofol and remifentanil, is often preferred in these cases, as it offers superior stability for neuromonitoring. Proper positioning is another cornerstone of care, as improper alignment during surgery can exacerbate spinal instability or lead to additional neurological damage. Devices such as rigid cervical collars or halo traction systems help immobilize the spine while allowing the surgeon to perform the necessary procedure (4).
Postoperative care requires vigilant monitoring for complications, including respiratory failure, worsening neurological deficits, or hemodynamic instability. Pain management is critical, but excessive sedation should be avoided as it may compromise respiratory function. Multimodal analgesia, which combines opioids with regional techniques or non-opioid medications, is often the preferred strategy. Patients with high cervical spine injuries may require prolonged mechanical ventilation, and these patients should be closely monitored in the ICU. If possible, early mobilization and physiotherapy can be integral to reducing complications and improving functional recovery (5).
Anesthesia management of patients undergoing cervical spine stabilization requires a multidisciplinary approach that prioritizes airway safety, spine protection, and hemodynamic stability. Advances in imaging, airway technology, and neuromonitoring have greatly improved the safety of these procedures, but successful outcomes still depend on detailed preoperative planning and intraoperative vigilance.
References
- Kwon WK, Ham CH, Byun J, et al. Surgical and Neurointensive Management for Acute Spinal Cord Injury: A Narrative Review. Korean J Neurotrauma. 2024;20(4):225-233. Published 2024 Dec 26. doi:10.13004/kjnt.2024.20.e44
- Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012;116(3):629-636. doi:10.1097/ALN.0b013e318246ea34
- Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104(6):1293-1318. doi:10.1097/00000542-200606000-00026
- Gonzalez AA, Jeyanandarajan D, Hansen C, Zada G, Hsieh PC. Intraoperative neurophysiological monitoring during spine surgery: a review. Neurosurg Focus. 2009;27(4):E6. doi:10.3171/2009.8.FOCUS09150
- Yoo JS, Ahn J, Buvanendran A, Singh K. Multimodal analgesia in pain management after spine surgery. J Spine Surg. 2019;5(Suppl 2):S154-S159. doi:10.21037/jss.2019.05.04