The confirmation of residual foreign bodies in thoracic spinal sharp injuries is an absolute indication for surgical exploration[7]. For anesthesiologists, the ability to establish a safe airway is crucial for the success of the surgical anesthesia. Routine induction of endotracheal intubation in the supine position is difficult to achieve, and even operating in the lateral position may cause displacement of the sharp instrument, leading to irreversible risk of high-level paraplegia. The limitations of body position inevitably increase the difficulty and risk of general anesthesia. Therefore, it is particularly important to make adequate pre-anesthetic preparations, optimize the induction plan, and successfully complete endotracheal intubation for such patients without increasing the risk of secondary injury.
Typically prone position surgery involves inducing anesthesia in the supine position and then turning the patient into the prone position for the surgery. However,it is risks for patients with thoracic spinal cord injuries. Any change in position can cause the blade to shift, further exacerbating the spinal cord injury and increasing the risk of damage to the thoracic organs. Although a previous report shows that patients with traumatic thoracic spine injuries can undergo tracheal intubation using a direct laryngoscope in the prone position[8], this technique carries certain risks. There is very little experience in performing this procedure, and it is rarely used by anesthesiologists in routine scheduled surgeries. On the other hand, it is difficult to assess the patient's airway condition in the prone position. Additionally, this patient had consumed a large amount of alcohol, putting at a high risk for aspiration. If there were difficulties in airway management after anesthesia induction, mask ventilation could become challenging and even pose a life-threatening risk. Therefore, we chose to perform tracheal intubation in the prone position under sedation, even if there is reflux of gastric contents, it is less likely to cause airway obstruction as long as promptly and adequately suctioned.
The successful use of LMA as a backup plan for anesthesia has been reported previously in the literature for endotracheal intubation under general anesthesia in the prone position [9]. However, these reports were all from non-full stomach patients with a relatively low risk of aspiration. Although the prone position is advantageous for patients at risk of aspiration, as refluxed material can flow out of the mouth, preventing airway obstruction, for patients who appeared intoxicated and uncooperative, using LMA for intubation can result in passive airway management if there is a significant reflux of gastric contents during the procedure. This can potentially lead to an emergency airway situation.Therefore, the application of LMA in such patients still needs to be carefully considered.
Although the use of retained spontaneous breathing tracheal intubation has been widely applied, unlike others, patients with thoracic spinal cord injuries have strict requirements for changes in position. Therefore, it is necessary to have a comprehensive surface anesthesia of the airway to avoid severe cough reflex during tracheal intubation. Due to the patient being in a prone position, it is very difficult to perform a cricothyroid membrane puncture, so we used a staged surface anesthesia of the oral-pharyngeal region and the trachea combined with appropriate intravenous sedation to successfully complete the tracheal intubation. During the procedure, the patient had almost no reflex body movement, which is inseparable from the comprehensive staged surface anesthesia of the airway.We encountered a case of thoracic spinal cord sharp instrument injury in the emergency department during our clinical work. The patient had a spinal cord stab injury due to a fight after abusing alcohol. The patient was placed in a prone position and taken to the operating room for exploration. Under moderate sedation, we performed fiberoptic bronchoscopy-guided intubation in the prone position. Practice has proved that awake fiberoptic bronchoscopy-guided intubation in the prone position is safe and feasible, providing better reference for clinical practice.
In conclusion, our clinical experience with anesthesia management in this patient suggests that for patients with full stomachs and spinal cord injuries caused by stab wounds, excellent staged airway surface anesthesia and appropriate sedation can effectively facilitate tracheal intubation in the prone position, minimizing patient injury caused by positional changes. Meanwhile, our experience indicates that this technique is possible and might be considered in situations similar to those described in our report.