Risk factors and treatment of difficult intubation during retropharyngeal hematoma evacuation following anterior cervical spine surgery: a retrospective study

doi:10.21203/rs.3.rs-4117597/v1

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Risk factors and treatment of difficult intubation during retropharyngeal hematoma evacuation following anterior cervical spine surgery: a retrospective study

https://doi.org/10.21203/rs.3.rs-4117597/v1

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Background

Postoperative retropharyngeal hematoma (RH) following anterior cervical spine surgery (ACSS) can cause acute airway obstruction (AAO). In severe cases, difficult intubation (DI) may occur, posing serious challenges to airway management. The purpose of this retrospective study was to investigate the incidence and risk factors for DI and to explore airway management in RH evacuation following ACSS.

Methods

A series of 40 consecutive patients who underwent RH evacuation following ACSS were retrospectively identified at Peking University Third Hospital from March 2010 to March 2023. Patients were categorized into the DI group or no-DI group. Demographic, clinical symptom, and airway assessment data were recorded to identify risk factors for DI.

Results

The incidence of postoperative RH out of all ACSS surgery was 0.2% (40/16,127). General anesthesia was applied for RH evacuation in all 40 patients. The incidence of DI during RH evacuation was 35% (14/40). Thirty-nine patients were successfully treated and discharged, and one patient died of hypoxic-ischemic encephalopathy 24 days after RH evacuation. Class III & IV acute airway obstruction (AAO) (odds ratio [OR], 5.384; 95% confidence interval [CI], 1.098–26.398; P = 0.038) and time interval between symptom onset and airway intervention (TI) (OR, 2.073; CI [1.072–4.010]; P = 0.030) were found to be independent risk factors for DI. Patients with DI had longer tracheal catheter retention times and longer durations of stay in the intensive care unit (ICU) (P < 0.001).

Conclusions

Class III & IV AAO and TI are independent risk factors for DI during RH evacuation following ACSS. DI is associated with longer retention of the tracheal catheter and longer duration of stay in the ICU. Appropriate airway intervention should be performed for high-risk patients.

Trial registration:

ChiCTR2200061982

Difficult intubation

Retropharyngeal hematoma

Anterior cervical spine surgery

Airway complication

Airway management

Emergency tracheotomy

Hematoma after anterior cervical spine surgery (ACSS) is an early complication that occurs in 0.4–5.6% of patients [1–12]. These hematomas can be classified into one of two types: spinal epidural hematoma (SEH) or retropharyngeal hematoma (RH). SEH may induce neurological deficits. RH can exert direct pressure on the airway, resulting in notable enlargement of the neck area, prevertebral soft tissues, posterior pharyngeal wall, the base of the tongue, and potentially the facial region. These effects could culminate in severe acute airway obstruction (AAO) [13–15]. The reported incidence of AAO caused by hematoma ranges from 0.2 to 1.9% [14].

Airway management during RH evacuation is challenging. Facemask ventilation and tracheal intubation can be difficult. Severe neck swelling may hinder cricothyrotomy or tracheotomy. Improper airway management may lead to a “Cannot intubate Cannot Oxygenate (CICO)” scenario, which is associated with severe morbidity and mortality [16.17]. Therefore, effective airway management should be undertaken to prevent catastrophic consequences.

Few comprehensive and systematic studies have been conducted on difficult intubation (DI) during RH evacuation after ACSS in the current literature. The purpose of the present study was to document cases of RH at our institution within a 13-year timeframe, investigate the incidence and risk factors contributing to DI, and share our experiences regarding airway management in these cases. We preliminarily devised airway management protocols in patients undergoing RH evacuation according to their clinical manifestations and progression of the condition.

2.1 Patient selection

Sixty-four patients with postoperative hematoma were identified from 16,127 patients who received ACSS at Peking University Third Hospital from March 2010 to March 2023. Patients with incomplete medical records, cervical trauma or tumor, or epidural hematoma were excluded.

The definition of postoperative RH following ACSS in the present study was symptomatic postoperative RH manifested as respiratory distress, dysphagia or other symptoms of hematoma, which was confirmed by magnetic resonance imaging (MRI), color Doppler ultrasound or surgical evacuation [12]. DI was defined as a clinical scenario necessitating more than three attempts by an experienced anesthesiologist to perform endotracheal intubation [18.19]. Finally, 40 patients who underwent evacuation due to postoperative RH were included in the study. These patients were subsequently divided into DI group and no-DI group (Fig. 1).

2.2 Data collection

The following data from both groups were summarized and analyzed: gender, age, modified Japanese Orthopedic Association (m-JOA) scale score, body mass index (BMI), medical comorbidities, surgical segments, blood loss during ACSS, hematoma volume, symptoms at the onset of RH, time interval between symptom onset and airway intervention (TI), retention time of the tracheal catheter and duration of stay in the intensive care unit (ICU).

In addition to clinical symptoms, there is no universally applicable standard for assessing the severity of AAO. We categorized the postoperative AAO into Class I–IV according to the patient’s level of consciousness, degree of dyspnea, and oxygenation status [20.21]. The postoperative AAO classifications are shown in Table 1.

Table 1

Classification of acute airway obstruction
Classification	Description
Class Ⅰ Mild obstruction	The patient is presently in good health and does not experience any difficulty breathing at rest, although it may be present during physical activity.
Class Ⅱ Moderate obstruction	The patient experiences mild inspiratory dyspnea at rest, which may worsen during physical activity. There are no obvious symptoms of hypoxia.
Class Ⅲ Severe obstruction	Patients may become restless or experience panic due to a lack of oxygen. Obvious dyspnea, a louder laryngeal chirp, and three concave signs may be observed. The patient may also present with a rapid pulse and elevated blood pressure. The compensatory function of the circulatory system remains good.
Class Ⅳ Life-threatening obstruction	The patient experiences extreme dyspnea, and because of the severe lack of oxygen and accumulation of carbon dioxide, the patient is cyanotic, has a weak pulse and decreased blood pressure, or is in a coma.

In terms of airway assessment, modified Mallampati test (MMT) result was collected. MMT was evaluated by asking the patient to sit or stand upright and open the mouth with maximum tongue protrusion without phonation: Class I - visualization of the faucial pillars, soft palate, and entire uvula; Class II - visualization of the faucial pillars, soft palate, and uvula; Class III - visualization of the soft palate and base of the uvula; Class IV - only the hard palate is visible on the roof of the mouth [22]. Additionally, information regarding the approach used for airway intervention was collected.

2.3 Statistical analysis

Continuous variables conforming to a normal distribution were presented as mean ± standard deviation, and comparisons between two groups were conducted via Student’s t test. Non-normally distributed data were presented as median (interquartile range), and the Mann–Whitney U test was used for comparisons between two groups. Significant differences in categorical variables were assessed using Fisher’s exact test. P < 0.05 was considered statistical significant. A binary logistic regression model was applied to identify multivariate predictors, with odds ratios (ORs) and 95% confidence intervals (95% CIs) used to denote the strength and direction of association. The receiver operating characteristic (ROC) curve was used to describe the discrimination of predictive indicators. The area under the curve (AUC) was used as a quantitative index. The Youden’s index (= sensitivity + specificity − 1) was calculated, and the highest score was the optimal predictive cut-off value. The statistical analyses were conducted using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA).

The number of cases who underwent RH evacuation following ACSS during the study period determined the sample size. According to the principle that the number of events per variable, that is, the number of outcome events corresponding to each independent factor is not less than 5. In the logistics model with DI as the outcome event, two or three independent variables could be considered.

3.1 Differences between the DI group and the no-DI group

A total of 16,127 patients underwent ACSS during the study period, 40 (0.2%) of whom developed postoperative RH necessitating hematoma evacuation under general anesthesia. Among these cases, 14 patients exhibited signs of DI, while 26 patients showed no indication of DI during the RH evacuation surgery.

In the DI group, five patients were classified as Class II AAO, six as Class III, and three as Class IV. In the no-DI group, 21 patients were classified as Class I or II AAO, four as Class III, and only one patient was classified as Class IV. The study findings revealed a significantly higher proportion of patients with Class III & IV AAO in the DI group (64.3%) compared to the no-DI group (19.2%) (P = 0.007). Moreover, the difference in the TI was statistically significant between the DI group (2.0 [2.6] hours) and the no-DI group (1.0 [0.6] hours) (P = 0.002).

There were significant differences between the two groups in terms of the retention time of the tracheal catheter and duration of stay in the ICU (P < 0.001). However, no significant differences were found in the remaining factors, such as sex, age, m-JOA scale score, BMI, medical comorbidities, surgical segments, blood loss during the ACSS, hematoma volume, or MMT score. The details regarding patient characteristics and clinical observations within the DI and no-DI groups are shown in Table 2.

Table 2

Comparison between the difficult intubation group and the no-difficult intubation group
	DI Group N = 14	No-DI Group N = 26	Z/T	P values
Gender (Male)	11(78.6%)	16(61.5%)		0.316
Age (≥ 55 years)	7(50.0%)	11(42.3%)		0.744
BMI (≥ 26kg/m²)	1(7.1%)	8(30.7%)		0.124
History (Hypertension)	4(28.6%)	7(26.9%)		1.000
Admission m-JOA scores (≤ 12)	4(28.6%)	4(15.3%)		0.416
Number of surgical segments	3(2.0)	3(0.2)	-0.315	0.753
Operation segments including or above C4	9(64.3%)	12(46.1%)		0.333
EBL in the ACSS(ml)	50.0(50.0)	25.0(40.0)	-1.121	0.262
TI(hours)	2.0(2.6)	1.0(0.6)	-3.138	0.002
Class of AAO (Ⅲ & Ⅳ)	9(64.3%)	5(19.2%)		0.007
Score of MMT*(Ⅲ & Ⅳ)	8(72.7%)	10(38.4%)		0.146
Hematoma volume(ml)	50(43.7)	40.0(80.0)	-0.444	0.657
Tracheal catheter retention time(hours)	68.5(216.5)	0.0(4.63)	-4.741	< 0.001
Duration of stay in the ICU(hours)	64.0(101.0)	0.0(5.0)	-4.084	< 0.001
Values are presented as the median (interquartile range) or the number (%).
*Missing data for four coma patients.
DI, difficult intubation; BMI, body mass index; m-JOA, modified Japanese Orthopedic Association; ACSS, anterior cervical spine surgery; TI, time interval between symptom onset and airway intervention; AAO, acute airway obstruction; MMT, modified Mallampati test; EBL, estimated blood loss; ICU, intensive care unit.

Binary multivariate logistic regression (backward Wald) analyses identified two independent correlative factors: Class III & IV AAO and TI. The OR and 95% CI of the two indicators were 5.384 (1.098–26.398) and 2.073(1.072–4.010), respectively (Table 3).

Table 3

Predictors for difficult intuition identified by binary multivariate logistic regression (backward-Wald) model
Variable	Β	SE	P-value	OR	95% CI
TI	0.729	0.337	0.030	2.073	1.072–4.010
Class of AAO (Ⅲ & Ⅳ)	1.683	0.811	0.038	5.384	1.098–26.398
Constant	-2.643	0.828	0.001	0.071
SE, standard error; OR, odds ratio; 95%CI, 95% confidence interval; TI, time interval between symptom onset and airway intervention; AAO, acute airway obstruction.

The AUC of TI was 0.795 (95% CI 0.644–0.947). The Youden’s index (sensitivity + specificity − 1) was applied to define an optimal cut-off value which take both sensitivity and specificity into account. According to the highest Youden’s index, the cut-off value of TI was set to 1.25, with the sensitivity and specificity was 0.786 and 0.769, respectively (Table 4).

Table 4

Calculated cut-off values for TI.
Cut-off point	Sensitivity	Specificity	Youden’s index
0.7500 1.2500 1.7500 2.5000 3.2500 3.7500	0.929 0.786 0.643 0.429 0.429 0.357	0.308 0.769 0.808 0.808 0.962 0.962	0.237 0.555 0.451 0.237 0.391 0.319
TI: time interval between symptom onset and airway intervention.

3.2 Airway management and recovery outcomes

In the DI group, three patients underwent awake fiberoptic bronchoscopy (FOB) intubation, three patients underwent awake FOB intubation after failure of video laryngoscopy (VL) intubation, four patients underwent tracheotomy after failure of VL or FOB intubation (two of whom underwent emergency tracheotomy due to a CICO scenario), one patient underwent shikani optical stylet intubation after failure of VL intubation, and three patients with cyanosis and coma were successfully intubated with VL after multiple attempts in the ward. In the no-DI group, 25 patients were intubated with VL under general anesthesia induction in the operating room (OR), and one patient with cyanosis and coma in the ward was successfully intubated with VL on the first attempt and was transferred to the OR for hematoma evacuation. The details pertaining to airway management in the 40 patients are shown in Fig. 2.

Of the two patients who underwent emergency tracheotomy due to a CICO scenario, one patient experienced failure of anesthetized VL intubation. The patient was a 49-year-old woman underwent ACSS at the C6-7 level under general anesthesia after endotracheal intubation. After surgery, the patient was extubated following reversal of anesthesia. Approximately one hour after tracheal extubation, the patient experienced mild dyspnea and neck swelling. Oxygen was administered by inhalation through a nasal catheter in the ward, and the patient was monitored. Five hours after ACSS, the patient experienced exacerbation of dyspnea and neck swelling. Considering the possibility of RH, the patient was then transferred to the OR for hematoma evacuation. After entering the OR, the wound was opened immediately under local anesthesia. The patient gradually became increasingly restless and agitated, and AAO was classified as level III. After an intravenous injection of 80 mg propofol, ventilation with a facemask became difficult, and several attempts to use VL for tracheal intubation were unsuccessful. Insertion of a supraglottic airway was also difficult. With an oxygen saturation reading as low as 10%, an emergency tracheotomy was performed. After successful tracheotomy and the administration of a neuromuscular blocking agent, VL was repeated, revealing only a small portion of the epiglottis. VL combined with video FOB revealed evident epiglottic swelling and a narrow airway space between the epiglottis and the posterior pharyngeal wall, making glottis exposure challenging. After hematoma evacuation, the patient was admitted to the ICU for respiratory support, and the tracheostomy was discontinued on the 11th postoperative day (Fig. 3a-f).

In the present study, thirty-nine patients received successful treatment and were subsequently discharged. One patient, among the three patients in the DI group displaying symptoms of cyanosis and coma, died of hypoxic-ischemic encephalopathy 24 days after hematoma evacuation.

4.1 Incidence and risk factors for DI associated with RH after ACSS

The incidence of hematoma after ACSS ranges from 0.4–5.6% [1–12], and the reported incidence of AAO caused by RH ranges from 0.2–1.9% [14]. In the present study, we reviewed 16,127 patients and found that 40 patients (0.2%) had postoperative RH, which was consistent with previous reports [1–12]. However, to date, studies specifically investigating DI associated with RH after ACSS in a large patient population are lacking. O’Neill et al. reported that of the 17 patients who developed hematoma following ACSS, two patients required cricothyrotomy [10]. Mark et al. reported one case of airway compromise secondary to hematoma following anterior cervical discectomy and fusion, in which emergent open tracheostomy was performed [14]. Song et al. reported that four patients with AAO underwent hematoma evacuation, and cricothyroidotomy was performed on one patient [21]. In the present study, none of the 40 patients experienced DI during ACSS. However, 35% of the 40 patients who underwent tracheal intubation after hematoma formation experienced DI, two of whom required emergency tracheotomy due to the CICO situation.

Several factors contributed to the DI. Following the formation of a hematoma, the anatomical structures of the neck, posterior pharyngeal wall, tongue and larynx were altered, resulting in an AAO above the glottis. This obstruction ultimately posed a challenge to both face mask ventilation and tracheal intubation. In the present study, 14 patients developed Class III & IV AAO, nine of whom experienced DI. The statistical results indicated that Class III & IV AAO was highly suggestive of DI (OR, 5.384; 95% CI, 1.098–26.398; P = 0.038). This may be due to the narrowing of the supraglottic airway space after hematoma formation, resulting in DI. According to the American Society of Anesthesiologists Practice Guidelines for Management of Difficult Airways [23], patients with AAO should be considered at high risk for difficult airways, and our data supported the notion that patients with Class III & IV AAO were more likely to experience DI.

Song et al. reported that patients with RH could be treated with close observation or hematoma removal according to changes in respiratory status, surgical site conditions, and patient behavior [21]. Of the nine patients with RH, five patients underwent close observation. Four patients underwent surgery to remove the hematoma, including one patient who received cricothyrotomy. The current study identified differences between the two groups in the TI, indicating a potential airway risk in the observational management of RH. In this study, TI was significantly longer in the DI group [2.0(2.6) vs, 1.0(0.6), P = 0.002]. Additionally, TI was identified as one of the two independent correlative predictors of DI, with an AUC of 0.795 (95% CI 0.644–0.947), indicating a potential airway risk in the observational management of RH. Early evacuation of hematoma and airway intervention may reduce the incidence of DI and the need for an emergency airway.

Among all the proposed predictors of DI, cervical range of motion (ROM) is a crucial factor [24]. Cervical spondylosis patients suffer from limitations in terms of cervical mobility [25.26], and the ACSS reduces the total ROM of the cervical spine in the sagittal plane [27]. A restricted cervical ROM may be a risk factor for DI in patients with RH after ACSS. However, cervical range of motion (ROM) was measured based on objective criteria due to the emergency of RH. Therefore, cervical ROM was not analyzed in the present study.

Some appearance indicators of airway assessment, such as thyromental distance, sternomental distance, and inter-incisor gap, have a significant correlation with DI [28]. However, the appearance indicators do not necessarily reflect changes in the internal anatomy of the airway in patients with RH. MMT can reflect the structure of the patient's oral cavity, but poor correlation with laryngoscopy exposure grading has been reported in the literature [29]. In the four comatose patients, this test could not be performed. The present study found no statistically significant correlation between MMT and DI in patients with RH.

Extubating a challenging or difficult airway remains a high-risk situation, particularly in patients with RH. Edema of the airway may become worse after two operations and multiple tracheal intubations. Even on the ninth day after hematoma evacuation, the CT scan still showed significant edema in the prevertebral soft tissue (Fig. 3e). In the present study, no patients experienced reintubation after hematoma evacuation, and DI was associated with longer retention of the tracheal catheter and longer duration of stay in the ICU.

4.2 Airway management in RH evacuation

In the present study, 28 patients underwent anesthetized VL intubation, and eight underwent unanesthetized VL intubation, three and four failures, respectively. VL can improve the visualization of glottic structures by one to two grades using the CL classification system and has a higher first-pass success rate than direct laryngoscopy in emergency patients with difficult airways [30.31]. Additionally, the VL is less affected by secretions or blood and takes less time to perform than the FOB is, especially in coma patients. Among the four patients with cyanosis and coma, three were successfully intubated with VL after multiple attempts in the ward. The remaining patient was successfully intubated on the first attempt at VL. Therefore, in patients who are in a coma caused by AAO due to RH, VL may be the first choice.

As a “gold standard” tool for managing difficult airways, awake FOB intubation is a safe choice for awake intubation [32]. In the present study, nine patients underwent awake FOB intubation, including six successful and three unsuccessful cases. Among the six patients with successful awake FOB intubation, two underwent awake FOB intubation after awake VL, and one underwent awake FOB intubation after awakening from anesthesia. Among the three patients with failed awake FOB intubation, one required emergency tracheotomy after experiencing a progressive decrease in oxygen saturation during the procedure, while the other two patients underwent awake tracheotomy under local anesthesia. It was important to note that patients with RH who undergo awake FOB intubation were at risk of further hypoxia. Therefore, it is crucial to always monitor patients’ level of consciousness and oxygen saturation. If the patient becomes restless, panic, or anxious or if oxygen saturation progressively declines, the procedure should be stopped immediately. Facemask oxygen inhalation should be maintained, and emergency front-of-neck access (FONA) should be established quickly to prevent severe hypoxia.

In the airway management of patients with difficult airways, it is critical to maintain consciousness and spontaneous breathing to avoid difficult ventilatory situations [23]. In the DI group, we attempted to perform VL on two patients after administering propofol for moderate sedation. However, both patients exhibited difficulty with facemask ventilation and glottis exposure. One patient was intubated while awake under the guidance of FOB after gradually regaining consciousness. In the other patient, a CICO scenario occurred, and emergency tracheotomy was performed. After tracheostomy and administration of a neuromuscular blocking agent, VL combined with video FOB revealed a very small airway between the epiglottis and the posterior wall of the pharynx, which still made it difficult to expose the glottis (Fig. 3d). Numerous studies support the notion that neuromuscular blockade can improve facemask ventilation and visualization of the vocal cords [33.34]. However, in patients with severe AAO due to RH, the improvement may not be significant.

To manage AAO caused by RH after ACSS, an emergency airway team should be composed of orthopedic surgeons, anesthesiologists, and otolaryngologists. The orthopedic surgeons promptly transfer the patient to the OR, where the anesthesiologists and otolaryngologists perform airway intervention as soon as possible. For patients with Class I or II AAO, awake or anesthetized VL or FOB intubation is feasible. It is crucial to always have a FONA plan in place. For patients with Class III AAO, awake FOB intubation should be performed with a limited number of attempts while maintaining spontaneous breathing. It is important to prepare for awake FONA patients when they are experiencing an emergency. For patients with Class IV AAO, immediate intubation with VL should be attempted. In the event of failure, FONA should be performed immediately by otolaryngologists (Fig. 4).

Our study has several limitations. Firstly, its retrospective design could potentially affect the precision of the conclusion drawn. Secondly, the sample size was limited due to the low incidence of RH. Thirdly, certain clinical data were absent. MRI and color Doppler ultrasound assessments of the neck were not performed due to the onset of hematoma. Fourthly, incomplete information regarding neck circumference, cervical ROM, and a quantitative analysis of posterior pharyngeal wall swelling limits comprehensive evaluation.

retropharyngeal hematoma

ACSS

anterior cervical spine surgery

AAO

acute airway obstruction

difficult intubation

time interval between symptom onset and airway intervention

ICU

intensive care unit

SHE

spinal epidural hematoma

CICO

Cannot intubate Cannot Oxygenate

MRI

magnetic resonance imaging

m-JOA

modified Japanese Orthopedic Association

MMO

maximum mouth opening

BMI

body mass index

ROM

cervical range of motion

MMT

modified Mallampati test

odds ratio

confidence intervals

operating room

SpO₂

oxygen saturation

video laryngoscopy

FOB

fiberoptic bronchoscopy

FONA

front-of-neck access.

Ethics approval and consent to participate

This study was approved by the Medical Scientific Research Ethics Committee of Peking University Third Hospital (IRB00006761-M2017287, 2022.05.22).

Written informed consent for publication of clinical details and/or clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.

Consent for publication

The participants have consent to have these images published.

Availability of data and materials

The datasets supporting the conclusions of this article are available in the [Mendeley Data] repository, at https://data.mendeley.com/datasets/72vtpstbm7/1

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by grants to MX from the Capital Clinical Characteristic Applied Research Project (Z181100001718109), grants to YQ from the Key Clinical Projects of Peking University Third Hospital (BYSYZD2022021), and Innovation and Transformation Project of Peking University Third Hospital (BYSYZHKC2022103).

Authors' contributions

YT, GL and MX contributed to the design and implementation of the study. YT and YQ collected data and analyzed the results. JF, MX, XG and ML worked on the manuscript. All authors discussed and approved the final manuscript.

Acknowledgements

Not applicable

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No competing interests reported.

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Risk factors and treatment of difficult intubation during retropharyngeal hematoma evacuation following anterior cervical spine surgery: a retrospective study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Trial registration:

Figures

1. Background

2. Methods

2.1 Patient selection

2.2 Data collection

2.3 Statistical analysis

3. Results

3.1 Differences between the DI group and the no-DI group

3.2 Airway management and recovery outcomes

4. Discussion

4.1 Incidence and risk factors for DI associated with RH after ACSS

4.2 Airway management in RH evacuation

5. Conclusions

List Of Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1