Analysis of the Risk Factors Associated with Prolonged Intubation or Reintubation after Anterior Cervical Spine Surgery

Management and treatment algorithm of airway complications after anterior cervical spine surgery: systematic review

Background

Airway-related complications are rare after cervical spine surgery but can be devastating and compromise a successful outcome. The objective of this systematic review is to provide an overview of the management of airway complications after anterior cervical spine surgery (ACSS) and propose a treatment algorithm for approaching the patient with a compromised airway.

Methods

A literature search was conducted in PubMed and adapted for use in other databases, including the Cochrane Register of Controlled Trials, Cochrane Library Health Technology Assessment Database, Embase, and the National Health Service (NHS) Economic Evaluation Database.

Results

A total of 117 papers received a full text review. Thirty-seven studies were categorized as "management" and included. An additional four references were extracted from other references for a total of 41 studies.

Conclusions

Most of the available evidence on airway compromise after ACSS is level III or IV. Similarly, most available evidence on the management of acute airway complications comes from case reports or anecdotal publications. There are currently no methods in place to stratify the risk of airway complications in patients undergoing these guidelines on the management of these complications when they occur. This review is focused on practice, including management of such complications with a proposed treatment algorithm.

Risk Factors for Reintubation After Anterior Cervical Spine Surgery: Comparative Study of Patients With Cervical Spine Trauma and Patients With Cervical Degenerative Disease

STUDY DESIGN

Single-center retrospective study.

OBJECTIVES

The aim was to compare the postoperative outcomes of anterior cervical spine surgery (ACSS) in patients with and without cervical spine trauma.

SUMMARY OF BACKGROUND

Few papers have addressed airway obstruction after anterior ACSS for patients with cervical spine trauma. This study aimed to compare airway obstruction after ACSS between patients with cervical degenerative disorders and cervical spine injuries and identify the risk factors for unplanned postoperative reintubation.

MATERIALS AND METHODS

Seventy-seven patients who underwent ACSS were enrolled in this retrospective study. There were 52 men and 25 women, with a mean age of 60.3±15.5 years old. The causes of surgery were as follows: 24 cervical spine fractures or dislocations, 12 spinal cord injuries without bony fracture, 19 disc herniations, and 22 myelopathies. The patients' characteristics, operative data, and risk factors for unplanned reintubation within 5 days postoperatively were analyzed using medical records.

RESULTS

Postoperative reintubation was performed in 3 patients (3.9%), all of whom suffered trauma. We further examined risk factors for reintubation in patients in the trauma group. There was no significant difference between the reintubation (R) and nonreintubation (non-R) groups in age, sex, body mass index, amount of blood loss and operation time, preoperative paralysis severity, and the number of fused segments. Patients in group R had significantly higher rates of severe anterior element injury (100% vs. 27.3%, P =0.0011). Airway obstruction due to laryngopharyngeal edema and swelling was confirmed by laryngoscopy and computed tomography images.

CONCLUSIONS

Unplanned reintubation after ACSS occurred at a higher rate in trauma patients than in patients with degenerative disorders. Our results suggested that the severe damage to the anterior element of the cervical spine was associated with postoperative reintubation.

EVIDENCE LEVEL

Level IV.

Postoperative Airway Management after Anterior Cervical Spine Surgery: Retrospective Neurosurgical Multicenter Study

Airway complications that occur after anterior cervical spine surgery pose a life-threatening risk, which encompasses complications including prolonged intubation, unplanned reintubation, and/or necessity of tracheostomy. The present study aimed to identify the surgical risks associated with postoperative airway complications in neurosurgical training institutes. A retrospective, multicenter, observational review of data from 365 patients, who underwent anterior cervical spine surgery between 2018 and 2022, at three such institutes was carried out. Postoperative airway complication was defined as either the need for prolonged intubation on the day of surgery or the need for unplanned reintubation. The perioperative medical information was obtained from their medical records. The average age of the cohort was over 60 years, with males comprising approximately 70%. Almost all surgeries predominantly involved anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion, with most surgeries occurring at the level of C5/6. In total, 363 of 365 patients (99.5%) were extubated immediately after surgery, and the remaining two patients were kept under intubation because of the risk of airway complications. Of the 363 patients who underwent extubation immediately after surgery, two (0.55%) required reintubation because of postoperative airway complications. Patients who experienced airway complications were notably older and exhibited a significantly lower body mass index. The results of this study suggested that older and frailer individuals are at an elevated risk for postoperative airway complications, with immediate postoperative extubation generally being safe but requiring careful judgment in specific cases.

Airway Complications After Anterior Cervical Spine Surgery: Etiology and Risk Factors

STUDY DESIGN

Narrative Review.

OBJECTIVE

To provide an overview of etiology and risk factors of airway complications after anterior cervical spine surgery (ACSS).

METHODS

A search was performed in PubMed and adapted for use in other databases, including Embase, Cochrane Library, Cochrane Register of Controlled Trials, Health Technology Assessment database, and NHS Economic Evaluation Database.

RESULTS

81 full-text studies were reviewed. A total of 53 papers were included were included in the review and an additional four references were extracted from other references. 39 papers were categorized as etiology and 42 as risk factors.

CONCLUSIONS

Most of the literature on airway compromise after ACSS is level III or IV evidence. Currently, there are no systems in place to risk-stratify patients undergoing ACSS regarding airway compromise or guidelines on how to manage patients when these complications do occur. This review focused on theory, primarily etiology and risk factors.

An Artificial Intelligence Approach to Predicting Unplanned Intubation Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Level III retrospective database study.

OBJECTIVES

The purpose of this study is to determine if machine learning algorithms are effective in predicting unplanned intubation following anterior cervical discectomy and fusion (ACDF).

METHODS

The National Surgical Quality Initiative Program (NSQIP) was queried to select patients who had undergone ACDF. Machine learning analysis was conducted in Python and multivariate regression analysis was conducted in R. C-Statistics area under the curve (AUC) and prediction accuracy were used to measure the classifier's effectiveness in distinguishing cases.

RESULTS

In total, 54 502 patients met the study criteria. Of these patients, .51% underwent an unplanned re-intubation. Machine learning algorithms accurately classified between 72%-100% of the test cases with AUC values of between .52-.77. Multivariable regression indicated that the number of levels fused, male sex, COPD, American Society of Anesthesiologists (ASA) > 2, increased operating time, Age > 65, pre-operative weight loss, dialysis, and disseminated cancer were associated with increased risk of unplanned intubation.

CONCLUSIONS

The models presented here achieved high accuracy in predicting risk factors for re-intubation following ACDF surgery. Machine learning analysis may be useful in identifying patients who are at a higher risk of unplanned post-operative re-intubation and their treatment plans can be modified to prophylactically prevent respiratory compromise and consequently unplanned re-intubation.

Impact of delay extubation on the reintubation rate in patients after cervical spine surgery: a retrospective cohort study

BACKGROUND

The incidence of cervical airway obstruction after cervical spine surgery (CSS) ranges from 1.2 to 14%, and some require reintubation. If not addressed promptly, the consequences can be fatal. This study investigated delayed extubation's effect on patients' reintubation rate after cervical spine surgery.

METHODS

We performed a retrospective case-control analysis of cervical spine surgery from our ICU from January 2021 to October 2022. Demographic and preoperative characteristics, intraoperative data, and postoperative clinical outcomes were collected for all 94 patients. Univariable analysis and multivariable logistic regression were used to analyze postoperative unsuccessful extubation risk factors following cervical spine surgery.

RESULTS

The patients in the early extubation (n = 73) and delayed extubation (n = 21) groups had similar demographic characteristics. No significant differences were found in the reintubation rate (0 vs. 6.8%, p = 0.584). However, the delayed extubation group had significantly more patients with 4 and more cervical fusion segments (42.9 vs. 15.1%, p = 0.013),more patients with an operative time greater than 4 h (33.3 vs. 6.8%, p = 0.004)and all patients involved C2-4 (78 vs. 100%, p = 0.019).Also, patients in the delayed extubation group had a longer duration of ICU stay (152.9 ± 197.1 h vs. 27.2 ± 45.4 h, p < 0.001) and longer duration of hospital stay (15.2 ± 6.9 days vs. 11.6 ± 4.1 days, p = 0.003). Univariate and multivariate analysis identified the presences of cervical spondylotic myelopathy (CSM) (OR 0.02, 95% CI 0-0.39, p = 0.009) and respiratory diseases (OR: 23.2, 95% CI 2.35-229.51, p = 0.007) as unfavorable prognostic factor for reintubation.

CONCLUSIONS

Our analysis of patients with cervical spondylosis who received CSS indicated that delayed extubation was associated with the presence of respiratory diseases and CSM, longer operative time, more cervical fusion segments, and longer duration of ICU and hospital stays.

Does Arterial Blood Gas (ABG) Provide a Safety Net for Extubation in Surgical Patients?

Background Extubation has always been a critical aspect of anaesthesia. Guidelines and recommendations are in place for achieving successful extubation, but the risk of failure always persists. Through this study, we assess whether arterial blood gas (ABG) values taken intraoperatively help predict extubation success in the operation theatre. Materials and methods This was a prospective observational study for one year of extubated patients whose blood gas values were not within the normal range. The patients of age 18 years and above undergoing high-risk elective and emergency surgeries where at least one intraoperative arterial blood sample was taken for blood gas analysis were included. Apart from parameters of ABG demographic data, urgency and duration of surgery, blood loss, urine output, use of intraoperative fluid(s), and blood product(s) were also observed.  Results Of 578 patients enrolled, 116 patients were extubated based on the predefined extubation criteria. Of these, 24 patients were reintubated within 24 hours. ABG parameters such as partial pressure of arterial oxygen (PaO₂) and serum HCO_3- levels were significantly lower in the reintubated patients compared to non-reintubated patients (p-values of 0.045 and 0.003, respectively). Conclusion This study showed that the PaO₂ <100 mm Hg or ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) of less than 200 and an HCO_3- value of less than 18 are plausible ABG parameters to decide extubation in post-surgery patients in OT. PaCO₂, base deficit, and lactate were less reliable parameters for planning extubation.

Respiratory Compromise After Anterior Cervical Spine Surgery: Incidence, Subsequent Complications, and Independent Predictors

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Respiratory compromise (RC) is a rare but catastrophic complication of anterior cervical spine surgery (ACSS) commonly due to compressive fluid collections or generalized soft tissue swelling in the cervical spine. Established risk factors include operative duration, size of surgical exposure, myelopathy, among others. The purpose of this current study is to identify the incidence and clinical course of patients who develop RC, and identify independent predictors of RC in patients undergoing ACSS for cervical spondylosis.

METHODS

A large, prospectively-collected registry was used to identify patients undergoing ACSS for spondylosis. Patients with posterior cervical procedures were excluded. Baseline patient characteristics were compared using bivariate analysis, and multivariate analysis was employed to compare postoperative complications and identify independent predictors of RC.

RESULTS

298 of 52,270 patients developed RC (incidence 0.57%). Patients who developed RC had high rates of 30-day mortality (11.7%) and morbidity (75.8%), with unplanned reoperation and pneumonia the most common. The most common reason for reoperations were hematoma evacuation and tracheostomy. Independent patient-specific factors predictive of RC included increasing patient age, male gender, comorbidities such as chronic cardiac and respiratory disease, preoperative myelopathy, prolonged operative duration, and 2-level ACCFs.

CONCLUSION

This is among the largest cohorts of patients to develop RC after ACSS identified to-date and validates a range of independent predictors, many previously only described in case reports. These results are useful for taking preventive measures, identifying high risk patients for preoperative risk stratification, and for surgical co-management discussions with the anesthesiology team.

A novel technique using ultrasonography in upper airway management after anterior cervical decompression and fusion

Background

Airway complications are the most serious complications after anterior cervical decompression and fusion (ACDF) and can have devastating consequences if their detection and intervention are delayed. Plain radiography is useful for predicting the risk of dyspnea by permitting the comparison of the prevertebral soft tissue (PST) thickness before and after surgery. However, it entails frequent radiation exposure and is inconvenient. Therefore, we aimed to overcome these problems by using ultrasonography to evaluate the PST and upper airway after ACDF and investigate the compatibility between X-ray and ultrasonography for PST evaluation.

Methods

We included 11 radiculopathy/myelopathy patients who underwent ACDF involving C5/6, C6/7, or both segments. The condition of the PST and upper airway was evaluated over 14 days. The Bland–Altman method was used to evaluate the degree of agreement between the PST values obtained using radiography versus ultrasonography. The Pearson correlation coefficient was used to determine the relationship between the PST measurement methods. Single-level and double-level ACDF were performed in 8 and 3 cases, respectively.

Results

PST and upper airway thickness peaked on postoperative day 3, with no airway complications. The Bland–Altman bias was within the prespecified clinically nonsignificant range: 0.13 ± 0.36 mm (95% confidence interval 0.04–0.22 mm). Ultrasonography effectively captured post-ACDF changes in the PST and upper airway thickness and detected airway edema.

Conclusions

Ultrasonography can help in the continuous assessment of the PST and the upper airway as it is simple and has no risk of radiation exposure risk. Therefore, ultrasonography is more clinically useful to evaluate the PST than radiography from the viewpoint of invasiveness and convenience.

Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting

BACKGROUND

Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol.

METHODS

A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered.

RESULTS

A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day.

CONCLUSION

In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.

Unplanned Postoperative Reintubation in Children with Bronchial Asthma

Unplanned postoperative reintubation is a serious complication that may increase postsurgical hospital length of stay and mortality. Although asthma is a risk factor for perioperative adverse respiratory events, its association with unplanned postoperative reintubation in children has not been comprehensively examined. Our aim was to determine the association between a preoperative comorbid asthma diagnosis and the incidence of unplanned postoperative reintubation in children. This was a retrospective cohort study comprising of 194,470 children who underwent inpatient surgery at institutions participating in the National Surgical Quality Improvement Program–Pediatric. The primary outcome was the association of preoperative asthma diagnosis with early, unplanned postoperative reintubation (within the first 72 hours following surgery). We also evaluated the association between bronchial asthma and prolonged hospital length of stay (longer than the 75th percentile for the cohort). The incidence of unplanned postoperative reintubation in the study cohort was 0.5% in patients with a history of asthma compared with 0.2% in patients without the diagnosis (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.71–2.89). This association remained significant after controlling for several clinical characteristics (OR: 1.54, 95% CI: 1.17–2.20). Additionally, asthmatic children were more likely to require a hospital length of stay longer than the 75th percentile for the study cohort (adjusted OR: 1.05, 95% CI: 1.01–1.10). Children with preoperative comorbid asthma diagnosis have an increased incidence of early, unplanned postoperative reintubation and prolonged postoperative hospitalization following inpatient surgery. By identifying these patients as having higher perioperative risks, it may be possible to institute strategies to improve their outcomes.

Failure to extubate and delayed reintubation in elective lumbar fusion: An analysis of 57,677 cases

OBJECTIVES

There is a scarcity of literature exploring the consequences of Failure To Extubate (FTE) and Delayed Reintubation (DRI) in spine surgery. While it is reasonable to believe that patients who FTE or undergo DRI after Posterior Lumbar Fusion (PLF) and Transforaminal Lumbar Interbody Fusion (TLIF) are at risk for graver outcomes, there is minimal data to explicitly support that. The goal of this study was to investigate the morbidity and mortality associated with FTE and DRI after lumbar spine surgery in a large pool of patients.

PATIENTS AND METHODS

We conducted a retrospective multicenter study of patients that underwent elective posterior lumbar fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2016. We excluded patients with disseminated cancer, metastatic disease to the neural axis, patient with spinal epidural abscess, and patients with ventilator dependency prior to the operation.

RESULTS

57,677 patients from 2006 to 2016 were identified; 55 patients (0.1 %) had FTE and 262 patients (0.46 %) had DRI. The incidence of pneumonia was 27.2-fold greater in the FTE group and septic shock was 63.5-fold greater. All complications listed below are significance to p < 0.001. Deep vein thrombosis, pulmonary embolism, myocardial infarction and cardiac arrest were respectively, 10.4-, 12.2-, 22.8-, and 45.5- fold greater in the FTE group. Overall complication rate differed significantly between the two groups and were 9.8-fold greater in the FTE group. FTE was associated with increased, length of stay and all complications except DVT and pulmonary embolism. FTE was profoundly associated with severe complications (OR 13.0, 95 % CI 7.2-23.5) and mortality (OR = 21.5, CI = 7.5-61.0). The DRI group had a significantly higher morbidity (OR = 71.0, CI = 44.1-114.4), including overall complication (OR = 21.2, CI = 16.0-28.0) and severe complications (OR = 34.4, CI = 26.1-45.3). The DRI group had significantly higher rates of pneumonia (OR = 37.0), DVT (OR = 9.6) and pulmonary embolism (OR = 7.0), septic shock (OR = 60.5), myocardial infarction (OR = 32.1,) and cardiac arrest (OR = 236.4).

CONCLUSION

FTE and DRI were highly predictive of morbidity and mortality. Overall, investigations of the effects of FTE and DRI following spine procedures are lacking. This large multi-center national database review is one of the first to provide insight into the consequences of FTE and DRI in lumbar fusion cases. Future investigation into the consequences and predictors of FTE and DRI in spine surgery are required.

A Case Report Describing Three Cases of Challenging or Failed Intubation after Cervical Spine Surgery: A Peril of Early Extubation

Postoperative airway complications can be a common, yet perhaps underappreciated, complication in patients undergoing cervical spine surgery. Presented here are three cases in which patients experienced postoperative airway compromise, resulting in difficulty establishing a secure airway following cervical spine operations. Establishing factors that contribute to airway complications after cervical spine surgery can aid in early identification of high-risk patients to create an appropriate airway management strategy. Ultimately, the frequency of airway difficulty after removal of the endotracheal tube in patients undergoing cervical spine surgery should not be taken lightly.

Thirty-Day Unplanned Reintubation Following Pleurodesis: A Retrospective National Registry Analysis

OBJECTIVE

To examine risk factors associated with 30-day unplanned reintubation after pleurodesis.

DESIGN

A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program surgical outcomes registry.

SETTING

United States hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

PARTICIPANTS

The study comprised 2,358 patients who underwent video-assisted thorascopic surgery for pleurodesis from 2007 to 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The final sample included 2,358 cases, of which 93 (3.9%) required 30-day unplanned reintubation. Cases with 30-day unplanned reintubation, compared to those without, had higher unadjusted rates of American Society of Anesthesiologists physical status (ASA PS) score ≥4 (54.8% v 27.2%), preoperative dyspnea (71% v 57%), congestive heart failure (14% v 5.4%), functional dependence (28% v 10.3%), and diabetes mellitus (29% v 17.8%) (all p < 0.05). Patients with 30-day reintubation experienced higher unadjusted rates of 30-day outcomes including mortality (50.5% v 10.1%), pneumonia (28% v 4.9%), ventilator dependence (50.5% v 10.1%), sepsis (7.5% v 1.9%), myocardial infarction (5.4% v 0.1%), cardiac arrest (18.3% v 0.6%), transfusion (14% v 4.5%), and reoperation (15.1% v 3.2%) (all p < 0.05). The odds of 30-day unplanned reintubation were increased significantly on multivariable analysis for patients with ASA PS score ≥4, functional dependence, disseminated cancer, renal dialysis, and weight loss (all p < 0.05).

CONCLUSION

Given the dearth of population-based studies addressing risk factors of reintubation after pleurodesis, this study suggests further review of preoperative optimization, which is required to improve patient outcomes and safety.