Unstable C-spine for fixation

Gabrielle Morris

70F severe rheumatoid arthritis with unstable C-spine deformity requiring fixation from cervical to thoracic spine

Background

  • RA
    • Weekly MTX + prednisone 7.5mg OD
  • Distance patient 
  • Unsupported at home, IADLs

Issues:

  • Lower neck instability – Progressive
  • Previous C-spine fixation – uneventful AFOI
    • Post-op infected hardware requiring removal/replacement
    •  McGrath+ bougie – no airway issues documented
    • ICU admission post-operatively
  • Severe respiratory disease – bronchiectasis and severe pHTN
    • Puffers, saline nebs – productive of 100ml sputum everyday post saline nebuliser
    • Weekly percussion Physiotherapy – patient feels very beneficial for sputum clearance
    • Stable disease, home O2 not indicated

Discussion

Perioperative optimisation

  • Cardiology and respiratory review in last 6/12 – nil optimisation required
  • Prehabiliation – benefits of perioperative physiotherapy and secretion management?
    • postural drainage has minimal evidence base, percussion has better evidence if high sputum load, oscillatory PEP is most useful. Increasing use, in CF population

Conduct of anaesthesia

  • AFOI vs asleep FOI – uneventful intubation post insertion of original hardware
  • However, has had further hardware since and now an unstable neck
  • Patient not assessed clinically – difficult to ascertain what is required until face-to-face review

Plan:

  • Proceed to surgery
  • Prehab coordinator has organized extra perioperative physiotherapy sessions close to patients home
  • Patient will attend outpatient PT here for 2 days leading up to admission