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In vivo ultrasound real-time motion of the cervical spine during intubation under manual in-line stabilization: a comparison of intubation methods

Published online by Cambridge University Press:  01 January 2008

E. Gercek ,
B. M. Wahlen  and
P. M. Rommens
E. Gercek*
Affiliation:
Johannes Gutenberg-University of Mainz, Clinic of Trauma Surgery, Mainz
B. M. Wahlen
Affiliation:
Julius Maximillians-University of Wuerzburg, Clinic of Anaesthesiology, Wuerzburg, Germany
P. M. Rommens
Affiliation:
Johannes Gutenberg-University of Mainz, Clinic of Trauma Surgery, Mainz
*
Correspondence to: Erol Gercek, Clinic of Trauma Surgery, Johannes Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany. E-mail: gercek@unfall.klinik.uni-mainz.de; Tel: +496131172845; Fax: +496131176687
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Summary

Background and objective

In emergency trauma situations, manual in-line stabilization of the cervical spine is recommended to reduce cervical spine movement during intubation. The aim of this study was to compare the effect of manual in-line stabilization during different intubation techniques on three-dimensional cervical spine movements and times to intubation.

Methods

Forty-eight subjects without any history of trauma, inflammatory or degenerative disorder of the cervical spine were randomly grouped, regardless of gender or age. All underwent elective surgery under general anaesthesia. Under manual in-line stabilization, laryngeal intubation with Macintosh laryngoscope, intubating laryngeal mask airway, fibre-endoscopic oral intubation and fibre-endoscopic nasal intubation was performed. During the intubation process, cervical three-dimensional motion was detected by an ultrasound real-time motion analysis system and intubation times were measured.

Results

Cervical spine range in the extension/flexion direction of orolaryngeal intubation with Macintosh (17.57 ± 8.23°) showed significantly more movement than using the intubating laryngeal mask airway (4.60 ± 1.51°) and fibreoptic procedures. Intubating laryngeal mask airway was significantly different than the fibreoptic intubation techniques. There was also a significant difference between oral (3.61 ± 2.25°) nasal and (5.88 ± 3.11°) fibreoptic intubation. Times to intubation all differed significantly (P < 0.05) for the Macintosh laryngoscope (27.25 ± 8.56 s) and for the intubating laryngeal mask airway (16.5 ± 9.76 s). Fibreendoscopic laryngoscopic oral (52.91 ± 56.27 s) and nasal (82.32 ± 54.06 s) intubation resulted in further prolongation of the times to intubation.

Conclusions

The intubating laryngeal mask airway with manual in-line stabilization is a potentially useful adjunct to intubation of patients with potential cervical spine injury, if there are no contraindications to these methods. These results predict that fibreoptic procedures may be a safe instrument for airway management in patients with potential cervical spine injuries; however, the main disadvantages are the longer intubation times.

Keywords

INTUBATION INTRATRACHEALULTRASONOGRAPHY, neck motionSPINAL CORD INJURIES, neck traumaLARYNGOSCOPESLARYNGEAL MASKS
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 25 , Issue 1 , January 2008 , pp. 29 - 36
Copyright
Copyright © European Society of Anaesthesiology 2007

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References

1.Crosby, E. Airway management after upper cervical spine injury: what have we learned? Can J Anaesth 2002; 49: 733–744.CrossRefGoogle ScholarPubMed
2.Hastings, RH, Kelley, SD. Neurologic deterioration associated with airway management in a cervical spine-injured patient. Anesthesiology 1993; 78: 580–583.CrossRefGoogle Scholar
3.Stiell, IG, Clement, CM, McKnight, RD et al. . The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003; 349: 2510–2518.CrossRefGoogle ScholarPubMed
4.Mallampati, SR, Gatt, SP, Gugino, LD et al. . A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429–434.CrossRefGoogle ScholarPubMed
5.Cormack, RS, Lehane, J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105–1111.CrossRefGoogle ScholarPubMed
6.Reid, DC, Henderson, R, Saboe, L, Miller, JD. Etiology and clinical course of missed spine fractures. J Trauma 1987; 27: 980–986.CrossRefGoogle ScholarPubMed
7.Macintosh, RR. A new laryngoscope. Lancet 1943; 1: 205.CrossRefGoogle Scholar
8.Benumof, JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996; 84: 686–699.CrossRefGoogle ScholarPubMed
9.Brimacombe, J. The advantages of the LMA over the tracheal tube or facemask: a meta-analysis. Can J Anaesth 1995; 42: 1017–1023.CrossRefGoogle ScholarPubMed
10.Waltl, B, Melischek, M, Schuschnig, C et al. . Tracheal intubation and cervical spine excursion: direct laryngoscopy vs. intubating laryngeal mask. Anaesthesia 2001; 56: 221–226.CrossRefGoogle ScholarPubMed
11.Crosby, ET. Airway management in adults after cervical spine trauma. Anesthesiology 2006; 104: 1293–1318.CrossRefGoogle ScholarPubMed
12.Youdas, JW, Carey, JR, Garrett, TR. Reliability of measurements of cervical spine range of motion – comparison of three methods. Phys Ther 1991; 71: 98–104discussion 105-106.CrossRefGoogle ScholarPubMed
13.Gilliam, J, Brunt, D, MacMillan, M, Kinard, RE, Montgomery, WJ. Relationship of the pelvic angle to the sacral angle: measurement of clinical reliability and validity. J Orthop Sports Phys Ther 1994; 20: 193–199.CrossRefGoogle Scholar
14.Gajraj, NM, Chason, DP, Shearer, VE. Comparison of the Belscope with the Macintosh laryngoscope. Br J Anaesth 1994; 72: 610–611.CrossRefGoogle ScholarPubMed
15.Hastings, RH, Vigil, AC, Hanna, R, Yang, BY, Sartoris, DJ. Cervical spine movement during laryngoscopy with the Bullard, Macintosh, and Miller laryngoscopes. Anesthesiology 1995; 82: 859–869.CrossRefGoogle ScholarPubMed
16.Brimacombe, J, Keller, C, Kunzel, KH et al. . Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers. Anesth Analg 2000; 91: 1274–1278.CrossRefGoogle ScholarPubMed
17.Hauswald, M, Sklar, DP, Tandberg, D, Garcia, JF. Cervical spine movement during airway management: cinefluoroscopic appraisal in human cadavers. Am J Emerg Med 1991; 9: 535–538.CrossRefGoogle ScholarPubMed
18.Sahin, A, Salman, MA, Erden, IA, Aypar, U. Upper cervical vertebrae movement during intubating laryngeal mask, fibreoptic and direct laryngoscopy: a video-fluoroscopic study. Eur J Anaesthesiol 2004; 21: 819–823.CrossRefGoogle ScholarPubMed
19.Sawin, PD, Todd, MM, Traynelis, VC et al. . Cervical spine motion with direct laryngoscopy and orotracheal intubation, an in vivo cinefluoroscopic study of subjects without cervical abnormality. Anesthesiology 1996; 85: 26–36.CrossRefGoogle Scholar
20.McClure, P, Siegler, S, Nobilini, R. Three-dimensional flexibility characteristics of the human cervical spine in vivo. Spine 1998; 23: 216–223.CrossRefGoogle ScholarPubMed
21.Bogduk, N, Mercer, S. Biomechanics of the cervical spine. I: normal kinematics. Clin Biomech (Bristol, Avon) 2000; 15: 633–648.CrossRefGoogle ScholarPubMed
22.Holmes, A, Wang, C, Han, ZH, Dang, GT. The range and nature of flexion-extension motion in the cervical spine. Spine 1994; 19: 2505–2510.CrossRefGoogle ScholarPubMed
23.Dvorak, J, Antinnes, JA, Panjabi, M, Loustalot, D, Bonomo, M. Age and gender related normal motion of the cervical spine. Spine 1992; 17: S393–S398.CrossRefGoogle ScholarPubMed
24.Castro, WH, Sautmann, A, Schilgen, M, Sautmann, M. Noninvasive three-dimensional analysis of cervical spine motion in normal subjects in relation to age and sex. An experimental examination. Spine 2000; 25: 443–449.CrossRefGoogle ScholarPubMed
25.Mannion, AF, Klein, GN, Dvorak, J, Lanz, C. Range of global motion of the cervical spine: intraindividual reliability and the influence of measurement device. Eur Spine J 2000; 9: 379–385.CrossRefGoogle ScholarPubMed
26.Walls, RM. Airway management in the blunt trauma patient: how important is the cervical spine? Can J Surg 1992; 35: 27–30.Google ScholarPubMed
27.Manoach, S, Paladino, L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med 2007.CrossRefGoogle ScholarPubMed
28.McLeod, AD, Calder, I. Spinal cord injury and direct laryngoscopy – the legend lives on. Br J Anaesth 2000; 84: 705–709.CrossRefGoogle Scholar
29.Richter, M, Wilke, HJ, Kluger, P, Claes, L, Puhl, W. Load-displacement properties of the normal and injured lower cervical spine in vitro. Eur Spine J 2000; 9: 104–108.CrossRefGoogle ScholarPubMed
30.Lennarson, PJ, Smith, D, Todd, MM et al. . Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg 2000; 92: 201–206.Google ScholarPubMed
31.Lennarson, PJ, Smith, DW, Sawin, PD, Todd, MM, Sato, Y, Traynelis, VC. Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. J Neurosurg 2001; 94: 265–270.Google ScholarPubMed
32.Hastings, RH, Wood, PR. Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers. Anesthesiology 1994; 80: 825–831.CrossRefGoogle ScholarPubMed
33.IIIDonaldson, WF, Towers, JD, Doctor, A, Brand, A, Donaldson, VP. A methodology to evaluate motion of the unstable spine during intubation techniques. Spine 1993; 18: 2020–2023.CrossRefGoogle ScholarPubMed
34.Majernick, TG, Bieniek, R, Houston, JB, Hughes, HG. Cervical spine movement during orotracheal intubation. Ann Emerg Med 1986; 15: 417–420.CrossRefGoogle ScholarPubMed
35.Kihara, S, Watanabe, S, Brimacombe, J et al. . Segmental cervical spine movement with the intubating laryngeal mask during manual in-line stabilization in patients with cervical pathology undergoing cervical spine surgery. Anesth Analg 2000; 91: 195–200.CrossRefGoogle ScholarPubMed
36.Watts, AD, Gelb, AW, Bach, DB, Pelz, DM. Comparison of the Bullard and Macintosh laryngoscopes for endotracheal intubation of patients with a potential cervical spine injury. Anesthesiology 1997; 87: 1335–1342.CrossRefGoogle Scholar
37.Wahlen, BM, Gercek, E. Three-dimensional cervical spine movement during intubation using the Macintosh and Bullard laryngoscopes, the bonfils fibrescope and the intubating laryngeal mask airway. Eur J Anaesthesiol 2004; 21: 907–913.CrossRefGoogle Scholar
38.Nolan, JP, Wilson, ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia 1993; 48: 630–633.CrossRefGoogle ScholarPubMed