A Retrospective Pilot Study for Preoperative Screening to Prevent Iatrogenic Cervical Spinal Cord Injury.

Anthony Diaz,Howard B Levene,David Mccarthy,Christopher Chin,Christina Matadial,Stephen S Burks

doi:10.7759/cureus.12550

Abstract

Purpose: The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series.Methods: Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure.Results: There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman’s and Spurling’s sign, independently, were significantly associated with a positive neck extension exam (p<0.05). Fourteen patients were recommended for cervical decompression prior to planned procedure.Conclusions: Our preoperative cervical spine clearance protocol is safe and may aid in identifying patients susceptible to iatrogenic cervical spine injury.

Highlights

Preoperative medical clearance is accepted as essential for minimizing surgical risk
We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series
Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six

Summary

Introduction

Preoperative medical clearance is accepted as essential for minimizing surgical risk. Often performed by an anesthesiologist or primary care physician, preoperative screening includes a critical review of the patient’s age, exercise capacity, medications, weight, alcohol and smoking use, pulmonary and cardiac risk, and additional factors depending on the indicated procedure [1,2,3,4,5]. While the preoperative medical clearance process can be thorough, screening for potential cervical spine disease is often overlooked. During a prolonged surgical procedure, patients may be exposed to mechanical and gravitational forces from neck positioning (eg, cervical hyperextension or hyperflexion) that when coupled with an existing cervical spine disease, may increase the likelihood of an iatrogenic cervical spinal cord injury [10]. Cervical spine disease and cervical spine instability have been strongly associated with difficulty and complications in airway evaluation and management, potentially exacerbating the risk for injury [11]

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