Bedside predictors of difficult airway - neck mobility.

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We read with great interest the comprehensive and important systematic review by Roth et al. 1 regarding bedside predictors of difficult airways. However, we missed from this article some data and comments regarding the importance of cervical spine mobility in predicting difficult airway management. Although this predictor is included in the Wilson score 2 which was analysed by Roth et al. 1, we believe that it should be referred to as an independent predictor of difficult laryngoscopy. In our clinical experience of 70 combined years as anaesthetic practitioners, we have encountered many cases of difficult airway management caused by limitation of cervical spine mobility. This is the case not only in patients with an immobilised cervical spine, as happens in cervical spine injury 3, rheumatoid arthritis, ankylosing spondylitis and other pathological conditions affecting the cervical spine, but also in older patients 4, often suffering from cervical spondylosis affecting cervical spine flexibility. Mashour et al. 5 reviewed the electronic charts of 14,053 patients and identified that 8.1% of them had some limitation of cervical spine movement. When compared with control patients, the incidence of difficult laryngoscopy and difficult tracheal intubation was more than twice as likely in patients with limitation of cervical spine mobility (p < 0.0001). There was no difference in the airway management difficulty, whether the movement limitation was in flexion or extension of the cervical spine. The authors concluded that difficulties in intubation should be anticipated in patients with limitation of cervical spine mobility who are ≥ 48 years old. In view of these findings, we believe that cervical spine mobility may be an independent predictor of difficult airway management.