What are the treatment options for difficulty breathing after cervical fusion?

Difficulty Breathing After Cervical Fusion: Treatment Approach

Immediate Assessment and Emergency Management

If acute airway obstruction develops after cervical fusion, immediate surgical evacuation of retropharyngeal hematoma is the definitive treatment, with emergency cricothyroidotomy as a life-saving rescue if intubation fails. 1

Recognize the Emergency

• Acute airway obstruction occurs in 1.15% of anterior cervical fusion cases and requires urgent recognition within minutes to hours. 1
• Critical warning signs include inspiratory stridor, anterior neck swelling, facial edema, dysphagia, and progressive respiratory distress. 1
• Most cases (67%) develop within 24 hours postoperatively, but delayed presentation can occur up to 72 hours or even years later. 1, 2
• Patients progressing to cyanosis require immediate airway intervention—do not delay for imaging. 1

Emergency Airway Management

Use videolaryngoscopy with manual in-line stabilization as the first-line intubation technique, removing only the anterior portion of any cervical collar. 3, 4, 5

• Videolaryngoscopy reduces cervical spine movement compared to direct laryngoscopy and improves first-pass success rates. 5
• Use jaw thrust rather than head tilt-chin lift for airway positioning to minimize cervical spine movement (4.8° vs 14.7° flexion-extension). 5
• Have a bougie or stylet immediately available as 22% of patients have nothing visible beyond the epiglottis with cervical immobilization. 5
• If intubation fails after 2-3 attempts, proceed immediately to emergency cricothyroidotomy per Difficult Airway Society guidelines. 3, 1

Surgical Evacuation

• Patients with inspiratory stridor, neck swelling, and facial edema progressing to respiratory distress require immediate surgical evacuation of hematoma. 1
• Sustained superficial venous bleeding or pumping from small muscular arterial branches is typically found at surgery. 1
• Reintubation was necessary in 6.4% of anterior cervical fusion cases, with 2.3% requiring it specifically for surgical complications. 6

Specific Causes and Their Management

Retropharyngeal Hematoma (Most Common Emergency)

• This is the most life-threatening cause requiring immediate surgical decompression. 1
• No specific preoperative risk factors have been identified—it can occur in any patient. 1
• Systematic evaluation with CT imaging is appropriate only if the patient is stable without respiratory distress. 1

Prevertebral CSF Collection

• Recurrent acute upper airway obstruction from CSF accumulation requires drainage and surgical repair of the dural tear. 2
• This presents as recurrent episodes rather than a single acute event. 2
• Laryngoscopy and intubation may be needed for acute episodes until definitive surgical repair is performed. 2

Soft Tissue Swelling

• Upper airway obstruction from severe soft tissue swelling is most common when C3 is included in the fusion. 6
• Methylprednisolone administration can reduce the incidence of postoperative swelling. 7
• Controlled ventilation may be required for 24-48 hours until swelling resolves. 6

Phrenic Nerve Palsy

• Unilateral phrenic nerve palsy can cause respiratory insufficiency requiring controlled ventilation. 6
• This typically manifests as inability to wean from the ventilator rather than acute obstruction. 6

Delayed Esophageal Perforation

• Esophageal perforation by cervical plate hardware can present years later with recurrent aspiration pneumonia, fever, dysphagia, and neck pain. 8
• Endoscopic evaluation is diagnostic. 8
• Treatment requires surgical repair using a sternocleidomastoid muscle flap. 8

Risk Stratification

High-Risk Surgical Factors

• Multilevel cervical spine surgery significantly increases dysphagia and respiratory complication risk. 7
• Upper cervical spine surgeries (especially involving C3) carry higher risk of airway obstruction. 6, 7
• Logistic regression confirms these as independent risk factors. 7

Preoperative Pulmonary Considerations

• COPD increases postoperative pneumonia risk 4-fold after cervical fusion. 3
• Congestive heart failure increases reintubation risk 2.6-fold. 3
• These patients require aggressive pulmonary optimization and closer postoperative monitoring. 3

Critical Pitfalls to Avoid

• Never delay airway intervention for imaging in patients with progressive respiratory distress—proceed directly to intubation or surgical evacuation. 1
• Do not attempt awake fiberoptic intubation routinely—videolaryngoscopy under anesthesia with appropriate precautions is equally safe and more practical. 3, 4
• Avoid multiple intubation attempts (limit to 2-3) to prevent airway trauma and hypoxemia. 5
• Do not use nasotracheal intubation in patients with potential skull base involvement—use orotracheal route only. 9
• Ensure multidisciplinary planning before any airway intervention in these high-risk patients. 3