Measures to prevent acute airway obstruction after anterior cervical spine surgery: a retrospective cohort study from Japan and a review of the literature

Study design: A retrospective cohort study and literature review. Purpose: We analyzed the clinical characteristics of acute airway obstruction (AAO) after anterior cervical spine surgery (ACSS), evaluated the effectiveness of newly implemented preventive measures, and assessed whether extubation immediately after surgery is practical. Overview of literature: AAO is a rare but potentially fatal complication after ACSS. Recent studies have focused on postoperative management strategies such as prolonged intubation in the intensive care unit; however, the feasibility and safety of immediate extubation have not been studied extensively. This study addressed this critical gap. Methods: We retrospectively reviewed data from patients who underwent ACSS and then immediate extubation according to policy at our institution between April 2006 and January 2019. Patients were categorized into AAO and non-AAO groups according to whether postoperative airway compromise necessitated reintubation or hematoma evacuation. Statistical analyses identified surgery-related risk factors associated with AAO. These findings and a review of the literature prompted the implementation of 10 preventive measures in February 2019. We then analyzed outcomes from 156 subsequent cases of ACSS. Results: AAO occurred in 7 (0.68%) of 1,036 patients. Significant risk factors included the number of fixed disc segments (p =0.031), instrumentation of a more cephalad upper vertebra (p =0.007), and use of a halo vest (p <0.001). Among 156 patients who underwent ACSS after preventive measures were implemented, no cases of AAO were observed, but statistical significance could not be determined because of the limited sample size. Conclusions: We systematically examined AAO prevention strategies and the potential effectiveness of 10 preventive measures. Despite these preventive measures, AAO cannot be prevented entirely; thus, rigorous monitoring after extubation is essential. Although the trend toward prolonged intubation is increasing, our findings suggest that immediate extubation is suitable for most patients.