Fluoroscopic observation of the occipitoatlantoaxial complex during intubation attempt in a rheumatoid patient with severe atlantoaxial subluxation.

ATLANTOAXIAL subluxation (AAS) is found in 11– 46% of patients with rheumatoid arthritis. Rheumatoid patients with AAS may be at risk of life-threatening neurologic injury caused by exacerbation of the subluxation in the head and neck position during airway maneuver; therefore, appropriate management of the cervical spine is essential. Tokunaga et al. have recommended the protrusion position, which is equal to the posture used in anesthesiology as the sniffing position, during intubation attempt in these patients to reduce subluxation. In contrast, previous studies have shown that accomplishment of the protrusion position sometimes results in worsening AAS in rheumatoid patients with severe instability of the occipitoatlantoaxial (OAA) complex. In cases of severe OAA instability, appropriate head and neck position during airway maneuver is poorly understood despite its importance. Minimizing movement of the cervical spine may be the only method for avoiding exacerbation of AAS and protecting the spinal cord. It is often difficult to predict the degree of cervical spine motion for laryngoscopy and intubation because the motion varies from individual to individual. Moreover, prediction is all the more difficult in patients with rheumatoid arthritis because their trachea is sometimes difficult to intubate. These indicate that, despite the necessity of minimizing cervical movement, the degree of the motion is not known until laryngoscopy and intubation are performed. Observation of the cervical motion during airway maneuver may provide a safer management. We report a case of fluoroscopic observation of the OAA complex during laryngoscopy and intubation in a rheumatoid patient with severe AAS. Case Report