Difficult Airway for Patients Undergoing Spine Surgeries

case 1 A 30‐year‐old male patient presented with ankylosing spondylitis and kyphosis for posterior ostomy, correction, and internal fixation. Physical examination showed fixed extension deformity of the neck with no movement, restricted mouth opening with Mallampati Grade III. The patient could not lie flat and denied snoring at night. Difficult laryngoscopy was anticipated due to stiffness of cervical vertebra and lateral position. Difficult airway cart including flexible fiberoptic bronchoscopy, laryngeal mask airway of different sizes and types, thyrocricocentesis kit, and percutaneous transtracheal jet ventilation were available for back‐up. The patient was monitored in the operative room with peripheral oxygen saturation, electrocardiogram, and noninvasive blood pressure. After preoxygenation with 100% oxygen using a mask, general anesthesia was induced with intravenous propofol, rocuronium, and fentanyl. Although the patient had easy facemask ventilation, we had difficulty in placing direct laryngoscopy into the mouth, and the patient was successfully intubated with fiberoptic bronchoscopy. There was no decrease of saturation or fluctuation of blood pressure during intubation. The operation lasted 4 h and the patient was successfully extubated postoperatively. case 2 A 9‐year‐old female patient was scheduled for posterior correction and internal fixation due to congenital arthrogryposis multiplex with scoliosis. She had a history of difficult intubation and the operation was canceled when she was scheduled for the same operation 3 months ago at a local hospital. Preoperative evaluation showed severe cervical– thoracic scoliosis, micrognathism, and short neck with limited extension [Figure 1a]. Her dentition was normal and mouth opening was limited with an interincisoral distance of about 2.5 cm. Mallampati Grade was II and her parents denied snoring at night. Our primary plan was to perform conventional intravenous induction since there was no difficult mask ventilation last time. Difficult airway cart was available for back‐up. We also discussed the possibility of surgical airway with surgeons and parents. After preoxygenation, propofol and fentanyl were given intravenously. After confirming the success of bag ventilation, McGrath laryngoscopy revealed Cormack–Lehane Grade II view. The patient was paralyzed with rocuronium. Endotracheal tube was placed and the position was confirmed with capnography. The surgeon successfully did internal fixation from T10 to S1, and the patient was sent to Intensive Care Unit for further observation and extubated 2 h after the operation. Difficult Airway for Patients Undergoing Spine Surgeries