Ankylosing spondylitis with a cervical fracture for fixation71-year-old man, 70 kg, for urgent posterior cervical fixation, prone

The patient

The examiner asks

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1. Consider

   What are the key issues?

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   • A 71-year-old with long-standing AS and an unstable C6–C7 fracture, for urgent prone fixation. Patient
   • At 71, after a fall and fracture, delirium risk is high; propofol over 1.5 mg/kg drops his BP badly.
   • His fused spine broke from a simple fall; the fracture sits where AS fractures usually do. Disease
   • Fixed flexion and 3 cm mouth opening: forcing his neck back can transect his cord. Airway
   • His diastolic murmur suggests aortic regurgitation; first-degree block fits AS conduction disease. Disease
   • Restricted chest wall means restrictive lung disease and less reserve after prone surgery.

2. Prepare

   How do you assess him?

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   • Full neurological exam documented now, as the baseline for every later check. Disease
   • CT of his whole spine; atlanto-axial subluxation is common in AS and often silent.
   • Echo for his regurgitation and aortic root before prone surgery.
   • Adalimumab raises infection risk; urgent surgery can't wait a dose cycle, so the team watches the wound.
   • Neuraxial noted as difficult for later: spinal placement fails more often in AS.
   • Airway plan shared with the surgeon: awake intubation, then awake turning prone. Airway

3. Plan

   How will you secure his airway and position him?

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   • Awake flexible bronchoscopic intubation, neck kept in his own flexed position. Airway
   • Topical lidocaine kept under 9 mg/kg lean weight; remifentanil TCI 1–3 ng/mL, no boluses.
   • Tube position confirmed by bronchoscope view and capnography before any induction.
   • He then turns himself prone on supports, and I confirm unchanged limb power first. Surgery
   • Head and shoulders padded to his deformity; no extension anywhere.
   • Arterial line; MAP held at 85–90 to protect his cord. Disease
   • TIVA so the surgeon can use motor evoked potentials. Surgery

4. Crisis

   After awake prone positioning, before induction, he says his hands feel weak; grip is clearly weaker. BP 102/58, HR 60. What do you do?

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   • New deficit after turning: this is cord compromise until proven otherwise; I do not induce. Crisis
   • Stop, tell the surgeon, and return his neck to the flexed alignment he had before the turn.
   • Noradrenaline 0.05–0.3 mcg/kg/min, aiming for a MAP of 85–90; avoid phenylephrine-driven bradycardia with his AR.
   • Repeat neurology; if it does not recover, urgent imaging before the surgeon decides.
   • Every check documented with times. After surgery

5. Crisis

   After surgery he is extubated over an airway exchange catheter. Twenty minutes later he has stridor and SpO2 90% on 10 L/min. BP 150/80, HR 105. What do you do?

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   • Stridor from airway oedema after long prone surgery: call for help, sit him up, 100% oxygen. Crisis
   • Dexamethasone 4–8 mg IV and nebulised racemic adrenaline 0.5–0.75 mL of 2.25%.
   • No more than 2 L/min oxygen through the exchange catheter; it can cause barotrauma.
   • If worsening, reintubate over the catheter with a smaller tube; first-pass success is higher.
   • Videolaryngoscope only with no neck extension; front-of-neck kit and surgeon at the bedside.
   • ICU for a delayed extubation once the swelling settles. After surgery