We have herein reported our airway and surgical management experiences in a case of devastating soft tissue disruption of the posterior neck. Direct rupture of neck restraints, including the nuchal, interspinous, and flavum ligaments, leads to severe spinal instability [
4‐
6]. Therefore, the key to airway management is to minimize movement of the cervical spine. This case also illustrates that PNI of the posterior cervical neck requires immediate surgical treatment even when great vessel injury is absent.
This case illustrates the considerations required when managing the airway of patients with disrupted posterior neck restraints. According to the porcine trauma model described by Oxland
et al. [
4], complete injury to both the interspinous and flavum ligaments increases flexion motion by 180 %. Using human cadaver models, Richter
et al. [
5] also showed that interspinous and flavum ligament injury increases spinal instability in flexion/extension, axial rotation, and lateral bending. Thus, all neck movements, especially flexion, must be avoided when managing an airway. A variety of different endotracheal intubation (ETI) methods has been used to attain this purpose. Direct laryngoscopy with manual in-line cervical immobilization is a traditional ETI strategy in patients with multiple traumas who are at risk for or have spinal cord injury [
7,
8]. We used this conventional, trusted technique and achieved a satisfactory outcome. Another attractive choice is ETI using video laryngoscopy. At least in planned anesthesia, video laryngoscopy can reduce the movement of the cervical spine during ETI compared with conventional laryngoscopy [
9‐
11]. Use of a bougie as an aid during video laryngoscopy may further reduce movement [
11]. The anesthesiology literature also reveals that video laryngoscopy can offer a better glottic view than conventional laryngoscopy in patients with limited neck movement [
12]. Nevertheless, whether video laryngoscopy can reduce neck movement in the emergency setting has not been elucidated [
9‐
11]; whether it is more successful in trauma subsets of patients is also unclear [
12]. Nasotracheal intubation is also known to decrease motion of the spinal segments compared with oral intubation [
13], and fiber-optic intubation has been considered the gold standard technique with which to manage patients with restricted neck movement in planned anesthesia. However, nasotracheal intubation is less successful when used in the emergency setting [
1] and can cause serious complications, including nasopharyngeal bleeding and retropharyngeal perforation [
8]. Fiber-optic intubation is sometimes time-consuming, and the technique requires extensive training [
7]. It is well known that fiber-optic intubation has a high failure rate when this technique is used in the ED [
14]. Valero
et al. [
7] successfully used a laryngeal mask to manage a patient with a drill bit penetrating his spinal canal. They insisted that use of a laryngeal mask was highly effective in minimizing cervical spine movement and providing adequate ventilation during the operation. Because our patient had drunk alcohol immediately before his suicide attempt, we could not apply this technique in the present case.
The use of RSI is controversial for airway management in patients with PNI [
1‐
3] because such patients likely have an edematous and/or distorted airway, making both manual ventilation and ETI difficult. Therefore, we adequately prepared back-up ventilation and an intubation strategy before induction of anesthesia. However, at least in our case, there was no airway deformity and RSI was highly effective in facilitating safe ETI. The cough reflex may have abolished the cervical spine stability, and the cardiovascular response associated with ETI might have increased bleeding from the deeply lacerated posterior neck muscle. In this case, RSI successfully prevented both of these important adverse events and provided a satisfactory intubation condition. Logically thinking, PNI of the posterior neck is less likely to cause upper airway edema. Thus, RSI may be the most reasonable approach in patients with a penetrating posterior cervical injury.
This case also illustrates that deep laceration of the posterior cervical column can result in profound hypovolemic shock, even when great vessel injury is absent. The blood supply to the posterior cervical muscle is very rich, and manual hemostatic pressure may not be sufficient, as seen in this case. Therefore, immediate surgical intervention is vital in patients with profound posterior PNI.