Retrospective audit of airway management practices in children with craniocervical pathology

Abstract

Background

Craniocervical immobilisation using halo body orthoses may be required in the management of children with craniocervical junction pathology. To date, the effect of such immobilisation on perioperative anaesthetic management has not been addressed in large series.

Aim

To review the airway management of children requiring halo body orthoses undergoing general anaesthesia.

Methods

The study was a retrospective case note review from a single institution. The neurosurgical database was interrogated to identify all patients less than 16 years of age that required a halo body orthosis from 1996 to 2015. We used the electronic patient record to identify all procedures performed under general anaesthesia for these patients, either for halo application, or with the halo in situ. Details of techniques used for airway management were recorded, and paired data between individuals pre‐ and post‐halo application were compared. Demographic data, diagnosis and perioperative complications were also recorded.

Results

We identified 90 children that underwent placement of a halo body orthosis. A total of 269 anaesthetic records from these patients were analysed and classified as pre‐halo application, or halo in situ. Facemask ventilation was achieved in all patients, though some required simple airway adjuncts and may have been more difficult in the presence of the halo. Supraglottic airways were used successfully in many patients. There was a significant increase in the number of patients classed as Cormack and Lehane grades 3 or 4 on direct laryngoscopy with the halo in situ compared with before the halo was applied. The incidence of intubation using fibreoptic or videolaryngoscopy was higher with the halo in situ. Multiple intubation attempts were required in 3.4% (1/29) of patients undergoing anaesthesia for halo placement compared with 15.1% (11/73) undergoing anaesthesia with a halo in situ.

Conclusion

Airway management in children with cervical spine pathology should be anticipated to be more difficult than the general paediatric population. This is likely to be due to co‐existing pathology associated with cervical spine disease in children, limitation of neck movement to prevent further neurological injury, and the halo itself limiting access to the head. We recommend advanced preparation, and ensuring the immediate availability of an anaesthetist with skills in managing the paediatric difficult airway to avoid complications in this patient population.

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