+ Site Statistics
+ Search Articles
+ PDF Full Text Service
How our service works
Request PDF Full Text
+ Follow Us
Follow on Facebook
Follow on Twitter
Follow on LinkedIn
+ Subscribe to Site Feeds
Most Shared
PDF Full Text
+ Translate
+ Recently Requested

Severe subluxation in the sniffing position in a rheumatoid patient with anterior atlantoaxial subluxation

Severe subluxation in the sniffing position in a rheumatoid patient with anterior atlantoaxial subluxation

Anesthesiology 101(5): 1235-1237

SPECIAL attention should be paid to airway management in rheumatoid patients with atlantoaxial subluxation (AAS) because they may be at risk of life-threatening neurologic injury caused by worsening the subluxation in the head and neck position during airway maneuver. 1-5 Atlantoaxial subluxation is found in 11-46% of patients with rheumatoid arthritis and is classified into four groups according to the direction of the subluxation, including anterior AAS, posterior AAS, vertical AAS, and lateral AAS.6,7 Anterior AAS is the most prevalent form, accounting for 80% of all types of subluxations. 6,7 In rheumatoid patients with anterior AAS, the degree of subluxation has been estimated in association with flexion and extension at the entire cervical spine (the head and neck) as a functional unit. 6,7 During flexion of the entire cervical spine, the atlas separates anteriorly from the axis, and the subluxation is worsened. On the contrary, during extension, the atlas slides backward until it rests against the dens of the axis, and the subluxation is reduced. Therefore, standard anesthesia textbooks advocate avoiding flexion of the head and neck in rheumatoid patients with anterior AAS.3,4 The sniffing position is widely recommended as the standard head and neck position for conventional laryngoscopy.8,9 This position consists of two components, which are severe extension of the head at the occipitoatlantoaxial (OAA) complex and slight flexion of the neck at the subaxial cervical segments.8,9 In this position, the direction of movement of the OAA complex (head movement) and that of the subaxial segments (neck movement) are opposite.8,9 Theoretically, extension of the OAA complex reduces the subluxation, and flexion of the subaxial segments Makes it worse in rheumatoid patients with anterior AAS. In general, it is believed that accomplishment of the sniffing position is tolerated in these patients because the OAA complex where the subluxation occurs is extended, and the degree of the subaxial flexion is mild.2,10 However, whether this position is safe is still unknown. We report a case of the rheumatoid patient with anterior AAS that was markedly worsened by the sniffing position.

Please choose payment method:

(PDF emailed within 0-6 h: $19.90)

Accession: 012551244

Download citation: RISBibTeXText

PMID: 15505464

DOI: 10.1097/00000542-200411000-00028

Related references

Transoral anterior approach for extensive anterior decompression at the C3 vertebra level in a patient with severe atlantoaxial vertical subluxation and rheumatoid arthritis. Spinal Cord 44(1): 52-55, 2005

Fluoroscopic observation of the occipitoatlantoaxial complex during intubation attempt in a rheumatoid patient with severe atlantoaxial subluxation. Anesthesiology 111(4): 917-919, 2009

Dominant vertebral artery injury during posterior atlantoaxial transarticular screw fixation in a juvenile rheumatoid arthritis patient with atlantoaxial subluxation. Acta Medica Okayama 66(1): 77-81, 2012

Anterior atlantoaxial subluxation in a patient with DISH. Journal of Rheumatology 26(7): 1639-1640, 1999

Dyspnea caused by atlantoaxial subluxation in a patient with rheumatoid arthritis. Case Reports in Emergency Medicine 2012: 170956, 2012

Anterior atlantoaxial subluxation in a patient with diffuse idiopathic skeletal hyperostosis. Journal of Rheumatology 23(8): 1441-1444, 1996

Craniocervical junction abnormalities with atlantoaxial subluxation caused by ventral subluxation of C2 in a dog. Open Veterinary Journal 7(1): 65-69, 2017

A multivariate analysis of risk factors for anterior atlantoaxial subluxation and an evaluation of the effect of glucocorticoid treatment on the upper rheumatoid cervical spine. Clinical Rheumatology 10(4): 413-418, 1991

Relation between atlantoaxial (C1/2) and cervical alignment (C2-C7) angles with Magerl and Brooks techniques for atlantoaxial subluxation in rheumatoid arthritis. Journal of Orthopaedic Science 11(4): 347-352, 2006

Acute retropharyngeal calcific tendinitis in an unusual location: a case report in a patient with rheumatoid arthritis and atlantoaxial subluxation. Korean Journal of Radiology 12(4): 504-509, 2011

Quadriparesis complicating atlantoaxial subluxation and ossification of the posterior longitudinal ligament in a patient with rheumatoid arthritis. A case report. Journal of Bone and Joint Surgery. American Volume 87(6): 1354-1357, 2005

Recurrent embolic strokes associated with vertical atlantoaxial subluxation in a patient with rheumatoid arthritis: a case report and review of literature. Journal of Stroke and Cerebrovascular Diseases 22(8): E676-E681, 2013

Acquired Chiari malformation secondary to atlantoaxial vertical subluxation in a patient with rheumatoid arthritis combined with atlanto-occipital assimilation. Neurologia Medico-Chirurgica 52(9): 683-686, 2012

Acquired Chiari Malformation Secondary to Atlantoaxial Vertical Subluxation in a Patient With Rheumatoid Arthritis Combined With Atlanto-occipital Assimilation. Neurologia medico-chirurgica 52(9): 683-686, 2012

Traumatic anterior atlantoaxial subluxation occurring in a professional rugby athlete: case report and review of literature related to atlantoaxial injuries in sports activities. Spine 29(3): E61-E64, 2004