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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.

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Accession: 012551244

Download citation: RISBibTeXText

PMID: 15505464

DOI: 10.1097/00000542-200411000-00028


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