Cervical spine motion with direct laryngoscopy and orotracheal intubation: An in vivo cinefluoroscopic study of subjects without cervical abnormality

Abstract

Background: Cervical spine kinetics during airway manipulation are poorly understood. This study was undertaken to quantify the extent and distribution of segmental cervical motion produced by direct laryngoscopy and orotracheal incubation in human subjects without cervical abnormality. Methods: Ten patients without clinical or radiographic evidence of cervical spine abnormality underwent laryngoscopy using a 3 Macintosh blade while under general anesthesia and neuromuscular blockade. Cervical motion was recorded with continuous lateral fluoroscopy. The intubation sequence was divided into distinct stages and the corresponding fluoroscopic images were digitized. Segmental motion, occiput through C5, was calculated for each stage using the digitized data. Results: During exposure and laryngoscope blade insertion, minimal displacement of the skull base and rostral cervical vertebral bodies was observed. Visualization of the larynx created superior rotation of the occiput and C1 in the sagittal plane, and mild inferior rotation of C3-C5. C2 maintained near-neutral posture. This pattern of displacement resulted in extension at each motion segment, with the most significant motion produced at the occipitoatlantal and atlantoaxial joints (mean = 6.8° and 4.7°, respectively). Incubation created slight additional superior rotation at the occiput and C1, without substantial alteration in the posture of C2-C5. After laryngoscope removal, position trended toward baseline at all levels, although exact neutral posture was not regained. Conclusions: This investigation quantifies the behavior of the normal cervical spine during direct laryngoscopy with a Macintosh blade. With this maneuver, the vast majority of cervical motion is produced at the occipitoatlantal and atlantoaxial joints. The subaxial cervical segments (C2- C5) are displaced only minimally. This study establishes a highly reliable and reproducible method for analyzing cervical motion in real time.