Complete quadriplegia after prone ventilation for COVID-19-related pneumonia
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A 71-year-old man with significant medical comorbidities presented with complete quadriplegia following extubation after prolonged COVID-19-related pneumonia.
Prior to intubation for hypoxic respiratory failure, he was noted to be moving all extremities. Due to worsening oxygenation, the patient underwent intermittent prone positioning and required a continuous paralytic due to ventilator dyssynchrony. He remained intubated for 18 days with completion of remdesivir and dexamethasone sodium phosphate treatment.
The patient had known cervical stenosis with bilateral upper extremity numbness, decreased dexterity and problems with balance that were previously evaluated at an outside facility with a recommendation for undergoing elective decompression.
On initial presentation, an MRI scan of the cervical spine revealed multilevel moderate to severe central and foraminal stenosis with cord compression most severe at C3-4 (Figure 1). There was increased cord hyperintensity compared with a previous MRI from 2019 compatible with compressive myelopathy. An outside MRI brain and electroencephalogram were both unremarkable.
Source: Tadhg O’Gara, MD
On exam, the patient made attempts to speak. Neurologic examination revealed 0/5 strength from C5-S1 with sensation not intact to light touch in all distributions from C5-S2. Furthermore the patient demonstrated an up-going Babinski sign bilaterally with 1+ reflex at the bilateral biceps, the triceps and the brachioradialis.
What are the treatment options?
See answer below.
Posterior cervical decompression, fusion to remove static components of compression
This patient demonstrates complete quadriplegia at C4 following prolonged intubation for COVID-19 in the setting of previous cervical spondylotic myelopathy (CSM).
Options for treatment include nonoperative management with or without a rigid cervical orthosis; anterior cervical decompression and fusion; posterior cervical laminoplasty; and posterior cervical decompression and instrumented fusion.
Given the American Spinal Injury Association Impairment A presentation, there was a low likelihood of functional recovery. Therefore, nonoperative management is not an unreasonable option. The patient and his family, however, wanted to make all efforts to restore function. Given this desire, nonoperative management was not chosen. Both anterior and posterior approaches to the cervical spine for stenosis and myelopathy have resulted in clinical improvement with controversy that exists regarding the best approach for decompression and deformity correction.
The posterior approach was chosen in this case because it allows an extensive decompression and because an anterior approach would risk further insult to his airway and respiratory status. A decompressive laminoplasty relieves spinal cord compression by elevating the posterior spinal elements en bloc and this option is reasonable. We instead chose to pursue a posterior cervical laminectomy to remove any of the static components and an instrumented fusion was added to eliminate the dynamic component of the disease and also not mitigate any future risk of postoperative kyphosis or instability.
Technique, postoperative course
General anesthesia was administered. The patient was positioned prone without excessive neck extension. A standard midline posterior approach to the spine was used. Appropriate levels were confirmed with fluoroscopy. Screw holes were made from C3-7 using the Ahn technique with excellent endpoints. Tracts were drilled into C2 for laminar screw placement. Using previously described techniques, 28-mm and 18-mm screws were placed into the right and left C2 lamina, respectively. A lobster-tail laminectomy was performed from C3-6. Lateral masses were decorticated with a high-speed burr and 12-mm 3.5 lateral mass screws were placed with acceptable purchase followed by rod fixation. Local morselized bone and allograft were packed lateral to the rods over the decorticated lateral masses from C2-7. Standard layered closure was performed.
Excellent hemostasis was achieved, and no drain was utilized. Final radiographs demonstrated no complicating features. Spinal restrictions included avoiding excessive lateral bending or rotation. The patient had an uneventful postoperative course and was discharged to an inpatient rehabilitation facility for his ongoing deficits. Four months postoperatively, he regained use of his extremities and bowel and bladder function and could ambulate with a cane. Radiographs at that time demonstrated a stable cervical fusion construct without hardware complication (Figure 2).
Discussion
With the COVID-19 pandemic, patients with moderate to severe acute respiratory distress syndrome have been reported to respond well to invasive ventilation in the prone position. Prone ventilation has been recommended in several critical care guidelines and garnered support from the international community, as well as from the trial in which prone positioning in severe acute respiratory distress syndrome was studied by Claude Guérin, MD, PhD, and colleagues for early use of prone positioning to improve oxygenation and reduce mortality. Prone positioning makes ventilation more homogenous with a decrease in dorsal alveolar collapse and reduced lung compression by the heart and diaphragm. Spinal instability and unstable fractures are listed as absolute contraindications to prone ventilation. Yet, for patients with preexisting cervical spine pathology, there is currently no standard of care for safe prone positioning. Prone positioning alone also worsens cervical canal stenosis in patients with preexisting cervical myelopathy, further exacerbated by vena cava compression.
Few accounts of spinal cord injury (SCI) and post-procedure quadriparesis in patients with preexisting CSM have been reported within the literature. Only 18 cases of SCI following elective non-spine surgery in patients with undiagnosed CSM have been described. It is difficult in this case to implicate prone positioning as a sole contributor to this patient’s spinal insult as there are other possible positional and vascular concerns during his initial treatment. For example, following his initial intubation in the ICU, he developed sinus bradycardia shortly thereafter for which cardiology was consulted and described its origin as multifactorial. Yet, the most frequent cardiac abnormality associated with a high SCI is bradycardia. It is unclear whether his intubation was difficult, as it required one attempt with use of a video laryngoscope. Several studies describe the extent to which airway management techniques angulate the cervical spine. Basic maneuvers such as a chin lift and jaw protrusion cause as much displacement as direct laryngoscopy. Interestingly, most cervical spine movement occurs in the upper cervical spine with minimal movement noted inferior to C3. In this case, the patient’s most severe canal stenosis occurred at C3-4 secondary to central disc protrusion.
While the vast amount of research has focused on safe management of the airway in patients with an unstable cervical spine or spinal pathology, there is little information available on safe, prone positioning techniques for these patients. While techniques vary with preferences of institutional practices and surgeons, the predominant techniques include the logroll method with manual in-line stabilization, the “sandwich and flip” technique with use of a special spine surgery table, and awake prone positioning. The logroll method requires coordination among providers; the sandwich and flip rotation has a learning curve and the potential for patient injury if done incorrectly; and awake prone positioning requires patient participation. Among these techniques, the sandwich and flip was associated with more than a 50% reduction in both flexion-extension and axial-lateral rotation when compared with the logroll method. Fortunately for this patient, he regained motor and sensation to his extremities and continues to improve his neurologic function.
This case illustrates the importance of awareness regarding patients with preexisting degenerative cervical conditions who may require intubation and prone positioning. CSM is often an underdiagnosed disease that requires more attention, especially amid the COVID-19 pandemic with increasing use of prone positioning for improved respiratory function.
- References:
- Boyle SL, et al. J Neuroanaesth Crit Care. 2020;doi:10.1055/s-0039-1687918.
- Chad T, et al. Clin Med (Lond). 2020;doi:10.7861/clinmed.2020-0179.
- Dorward IG, et al. Neurosurgery. 2011;doi:10.1227/NEU.0b013e318212a4d7.
- Guérin C, et al. N Engl J Med. 2013;doi:10.1056/NEJMoa1214103.
- Kim KA, et al. Spine J. 2006;doi:10.1016/j.spinee.2006.04.007.
- Mathkour M, et al. Clin Neurol Neurosurg. 2019;doi:10.1016/j.clineuro.2019.105549.
- Sánchez JAS, et al. Neurospine. 2020;doi:10.14245/ns.2040366.183.
- For more information:
- Evan M. Miller, MD, a third-year orthopedic surgery resident at Wake Forest University School of Medicine; Tadhg O’Gara, MD, an associate professor of orthopedic surgery and neurosurgery at Wake Forest University School of Medicine; and Donald J. Scholten II, MD, PhD, can be reached at Atrium Health Wake Forest Baptist, Department of Orthopaedics, 1 Medical Center Blvd., Winston-Salem, NC 27157. Miller’s email: evmiller@wakehealth.edu. O’Gara’s email: togara@wakehealth.edu. Scholten’s email: dscholte@wakehealth.edu.
- Edited by Steven D. Jones Jr., MD, and Donald (DJ) Scholten, MD, PhD. Jones is a chief resident in the department of orthopedic surgery at the University of Colorado. He will pursue a fellowship in sports medicine at Stanford University following residency completion. Scholten is a chief resident in the department of orthopedic surgery at Wake Forest University School of Medicine in Winston-Salem, North Carolina. He will be a sports medicine fellow at the University of Michigan following residency. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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