Acute upper airway obstruction after extubation due to excessive anteflexion of the neck with occipitocervical fusion

A patient developed upper airway obstruction immediately after tracheal extubation due to excessive anteflexion of the neck with occipitocervical fusion. A 59-year-old woman who had undergone mastectomy 17 years previously was scheduled for occipitocervical fusion for C2 vertebral metastasis. Retroflexion of her neck was restricted. Nasal intubation under sedation was performed using bronchial fiberscopy under fentanyl and propofol anesthesia. Emergence from anesthesia was smooth, and extubation was performed. Immediately after extubation, the patient could not breathe, and manual mask ventilation was impossible. Re-intubation was performed 30 minutes after the extubation. Oral fiberscopy revealed pharyngeal obstruction, and laryngeal edema was not observed. Fixation of her neck in excessive anteflexion was suspected to have caused her dyspnea. Therefore, re-operation was performed, and she was transferred to the intensive care unit under anesthesia. One day postoperatively, extubation was performed successfully with no dyspnea. Fixation of the neck in excessive anteflexion is one of the causes of upper airway obstruction after occipitocervical fusion. We must carefully observe cervical X-ray films to locate the upper airway obstruction, and careful extubation using a tube exchanger is strongly recommended in this operation.