Establishment Of A New Method Of Tracheal Extubation And Related Study Of Prevertebral Soft Tissue Changes After TARP Internal Fixation

Background and purposeTransoral atlantoaxial reduction plate?TARP?internal fixation can complete the atlantoaxial immediate reduction,bone graft fusion and fixation only through one way of transoral,and has unique advantages in the treatment of refractory atlantoaxial dislocation.However,TARP internal fixation is often accompanied by prevertebral soft tissue?PVST?swelling,which makes the tracheal extubation risky.Conventional approach of extubation has a delay in extubation and a high risk of airway obstruction after extubation.The first purpose of this study is to provide a new method for clinical tracheal extubation after TARP internal fixation by improving conventional approach.The second purpose is to measure the PVST thickness of patients with TARP internal fixation,and clarify the characteristic of postoperative PVST swelling.Materials and Methods1.318 patients received TARP internal fixation were divided into conventional approach of extubation group?CA group,142 patients?and improved approach of extubation group?IA group,176 cases?.On the basis of reaching the basic extubation indications,airway patency of CA group was judged by observing visually the pharyngeal and tongue swelling,and patients without swelling were extubated.Airway patency of IA group was assessed by cuff leak test?CLT?.and extubation was given to patients with negative CLT.Fiberoptic bronchoscopy?FBS?assisted extubation was performed for CLT positive patients on 3 days after surgery.The postoperative tracheal extubation time,incidence of postextubation stridor and tracheal reintubation within 24h after extubation were compared between the two groups.2.Preoperative and postoperative PVST thicknesses at C2,C3,and C4 segments were compared in 32 adult patients who underwent TARP internal fixation?group ??,And were compared with the PVST thickness of 32 patients who underwent anterior C3/C4 surgery?group ??and 32 patients received anterior C5/C6 surgery?group ??.The characteristic of PVST after TARP internal fixation were analyzed.Results1.Comparison between IA group and CA group.1.1 In the CA group,15?10.56%?and 50?35.21%?patients reached the extubation indication at 1 day and 2 days after operation.In the IA group,69?39.20%?and 75?42.61%?patients reached the extubation indication at 1 day and 2 days after operation.The early extubation rate during the first 2 days after surgry was significantly higher in the IA group than in the CA group?81.81%vs.45.76%??P<0.01?.Median extubation time was 2?1,2?days in the IA group and 3?2,3?days in the CA group.1.2 Seventeen patients had postextubation stridor with an incidence of 11.98%in the CA group.In contrast,10 patients had postextubation stridor with a morbidity rate of 5.69%in the IA group.There was a 2.11-fold increase in occurrence of postextubation stridor in the CA-treated patients compared to the IA-treated patients.The difference was statistically significant?P<0.05?.Seven patients?4.93%?required reintubation in the CA group and only one?0.57%?in the IA group.The reintubation rate in the CA-treated patients was 8₆5-fold higher than that in the IA-treated patients and was statistically different?P<0.05?.1.3 Eighteen patients in the IA group were successfully extubated with FBS assisted at 3d or 4d after surgery and the success rate of extubation is 100%.2.The change of PVST after TARP internal fixation2.1 The preoperative PVST thickness was consistent among the three segments in each group,and among the three groups at same segment.The postoperative PVST thickness at each segment of the three groups was significantly greater than that before surgery?P<0.01?.Postoperative comparison in group:the increase of postoperative PVST thickness among the three segments in group ? and ? were consistent.However,the increase of postoperative PVST thickness at C2 segment in group ? was significantly lower than that at C3 and C4.Postoperative comparison among groups:The increase of postoperative PVST thickness at the three segments in group ? was significantly higher than that in group ? and ??P<0.01?.The increase at C2 segment in group ? was higher than that in group ?,but the increase at C3 and C4 segments in group ? was lower than that in group ??P<0.05?.2.2 American Spinal Cord Injury Association?ASIA?grade and TARP internal fixation internal were predictors of postoperative PVST swelling.In a subgroup analysis of patients with ASIA D,it was found that only TARP internal fixation internal was the predictor of swelling.Conclusion1.The New method,in which CLT is used to assess airway patency and FBS is taken to assist extubation for CLT positive patients at 3 days after surgery,is superior to conventional approach of extubation.The former can not only benefits early extubation but also significantly reduce incidence of postextubation stridor and reintubation occurred within 24 hours.2.The degree of PVST swelling after TARP internal fixation is significantly higher than that of patients underwent anterior C3/C4 or C5/C6 surgery,therefore,postoperative management is needed to prevent airway complications due to PVST swelling.