AIRWAY MANAGEMENT IN PATIENTS WITH TRAUMATIC SPINAL CORD INJURY: A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.56238/levv17n58-041Keywords:
Spinal Cord Injuries, Airway Management, Intubation, TracheostomyAbstract
Introduction: Airway management in patients with traumatic spinal cord injury is a high-stakes component of acute trauma care because inadequate oxygenation, repeated airway attempts, and excessive cervical motion may worsen neurological and systemic outcomes. Respiratory compromise is particularly relevant in cervical injuries, in which early airway decisions may influence both immediate survival and subsequent ventilatory dependence.
Objective: To systematically evaluate the current evidence on airway management strategies in patients with traumatic spinal cord injury, with emphasis on initial intubation techniques, cervical motion restriction during airway intervention, tracheostomy timing, and downstream respiratory outcomes.
Methods: A systematic review was conducted using PubMed, Scopus, Web of Science, Cochrane Library, LILACS, ClinicalTrials.gov, and ICTRP. Eligible studies addressed airway management in traumatic spinal cord injury or directly relevant traumatic cervical spinal injury contexts, with priority given to human studies published within the predefined recent time window and expanded when necessary according to protocol. Study selection, data extraction, and methodological appraisal were structured according to PRISMA, with risk of bias assessed using RoB 2, ROBINS-I, or QUADAS-2 as appropriate, and certainty of evidence interpreted using GRADE.
Results and Discussion: Twenty studies were included in the final qualitative synthesis. The most consistent findings supported videolaryngoscopy as the preferred modern approach for initial tracheal intubation when cervical motion restriction is required, owing to better glottic visualization, higher first-pass success, and improved procedural efficiency in comparison with conventional techniques. The tracheostomy literature was more robust than the emergency intubation literature and consistently suggested that earlier tracheostomy was associated with shorter mechanical ventilation, shorter intensive care stay, shorter hospitalization, and fewer pulmonary complications, although mortality benefit remained uncertain. Additional evidence suggested clinically relevant roles for structured extubation assessment, dysphagia surveillance, decannulation planning, and selected use of diaphragm pacing in high cervical injury.
Conclusion: Current evidence favors a longitudinal, multidisciplinary airway strategy in traumatic spinal cord injury that combines expert initial airway control with early anticipation of prolonged respiratory support needs. Videolaryngoscopy appears to be the most consistently advantageous option for initial instrumentation under cervical motion restriction, while early tracheostomy should be considered in patients with severe cervical injury and high risk of sustained ventilatory dependence. More prospective multicenter studies are needed to strengthen the evidence base in real-world trauma settings.
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References
1 Eli, I., Lerner, D. P., & Ghogawala, Z. (2021). Acute traumatic spinal cord injury. Neurologic Clinics, 39(2), 471–488. https://doi.org/10.1016/j.ncl.2021.02.004
2 Wiles, M. D., Iliff, H. A., Brooks, K., Da Silva, E. J., Donnellon, M., Gardner, A., et al. (2024). Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society, Association of Anaesthetists, British Society of Orthopaedic Anaesthetists, Intensive Care Society, Neuro Anaesthesia and Critical Care Society, Faculty of Prehospital Care and Royal College of Emergency Medicine. Anaesthesia, 79(8), 856–868. https://doi.org/10.1111/anae.16290
3 Wiles, M. D. (2022). Airway management in patients with suspected or confirmed traumatic spinal cord injury: A narrative review of current evidence. Anaesthesia, 77(10), 1120–1128. https://doi.org/10.1111/anae.15807
4 d'Arville, A., Walker, M., Lacey, J., Lancman, B., & Hendel, S. (2021). Airway management in the adult patient with an unstable cervical spine. Current Opinion in Anaesthesiology, 34(5), 597–602. https://doi.org/10.1097/ACO.0000000000001040
5 Athanassoglou, V., Rogers, A., & Hofmeyr, R. (2024). In-hospital management of the airway in trauma. BJA Education, 24(7), 238–244. https://doi.org/10.1016/j.bjae.2024.03.004
6 Quinones, C., Wilson, J. P., Jr., Kumbhare, D., Guthikonda, B., & Hoang, S. (2024). Clinical assessment and management of acute spinal cord injury. Journal of Clinical Medicine, 13(19), 5719. https://doi.org/10.3390/jcm13195719
7 Laermans, J., Singletary, E. M., Macneil, F., Williamson, F., D’aes, T., Cimpoesu, D. C., et al. (2025). Spinal motion restriction for possible traumatic cervical spine injury: A scoping review. Cureus, 17(5), e84393. https://doi.org/10.7759/cureus.84393
8 Eugene, V., Hutzler, J., Kempema, J., Bradford, J., & Brown, C. V. R. (2024). The difficult airway in trauma: What you need to know. Journal of Trauma and Acute Care Surgery, 97(5), 661–669. https://doi.org/10.1097/TA.0000000000004402
9 Mubashir, T., Tahir, M., Mangi, M. A., Sahito, A., Das, S., Murad, M. H., et al. (2021). Early versus late tracheostomy in patients with acute traumatic spinal cord injury: A systematic review and meta-analysis. Journal of Intensive Care Medicine, 36(3), 346–355. https://doi.org/10.1177/0885066620962113
10 Foran, S. J., Taran, S., Singh, J. M., Kutsogiannis, D. J., & McCredie, V. A. (2022). Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis. Journal of Trauma and Acute Care Surgery, 92(1), 223–231. https://doi.org/10.1097/TA.0000000000003364
11 Sun, D., Liu, K., Jian, Y., Zhang, Z., & Zhao, H. (2023). Tracheostomy in traumatic cervical spinal cord injury: Early versus late tracheostomy. Clinical Neurology and Neurosurgery, 224, 107577. https://doi.org/10.1016/j.clineuro.2022.107577
12 Jian, Y., Liu, K., Sun, D., Zhang, Z., & Zhao, H. (2023). The dose-response relationship between age and tracheostomy in patients with traumatic cervical spinal cord injury: A restricted cubic spline function analysis. World Neurosurgery, 170, e380–e386. https://doi.org/10.1016/j.wneu.2022.11.024
13 Hayashi, T., Matsumoto, Y., Hirayama, S., Murakami, M., Wada, F., Mori, E., et al. (2023). Incidence and risk factors of pneumonia following acute traumatic cervical spinal cord injury. Archives of Physical Medicine and Rehabilitation, 104(8), 1441–1449. https://doi.org/10.1016/j.apmr.2022.11.015
14 Onders, R. P., Khansarinia, S., Ingvarsson, P. E., Road, J., Yee, J., Dunkin, B., et al. (2022). Diaphragm pacing in spinal cord injury can significantly decrease mechanical ventilation in multicenter prospective evaluation. Artificial Organs, 46(10), 1980–1987. https://doi.org/10.1111/aor.14221
15 Onders, R. P., Rose, E. A., Anderson, C., Yee, J. S., Road, J. D., Arishita, G., et al. (2023). Observational study of early diaphragm pacing in cervical spinal cord injured patients to decrease mechanical ventilation during the COVID-19 pandemic. Surgery, 173(3), 870–875. https://doi.org/10.1016/j.surg.2022.06.050
16 Zhang, R., Xu, X., Chen, H., Beck, J., Sinderby, C., Qiu, H., et al. (2023). Predicting extubation in patients with traumatic cervical spinal cord injury using the diaphragm electrical activity during a single maximal maneuver. Annals of Intensive Care, 13(1), 122. https://doi.org/10.1186/s13613-023-01217-7
17 Maremanda, K. R., Jayaram, K., & Durga, P. (2023). Comparison of intubation conditions between Airtraq, McGrath video laryngoscopes, and Macintosh under conditions of simulated trauma airway and rapid sequence induction intubation. Journal of Emergency Medicine, 64(3), 271–281. https://doi.org/10.1016/j.jemermed.2022.12.014
18 Kim, M. H., Kim, J. Y., Lee, J. S., Jo, A., & Kim, D. H. (2023). A novel technique of handling the blade for videolaryngoscopy intubation in patients with a semi-rigid neck collar: A prospective randomized controlled trial. Korean Journal of Anesthesiology, 76(5), 451–460. https://doi.org/10.4097/kja.22733
19 Kumari, A., Choudhuri, P., & Agrawal, N. (2023). A comparative study of the C-MAC D-blade videolaryngoscope and McCoy laryngoscope for oro-tracheal intubation with manual in-line stabilization of neck in patients undergoing cervical spine surgery. Journal of Anaesthesiology Clinical Pharmacology, 39(3), 435–443. https://doi.org/10.4103/joacp.joacp_471_21
20 Guo, N., Yang, F., Chen, W., Wang, X., Li, Y., & Chen, J. (2024). Comparison of outcomes between video laryngoscopy and flexible fiberoptic bronchoscopy for endotracheal intubation in adults with cervical neck immobilization: A systematic review and meta-analysis of randomized controlled trials. PLoS ONE, 19(10), e0313280. https://doi.org/10.1371/journal.pone.0313280
21 Shin, K. W., Lee, S. P., Kim, T., Choi, S., Kim, Y. J., Park, H. P., et al. (2024). Channelled versus nonchannelled Macintosh videolaryngoscope blades in patients with a cervical collar: A randomized controlled noninferiority trial. Canadian Journal of Anesthesia, 71(9), 1261–1271. https://doi.org/10.1007/s12630-024-02769-3
22 Sigaut, S., Roine, P., Moyer, J. D., Cipriani, F., De La Jonquire, C., Rousseau, M. A., et al. (2024). Evolution of airway management in patients with unstable cervical spine trauma: A retrospective cohort study. Canadian Journal of Anesthesia, 71(4), 553–554. https://doi.org/10.1007/s12630-024-02694-5
23 Essa, A., Shakil, H., Malhotra, A. K., Byrne, J. P., Badhiwala, J., Yuan, E. Y., et al. (2024). Quantifying the association between surgical spine approach and tracheostomy timing after traumatic cervical spinal cord injury. Neurosurgery, 95(3), 408–417. https://doi.org/10.1227/NEU.0000000000002892
24 Jo, W. Y., Choi, J. H., Kim, J., Shin, K. W., Choi, S., Park, H. P., et al. (2025). Cervical spine motion during videolaryngoscopic intubation using a Macintosh-style blade with and without the anterior piece of a cervical collar: A randomized controlled trial. Canadian Journal of Anesthesia, 72(1), 142–151. https://doi.org/10.1007/s12630-024-02849-4
25 Xie, Y., Zhao, W., Peng, R., Zhang, L., Jia, Y., Yang, M., et al. (2025). The influencing factors for tracheostomy decannulation after traumatic cervical spinal cord injury: A retrospective study. Spinal Cord, 63(1), 43–48. https://doi.org/10.1038/s41393-024-01048-8
26 Meißner, I., Dietmann, S., Hüller, G., Mach, O., Vogel, M., Ehret, M., et al. (2025). Risk factors for dysphagia after traumatic cervical spinal cord injury: A retrospective study. Archives of Physical Medicine and Rehabilitation, 106(8), 1189–1197. https://doi.org/10.1016/j.apmr.2024.12.014
27 Essa, A., Shakil, H., Malhotra, A. K., Nathens, A. B., Badhiwala, J., Yuan, E. Y., et al. (2025). Optimal tracheostomy timing after traumatic complete spinal cord injury: A comparative analysis of ultraearly, early, and delayed practice. Neurosurgery, 97(3), 569–579. https://doi.org/10.1227/NEU.0000000000003430
28 Zameni, N., Reddy, K., Singh, J. M., Taran, S., & McCredie, V. A. (2025). The impact of tracheostomy timing on the outcomes of patients with acute traumatic spinal cord injury: A systematic review and meta-analysis. Respiratory Medicine, 240, 108018. https://doi.org/10.1016/j.rmed.2025.108018
