Ankylosing spondylitis (AS) is defined as an inflammatory arthritis of the spine, always involving the sacroiliac joints. Cervical column and atlantooccipital articulation mobility are reduced, and in severe cases, the cervical vertebrae become fixed in a flexed position. This portion of the spine is also the most susceptible to fracture, particularly in hyperextension, an event that could lead to damage to the cervical spinal cord during maneuvers to manage the airway. Clinical judgment is critical regarding the timing and selection of the method for airway intervention. In our case of AS with fixed flexion deformity of the thoracic and thoracolumbar spine, supine position and head extension were not possible. We present an instance of successful use of a flexible fiberoptic intubation with light sedation and local block. A 48-year-old female was scheduled for right salpingo-oophorectomy because of ovarian cyst. She had been suffering from extensive AS, with the cervical spine markedly fixed in anterior flexion. Mallampati score was 3, and she could not open her mouth widely (20 mm when fully open) because of ankylosis of the jaw. We used a fiberoptic tracheal intubation for anesthesia in this awake patient, with remifentanil infusion and local mucosal anesthesia. The whole procedure was uneventful and smooth. In conclusion, flexible fiberoptic nasotracheal intubation in patients with severe AS is a safe alternative for successful airway management.
Keywords: Ankylosing spondylitis, difficult intubation, fiberoptic nasotracheal intubation