Long case #1 for the Final SOE
Information for the candidate
A 63 year old woman is scheduled for posterior cervical fusion on the elective neurosurgical list, for symptomatic cervical spondylosis.
She has a background of rheumatoid arthritis, hypertension and obstructive sleep apnoea. She has smoked 10 cigarettes a day for over 40 years and does not consume any alcohol.
Her medications include: Omeprazole, amlodipine, salbutamol and ipratropium inhalers, naproxen, atenolol and prednisolone 10mg daily.
On examination she has limited neck movement and reports tingling in her hands when flexing her neck.
Cardiovascular and respiratory examinations are largely unremarkable, however she does have a slight expiratory wheeze.
She has no loose teeth or dentures and has a BMI of 25.
Observations and Investigations
Observations
- HR 52 bpm
- BP 146/86 mmHg
- Respiratory rate 14 /m
- Temperature 36.8°C
Investigations
- Hb 130
- WCC 5.2
- Plt 230
- Na 130
- K 4.4
- Urea 6
- Creatinine 85
- ECG: Sinus bradycardia
Examiner's Questions
Please summarise the case
- This is a 63 year old woman listed for posterior cervical fusion
- She has multiple comorbidities of significance, including rheumatoid arthritis, hypertension and obstructive sleep apnoea, the severity of which is unknown
- She has a long smoking history and possible undiagnosed COPD
- She likely has a difficult airway with limited neck mobility and instability of the cervical spine
- She will need to be proned for the procedure
What further investigations are required?
- Previous anaesthetic history
- A thorough cardiovascular and respiratory history and examination to assess for ischaemic heart disease and obstructive lung disease
- Formal assessment of her obstructive sleep apnoea to assess severity
- Neurological examination to establish her current symptoms and neurological deficits
What features might you expect to see on lateral cervical spine xray?
- Disruption of vertebral canal lines, either anterior or posterior, or both
- Anterior subluxation of the atlas, demonstrated by increased distance between odontoid process of the axis and arch of the atlas
- Intervertebral disc space reduction