Abstract
Background: Airway management in advanced Ankylosing Spondylitis (AS) is highly challenging in emergency critical care and anaesthesiology. Progressive spinal ossification causes rigid cervical deformities that limit alignment for direct or video laryngoscopy 1.2. In neurocritical emergencies, acute deterioration and reduced patient cooperation leave little margin for error.
Case Presentation: An older man with a 45-year history of untreated advanced AS presented with altered sensorium and a Glasgow Coma Scale score of 6. CT imaging revealed a massive right gangliocapsular haemorrhage with intraventricular extension, midline shift and mass effect. Airway assessment showed extreme fixed cervical flexion, making standard orotracheal intubation impossible. In the supine position, his head remained suspended approximately 1.5 feet above the operating table due to the deformity.
Intervention: Anticipating a “cannot intubate” scenario, the team performed an emergency open surgical tracheostomy under local anaesthesia with mild sedation while maintaining the patient’s fixed position. Positioning was modified using pillow support to preserve cervical stability. A higher tracheal entry point below the cricoid cartilage was selected to avoid tube impingement against the sternum. A size 8 mm cuffed tracheostomy tube was successfully inserted within 12 minutes, improving oxygen saturation from 93% to 98%.
Conclusion: In patients with advanced AS and severe cervical deformity, early transition to a customised surgical tracheostomy may be lifesaving when translaryngeal intubation is not feasible. Prompt recognition of anatomical limitations and avoidance of cervical manipulation are critical for successful airway management.