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In Response to A New Orthotic Device for Maintaining Neck Flexion Following Tracheal…

We thank Drs. Ross and Postma for their letter regarding our recent publication and their effort to bring attention to a potential risk of cervical myelopathy from extreme flexion of the neck for which they cite several case reports dating from 1982 to 2001. First, we would like to state that none of the patients in our series developed any complications related to the orthotic. We must also highlight that in each of the reports cited, a chin to chest suture was used and there were additional factors, including decreased sensorium, trauma, cardiovascular instability, or preexisting spine pathology, which likely contributed to the devastating complications described. None of these were found in our patients who were all extubated at the conclusion of the surgery, were not sedated, and were ambulated on postoperative day 1 because their neck was well supported by the orthosis. Drs. Ross and Postma state that even short-term flexion may reduce spinal cord electrical potential but their cited reference notes that electrophysiological changes attributed to spinal cord compression on anesthetized patients were found in only 7 of 145 patients (4.5%). A large anterior compression component, and a large kyphotic angle in neck flexion at the most compressed level were the primary risk factors identified on logistic regression analysis. None of the patients in our series had underlying cervical spine disease. We agree with Schweiger et al. that laryngotracheal resection can be performed safely without a guardian stitch, however, their paper reports that they used “a head cradle which maintained neck flexion for 3 days... followed by an additional pillow at night time.” This necessitates patients to be in the horizontal position as shown in their figures and consequently does not allow for early mobilization, which is critical to decrease postoperative complications. In addition, “the patients were instructed to avoid hyperextension of the neck during their hospital stay,” which we find challenging to monitor or enforce. We design the custom orthosis with the neck in flexion between 35 and 45 degrees and are guided by patient feedback during the process. Postoperatively, patients readily reported any symptoms so the orthosis could be adjusted accordingly. Surgeons do need to use caution when placing patients into neck flexion if they are sedated or anesthetized as is often done in children. Newer technologies such as dynamic magnetic resonance imaging may be helpful in preoperatively guiding surgeons as to the optimal flexion in this group.