Difficult Airway Management in Patients with Ankylosing Spondylitis Undergoing General Anaesthesia

Vimitha F et al | DOI: 10.65188/nurexus.1093

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Journal of MedVerse Research & Practice

ISSN: 3107-4278

Difficult Airway Management in Patients with Ankylosing Spondylitis

Undergoing General Anaesthesia

F Vimitha

, M Milano

Postgraduate, Professor

Department of Anaesthesia, Duke-NUS Medical School, Singapore

Email ID: vimithafagu@gmail.Com

Submission Date: 13.06.2026

Accepted Date:20.07.2026

Published Date: 31.07.2026

DOI: 10.65188/nurexus.1093

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Airway management in patients with ankylosing spondylitis (AS) is a major anesthetic challenge due

to progressive cervical spine rigidity, limited neck extension, restricted mouth opening, and altered airway anatomy.

These changes increase the risk of difficult intubation, failed airway management, and perioperative complications.

Careful preoperative airway assessment and the use of advanced airway techniques are essential to ensure patient

safety during general anesthesia.

Case Presentation: We present a case series of five patients with ankylosing spondylitis who underwent various

surgical procedures under general anesthesia and were identified preoperatively as having anticipated difficult

airways. Airway management strategies were individualized according to the severity of cervical spine involvement

and airway assessment findings. Awake fibreoptic intubation, videolaryngoscopy, intubating laryngeal mask airway-

assisted intubation, and fibreoptic-guided rescue techniques were successfully employed. Conventional direct

laryngoscopy was unsuccessful in selected cases because of restricted cervical mobility and poor glottic visualization.

All patients were intubated successfully without major airway trauma, neurological injury, or significant hypoxemia.

Surgical procedures were completed uneventfully, and all patients had favorable postoperative outcomes with

complete recovery.

Conclusion: Patients with ankylosing spondylitis undergoing general anesthesia require meticulous preoperative

planning, comprehensive airway assessment, and individualized airway management strategies. Advanced airway

devices, particularly awake fibreoptic intubation and videolaryngoscopy, play a crucial role in securing the airway

while minimizing cervical spine movement. This case series highlights the importance of early anticipation of

difficult airway, adherence to difficult airway guidelines, and the availability of alternative airway devices to optimize

perioperative safety and improve patient outcomes.

Keywords: Ankylosing spondylitis; Difficult airway; General anesthesia; Awake fibreoptic intubation;

Videolaryngoscopy; Airway management; Cervical spine rigidity; Difficult tracheal intubation; Perioperative care;

Case series.

Introduction

Ankylosing spondylitis (AS) is a chronic, progressive inflammatory disorder belonging to the group of

seronegative spondyloarthropathies. It primarily affects the axial skeleton, particularly the sacroiliac joints

and vertebral column, resulting in progressive spinal stiffness, kyphotic deformity, and restricted mobility.

As the disease advances, ossification of the spinal ligaments, intervertebral discs, and facet joints leads to

fusion of the vertebral column, commonly referred to as a "bamboo spine." Extra-articular manifestations

CASE SERIES

ARTICLE

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involving the eyes, cardiovascular system, respiratory system, and peripheral joints may also occur, further

increasing perioperative risks [1,2]. Airway management in patients with ankylosing spondylitis presents a

significant challenge for anesthesiologists because of restricted cervical spine movement,

temporomandibular joint involvement, reduced mouth opening, fixed flexion deformity of the neck, and

decreased atlanto-occipital extension [2,3]. These anatomical alterations make conventional direct

laryngoscopy difficult or impossible and increase the risk of failed intubation, airway trauma, cervical spine

injury, neurological complications, and hypoxemia [3,4]. Furthermore, excessive manipulation of the rigid

cervical spine may precipitate vertebral fractures or spinal cord injury, particularly in patients with

advanced disease and osteoporosis [4].

Preoperative airway assessment plays a pivotal role in anticipating airway difficulties. Clinical evaluation

should include assessment of mouth opening, Mallampati classification, thyromental distance, sternomental

distance, neck circumference, cervical spine mobility, and previous history of difficult intubation [5].

Radiological evaluation of the cervical spine may provide additional information regarding spinal deformity

and instability. According to the American Society of Anesthesiologists (ASA) Difficult Airway

Guidelines, careful planning, preparation of alternative airway devices, and availability of experienced

personnel are essential for ensuring patient safety in anticipated difficult airway situations [5,6].

Awake fibreoptic intubation is widely regarded as the gold standard for airway management in patients

with severe ankylosing spondylitis because it allows maintenance of spontaneous ventilation while

minimizing cervical spine movement [6,7]. However, advances in airway management have expanded the

role of videolaryngoscopes, optical stylets, intubating laryngeal mask airways, flexible video

bronchoscopes, and combined airway techniques [7]. The choice of airway device depends on the severity

of spinal deformity, mouth opening, operator expertise, and availability of equipment. A well-formulated

difficult airway strategy, including readiness for emergency front-of-neck airway access, is essential to

reduce perioperative morbidity [6,7]. Patients with ankylosing spondylitis also present additional anesthetic

considerations beyond airway management. Restrictive lung disease resulting from costovertebral joint

involvement may impair pulmonary function and reduce respiratory reserve [2,8]. Cardiovascular

manifestations, including conduction abnormalities and aortic valve disease, may influence anesthetic

management [1,8]. Neuraxial anesthesia is frequently challenging because of ossification of spinal

ligaments and narrowing of the interspinous spaces, often necessitating general anesthesia even for

procedures where regional techniques would otherwise be preferred [8,9].

Despite advances in airway devices and anesthetic techniques, airway management in ankylosing

spondylitis remains a major perioperative challenge [6,9]. Careful preoperative planning, individualized

airway management strategies, and the availability of multiple rescue devices are crucial for achieving

successful outcomes. This case series describes five patients with ankylosing spondylitis who underwent

surgery under general anesthesia and required different airway management approaches based on their

anatomical characteristics and airway difficulty. The report highlights practical challenges, successful

airway strategies, and key lessons that may assist anesthesiologists in managing similar high-risk patients

safely [7,9].

Case Series

Case 1

A 45-year-old man with a 15-year history of ankylosing spondylitis was scheduled for elective total hip

replacement under general anesthesia. Preoperative airway assessment revealed a mouth opening of 3 cm,

Mallampati Grade IV, thyromental distance of 5 cm, and severely restricted cervical spine movement with

a fixed flexion deformity. Anticipating a difficult airway, awake fibreoptic nasotracheal intubation was

Vimitha F et al | DOI: 10.65188/nurexus.1093

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planned under topical airway anesthesia with light sedation. The trachea was successfully intubated on the

first attempt while maintaining spontaneous ventilation. General anesthesia proceeded uneventfully, and

the patient was extubated after complete recovery without airway-related complications.

Case 2

A 58-year-old woman with advanced ankylosing spondylitis underwent laparoscopic cholecystectomy. She

presented with severe cervical rigidity, reduced mouth opening (2.8 cm), and a previous history of difficult

intubation. Direct laryngoscopy provided a Cormack-Lehane Grade IV view. A videolaryngoscope was

immediately used, providing an improved glottic view (Grade II), allowing successful oral endotracheal

intubation with a bougie on the second attempt. Intraoperative and postoperative periods were uneventful,

and the patient was discharged on the third postoperative day.

Case 3

A 52-year-old man with ankylosing spondylitis and marked thoracolumbar kyphosis was posted for

inguinal hernia repair. Airway examination showed Mallampati Grade III, limited neck extension, and

reduced sternomental distance. An awake oral fibreoptic intubation was planned due to anticipated cervical

instability. Topical lignocaine anesthesia and dexmedetomidine infusion facilitated successful fibreoptic

intubation on the first attempt. The surgery was completed without complications, and extubation was

performed after ensuring complete neuromuscular recovery. The patient had an uneventful postoperative

course.

Case 4

A 60-year-old male with long-standing ankylosing spondylitis underwent emergency exploratory

laparotomy for intestinal obstruction. Airway assessment demonstrated mouth opening of only 2 cm, fixed

cervical flexion deformity, and inability to align the oral, pharyngeal, and laryngeal axes. Following failed

direct laryngoscopy, an intubating laryngeal mask airway (ILMA) was inserted, and endotracheal intubation

was successfully achieved through the device using a flexible bronchoscope. The patient required overnight

intensive care monitoring because of prolonged surgery but was extubated successfully the following

morning without neurological deficits.

Case 5

A 49-year-old woman with ankylosing spondylitis and severe cervical spine ankylosis was scheduled for

abdominal hysterectomy. Preoperative imaging demonstrated complete fusion of the cervical vertebrae with

minimal neck mobility. Considering the anticipated difficult airway, awake videolaryngoscopy was

attempted but failed due to poor glottic visualization. Fibreoptic bronchoscopy was subsequently performed

through an oral airway, resulting in successful endotracheal intubation while maintaining spontaneous

respiration. General anesthesia was completed safely, and the patient recovered without airway trauma or

postoperative respiratory complications.

Among the five patients, three required awake fibreoptic intubation as the primary airway technique, one

was successfully managed with videolaryngoscopy assisted by a bougie, and one required an intubating

laryngeal mask airway combined with fibreoptic bronchoscopy after failed direct laryngoscopy. No patient

developed hypoxemia, cervical spine injury, neurological complications, or failed airway. All patients were

successfully extubated after complete neuromuscular recovery and discharged without long-term airway-

related sequelae.

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Result

Variable

Case 1

Case 2

Case 3

Case 4

Case 5

Age (years)

Sex

Male

Female

Male

Female

Duration of

Ankylosing

Spondylitis

15 years

18 years

12 years

20 years

16 years

Scheduled

Surgery

Total Hip

Replacemen

Laparoscopic

Cholecystectomy

Inguinal

Hernia

Repair

Exploratory

Laparotomy

Abdominal

Hysterectomy

ASA Physical

Status

III

Mouth

Opening

3 cm

2.8 cm

3.2 cm

2 cm

2.5 cm

Mallampati

Grade

III

Cervical Spine

Mobility

Severely

Restricted

Fixed Flexion

Deformity

Restricted

Severely

Restricted

Complete Cervical

Ankylosis

Difficult

Airway

Anticipated

Yes

Initial Airway

Technique

Awake

Fibreoptic

Intubation

Direct

Laryngoscopy

Awake

Fibreoptic

Intubation

Direct

Laryngoscopy

Awake

Videolaryngoscop

Final

Successful

Technique

Awake

Fibreoptic

Intubation

Videolaryngoscop

e + Bougie

Awake

Fibreoptic

Intubation

ILMA +

Fibreoptic

Bronchoscop

Fibreoptic

Bronchoscopy

Number of

Intubation

Attempts

Cormack-

Lehane Grade

(DL)

Not

Attempted

Not

Attempted

Lowest SpO₂

(%)

Intraoperativ

Complications

None

Postoperative

ICU

Admission

Yes

Extubation

Uneventful

Uneventfu

Next Day

Uneventful

Hospital Stay

5 days

3 days

4 days

6 days

5 days

Outcome

Complete

Recovery

Complete

Recovery

Complete

Recovery

Complete

Recovery

Complete

Recovery

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Discussion

Ankylosing spondylitis (AS) is a chronic inflammatory disease characterized by progressive ossification

of the axial skeleton, resulting in severe restriction of cervical spine mobility and making airway

management one of the greatest challenges for anesthesiologists [9,10]. Miller's Anesthesia emphasized

that patients with advanced AS frequently present with limited neck extension, temporomandibular joint

involvement, and fixed cervical deformity, making conventional direct laryngoscopy difficult and

increasing the risk of airway trauma and neurological injury [9]. Similarly, Stoelting's Anesthesia and

Co-Existing Disease highlighted that excessive cervical spine manipulation during intubation may

precipitate vertebral fractures or spinal cord injury in patients with advanced ankylosing spondylitis,

underscoring the importance of meticulous preoperative planning and airway assessment [10].

In the present case series, all five patients demonstrated anticipated difficult airway features, including

reduced cervical spine mobility, restricted mouth opening, high Mallampati grades, and fixed flexion

deformity of the neck. These findings are comparable to those reported by Lakhotia et al., who described

cervical spine ankylosis, reduced atlanto-occipital extension, and temporomandibular joint involvement

as major predictors of difficult airway management in ankylosing spondylitis [11]. Trambadia et al. also

emphasized that combining multiple airway assessment tools improves the prediction of difficult

intubation compared with reliance on a single screening test [12]. Thorough preoperative airway

evaluation in our patients enabled individualized airway planning and appropriate selection of airway

devices. Awake fibreoptic intubation continues to be regarded as the gold standard for managing

anticipated difficult airways in severe ankylosing spondylitis because spontaneous ventilation is

maintained while minimizing cervical spine movement. The Difficult Airway Society (DAS) guidelines

published by Ahmad et al. recommended awake tracheal intubation whenever difficult airway

management is anticipated and loss of airway control could have catastrophic consequences [13].

Likewise, Yang et al. demonstrated successful awake fibreoptic intubation in patients with severe

ankylosing spondylitis undergoing thoracic surgery, reporting high success rates with minimal airway

complications [14]. In our series, awake fibreoptic intubation was successfully performed in patients

with severe cervical deformity, allowing safe airway control without neurological deterioration.

Recent advances in video laryngoscopy have expanded the options available for airway management in

ankylosing spondylitis. Apfelbaum et al., in the 2022 American Society of Anaesthesiologists (ASA)

Difficult Airway Guidelines, recommended video laryngoscopy as an effective alternative when direct

laryngoscopy is anticipated to be difficult [15]. Chen et al. described a double-visualization intubation

strategy combining video laryngoscopy with fibreoptic bronchoscopy, while Limalvin and Kurniawan

reported successful video laryngoscope-guided intubation in a patient with ankylosing spondylitis and

severe cervical rigidity [16,17]. In the present series, videolaryngoscopy successfully facilitated tracheal

intubation in one patient after failed direct laryngoscopy, highlighting its usefulness as an alternative

airway technique in appropriately selected patients. The successful outcomes observed in this case series

can be attributed to comprehensive preoperative airway assessment, individualized airway planning,

availability of advanced airway devices, and strict adherence to established difficult airway algorithms.

None of the patients experienced failed intubation, major airway trauma, neurological injury, or

postoperative respiratory complications. Carvalho et al. similarly reported successful airway

management in a conscious patient with ankylosing spondylitis using a carefully planned awake

intubation technique, emphasizing that meticulous preparation and experienced personnel remain the

key determinants of successful airway management in these high-risk patients [18].

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Summary

Difficult airway management remains one of the most significant anesthetic challenges in patients with

ankylosing spondylitis because of progressive cervical spine rigidity, restricted mouth opening, limited

neck mobility, and altered airway anatomy. These anatomical changes increase the risk of failed

intubation, airway trauma, hypoxemia, and neurological injury if not anticipated and managed

appropriately. The five cases presented in this series demonstrate the importance of meticulous

preoperative airway assessment and individualized airway management strategies based on the severity

of spinal involvement and predicted airway difficulty.

A variety of advanced airway techniques, including awake fibreoptic intubation, videolaryngoscopy,

intubating laryngeal mask airway-assisted intubation, and fibreoptic bronchoscopy, were successfully

employed to secure the airway while minimizing cervical spine manipulation. Careful preparation,

availability of alternative airway devices, and adherence to established difficult airway guidelines

contributed to successful intubation and favorable perioperative outcomes in all patients. None of the

patients experienced airway-related complications, neurological deficits, or failed intubation, and all

recovered without long-term sequelae. This case series emphasizes that successful airway management

in patients with ankylosing spondylitis relies on comprehensive preoperative evaluation, appropriate

selection of airway devices, and the expertise of the anesthesiology team. Increased awareness of the

unique airway challenges associated with this condition and timely implementation of advanced airway

management techniques can significantly improve patient safety and reduce perioperative morbidity.

Conclusion

Airway management in patients with ankylosing spondylitis undergoing general anesthesia remains a

significant challenge because of progressive cervical spine rigidity, limited mouth opening, and restricted

neck mobility, all of which increase the risk of difficult intubation and airway-related complications. A

comprehensive preoperative airway assessment, meticulous planning, and anticipation of potential

difficulties are essential for safe anesthetic management. The cases presented in this series demonstrate that

individualized airway strategies, including awake fibreoptic intubation, videolaryngoscopy, intubating

laryngeal mask airway, and fibreoptic-assisted techniques, can achieve successful airway control with

favorable outcomes while minimizing cervical spine manipulation. Adherence to established difficult

airway guidelines, the availability of advanced airway equipment, and the expertise of the anesthesiology

team are key to preventing complications and ensuring patient safety. Increased awareness of the unique

airway challenges associated with ankylosing spondylitis and the adoption of appropriate airway

management techniques can significantly improve perioperative outcomes and reduce morbidity in this

high-risk patient population.

Declaration

Consent: Written informed consent was obtained from the patient. All patient information has been

anonymized to maintain confidentiality.

Conflict of Interest: The authors declare that they have no competing interests or conflicts of interest

related to this work.

Funding: Nil

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