1. Prevent secondary spinal cord injury
2. Avoid worsening a difficult neurological baseline
3. Protect the airway with minimal cervical movement
4. Avoid hypotension, hypoxemia, hypercarbia, anemia, and hypoglycemia/hyperglycemia
5. Plan for postoperative respiratory, neurological, and airway monitoring

1. Key issues in this patient

Neurological disease

• Existing cervical cord dysfunction means even small reductions in cord perfusion or excessive neck movement may lead to further weakness.
• The left-hand power of 2/5 and sensory symptoms must be precisely documented preoperatively.
• Motor neuropathy may cause respiratory muscle weakness, bulbar dysfunction, autonomic dysfunction, altered response to neuromuscular blockers, and higher susceptibility to positioning-related nerve injury.
• If the weakness is progressing, newly asymmetric, associated with bladder/bowel deterioration, or accompanied by respiratory/bulbar symptoms, urgent neurological and surgical reassessment is necessary before anesthesia.

Cervical spine mass

• Anterior cervical approach: airway retraction, postoperative pharyngeal or laryngeal edema, recurrent laryngeal nerve dysfunction, hematoma, and dysphagia are major concerns.
• Posterior/prone approach: prone-positioning injuries, venous air embolism in selected positions, blood loss, pressure injury, and difficulty accessing the airway once positioned are concerns.

Diabetes and hypertension

2. Preoperative assessment and optimization

A. Multidisciplinary planning

• Spine/neurosurgeon
• Neurologist
• Anesthesia team experienced in cervical spine surgery
• Neurophysiology team if SSEP/MEP monitoring is planned
• ICU/HDU team if severe myelopathy, major respiratory weakness, prolonged surgery, or postoperative ventilatory concern is anticipated

• Exact cervical level and degree of cord compression
• Stability of cervical spine
• Anterior versus posterior position
• Need for neck flexion/extension
• Expected duration and blood loss
• Whether MEP, SSEP, EMG, or wake-up testing is required
• Plan if neuromonitoring deteriorates
• Expected postoperative airway swelling and suitability for immediate extubation

B. Document the baseline neurological state

• Motor power in all limbs, especially left hand and proximal/distal groups
• Sensory loss, paresthesia, pain distribution
• Tone, reflexes, plantar response if possible
• Gait and standing capacity
• Bowel and bladder function
• Cranial-nerve/bulbar symptoms: dysphagia, weak cough, dysarthria, aspiration
• Respiratory symptoms: orthopnea, weak cough, nocturnal dyspnea
• Presence of autonomic symptoms: postural dizziness, resting tachycardia, sweating abnormality, bowel dysmotility

C. Airway evaluation

• Mouth opening, Mallampati grade, thyromental distance, dentition
• Neck movement, pain, neurological worsening with movement
• Hoarseness, stridor, dysphagia, previous cervical operation or irradiation
• MRI or CT evidence of retropharyngeal extension, tracheal compression, or distorted anatomy
• Aspiration risk, especially if diabetic gastroparesis or bulbar dysfunction is suspected

Airway plan

• Video laryngoscope
• Flexible bronchoscope
• Intubating stylet/bougie
• Manual in-line stabilization
• Difficult-airway cart
• Surgical airway backup, particularly if anterior neck pathology distorts the airway

D. Respiratory assessment

• Room-air SpO₂
• Chest examination and chest X-ray if indicated
• ABG if hypercapnia, obesity hypoventilation, severe weakness, or respiratory symptoms
• Pulmonary function testing, especially FVC, if there is significant weakness, recurrent chest infection, weak cough, or suspected diaphragmatic involvement
• Negative inspiratory force if neuromuscular respiratory weakness is a concern

E. Cardiovascular and autonomic assessment

• ECG for all.
• Echocardiography if symptoms/signs of cardiac disease, poor functional capacity, or suspected diabetic cardiomyopathy.
• Renal function, electrolytes, hemoglobin, platelets, coagulation profile, blood group and crossmatch.
• Screen for orthostatic hypotension and autonomic instability.
• Continue chronic beta-blockers if prescribed.
• Most antihypertensives may be continued according to local protocol, but ACE inhibitors/ARBs are often withheld on the morning of major surgery when significant induction hypotension is a concern. Make this decision based on local policy and the indication for the drug.

F. Diabetes management

• Check HbA1c, renal function, fasting and perioperative glucose.
• Avoid prolonged fasting and dehydration.
• Withhold oral hypoglycemics according to local policy. SGLT2 inhibitors require advance withholding because of euglycemic ketoacidosis risk.
• Adjust basal insulin rather than stopping insulin completely in insulin-treated diabetes.
• Check capillary glucose before induction and at least every 1-2 hours intraoperatively for a major procedure.
• A practical target is approximately 100-180 mg/dL, avoiding both hypoglycemia and severe hyperglycemia.
• Screen for autonomic neuropathy and gastroparesis, which may increase aspiration and hemodynamic risks.

G. Inform and consent

• New or worsened neurological deficit, including weakness
• Need for awake intubation or difficult airway techniques
• Hemodynamic instability
• Delayed emergence or delayed extubation
• Postoperative ventilation/ICU admission
• Positioning-related nerve or pressure injury
• Need for blood transfusion
• Postoperative airway obstruction, particularly after anterior cervical surgery

3. Choice of anesthesia

General anesthesia is generally preferred

• Surgery involves the cervical spine and cord pathology.
• Pre-existing myelopathy makes interpretation of any postoperative neurological change difficult.
• There may be cord compression, altered CSF dynamics, or an unclear neurological diagnosis.

4. Intraoperative management

A. Monitoring

Standard monitoring

• ECG
• Noninvasive blood pressure initially
• Pulse oximetry
• Capnography
• Temperature
• Urine output for major or long cases
• Quantitative neuromuscular monitoring

Additional monitoring

• Arterial line before induction if severe myelopathy, expected hemodynamic lability, need for strict blood-pressure targets, major blood loss, prone positioning, or MEP monitoring.
• Two large-bore IV lines.
• Central venous access only if necessary for poor access, vasoactive infusions, anticipated major blood loss, or other indication.
• Point-of-care hemoglobin, electrolytes, ABG, and glucose as indicated.

B. Hemodynamic targets: protect cord perfusion

• Maintain MAP near or above the patient's normal baseline.
• A reasonable working target is often MAP 80-90 mmHg, unless contraindicated by cardiac status.
• Treat hypotension promptly with volume when appropriate and vasopressors such as norepinephrine or phenylephrine, selected according to heart rate and cardiac function.
• Avoid anemia, hypoxemia, hypercapnia, severe hypocapnia, and hypothermia.

C. Induction of anesthesia

• Preoxygenation, ideally head-up if tolerated.
• Judicious opioid to blunt sympathetic response without causing hypotension.
• Propofol is common, but reduce dose if frail, hypovolemic, autonomically unstable, or with impaired cardiovascular reserve.
• Etomidate may be considered if cardiovascular instability is anticipated.
• Carefully titrate induction drugs to response.
• Have vasopressor infusion or boluses ready before induction.

Neuromuscular blockade

• Use a non-depolarizing agent, commonly rocuronium or cisatracurium.
• Give the lowest effective dose.
• Use quantitative train-of-four monitoring, ideally at a non-affected site if feasible.
• Expect response to be variable in neuropathy. Do not rely on standard dosing alone.
• If MEP monitoring is planned, usually provide only intubating dose or avoid ongoing paralysis, depending on the neurophysiology protocol.
• Ensure complete reversal before extubation. ASA includes a dedicated neuromuscular blockade monitoring and reversal guideline.

D. Airway and cervical protection

• Maintain neutral neck alignment.
• Avoid excessive extension, flexion, rotation, or traction.
• Use manual in-line stabilization if needed.
• Avoid repeated attempts.
• Confirm tube position securely before turning prone.
• Recheck the tube after final surgical positioning because neck position can alter depth.

• Monitor endotracheal cuff pressure after surgical retractors are placed.
• Reassess cuff pressure periodically to reduce tracheal mucosal injury.
• Anticipate laryngeal edema, recurrent laryngeal nerve injury, and hematoma.

E. Maintenance anesthesia and neuromonitoring

• Establish reliable baseline signals before positioning and incision, ideally before major neck manipulation.
• Use total intravenous anesthesia, typically propofol plus a short-acting opioid infusion such as remifentanil, where appropriate.
• Avoid nitrous oxide.
• Avoid or minimize volatile anesthetics because they suppress evoked potentials. If used, keep them low, commonly no more than about 0.5 MAC depending on the monitoring protocol.
• Avoid continuous neuromuscular blockade when MEP or free-run EMG monitoring is required.
• Maintain stable temperature, oxygenation, PaCO₂, hematocrit, and MAP because each can affect evoked potentials.

If there is an acute MEP/SSEP signal loss

1. Inform surgeon and neurophysiologist immediately.
2. Stop surgical manipulation or traction.
3. Check technical causes: electrodes, cables, stimulation, artifact.
4. Reassess MAP and raise it promptly, commonly to at least 85-90 mmHg or as agreed with surgeon.
5. Correct hypoxia, hypocapnia/hypercapnia, anemia, hypothermia, electrolyte abnormalities.
6. Check anesthetic concentration and recent neuromuscular blocker administration.
7. Consider reversal of a recent positional change or hardware maneuver.
8. Obtain a wake-up assessment if signals do not recover and this is feasible and agreed by the team.

F. Positioning

Posterior/prone surgery

• Confirm secure ETT, IV lines, arterial line, eyes protected, and availability of emergency airway plan.
• Use a coordinated log-roll, keeping the neck neutral.
• Ensure no traction on brachial plexus.
• Keep arms neutral or abducted less than 90 degrees, with elbows padded.
• Pad ulnar nerves, fibular heads, knees, ankles, genitalia, breasts, and all pressure points.
• Avoid direct pressure on the eyes and check eyes periodically.
• Keep abdomen free to minimize venous congestion, blood loss, and ventilatory compromise.
• Avoid excessive cervical flexion, which may obstruct venous drainage, cause tongue/facial edema, or compromise ETT position.
• Recheck all pressure points after final positioning and periodically during a long procedure.

Anterior cervical surgery

• Supine with minimal extension only as required by surgeon.
• Avoid excessive extension in a patient with cervical cord compromise.
• Check ETT depth after neck extension.
• Ensure that the shoulders and arms are padded and not under excessive traction.

G. Blood conservation and temperature

• Crossmatch blood according to expected risk.
• Use cell salvage or tranexamic acid only if indicated by surgical magnitude and institutional policy.
• Monitor hemoglobin during prolonged or bloody surgery.
• Maintain normothermia with forced-air warming and warmed fluids.
• Correct coagulopathy promptly.

5. Emergence and extubation

• Fully awake and following commands
• Complete or near-complete quantitative neuromuscular recovery
• Adequate tidal volume, respiratory rate, cough, and oxygenation
• Hemodynamically stable
• No major new neurological concern
• No concern for severe airway edema, expanding neck swelling, difficult reintubation, or extensive anterior cervical dissection

Reasons to consider delayed extubation and ICU/HDU care

• Prolonged or difficult surgery
• Extensive anterior cervical dissection
• Significant airway edema or difficult intubation
• Major blood loss/resuscitation
• Poor respiratory reserve, hypercapnia, weak cough, bulbar dysfunction
• Persistent weakness beyond baseline
• Need for close serial neurological examination
• Unstable blood pressure or requirement for vasopressor infusion

6. Postoperative management

A. Location

• Severe myelopathy or significant baseline motor deficit
• Respiratory weakness
• Long procedure, major blood loss, or prolonged prone position
• Anterior cervical surgery with edema risk
• Intraoperative neuromonitoring event
• Vasopressor requirement
• Inadequate pain control without excessive opioids

B. Serial neurological assessment

• Consciousness
• Limb power compared with preoperative baseline
• Sensory symptoms
• New weakness or paresthesia
• Bladder function
• Neck pain/swelling
• Respiratory effort and cough

C. Analgesia

• Paracetamol unless contraindicated
• NSAID/COX-2 inhibitor only if surgeon agrees and renal function/bleeding risk allow
• Small, titrated doses of opioid rather than large long-acting doses
• Consider dexmedetomidine or low-dose ketamine in selected patients to reduce opioid requirement, with monitoring for bradycardia/hypotension or delirium as appropriate
• Continue pre-existing neuropathic agents carefully, accounting for sedation and renal function

D. Glucose and blood pressure

• Continue frequent glucose checks until eating reliably.
• Maintain glucose in a reasonable controlled range and promptly treat hypoglycemia.
• Avoid major BP swings.
• Continue cord-perfusion-focused BP targets in the immediate postoperative period if advised by surgeon/neurocritical care team.

E. VTE prevention and rehabilitation

• Mechanical prophylaxis unless contraindicated.
• Pharmacologic thromboprophylaxis timing should be agreed with the spine surgeon because of postoperative epidural/operative-site bleeding risk.
• Early physiotherapy, pressure-area care, and assisted mobilization are important because he already has poor standing and walking ability.

Practical summary for this specific patient

• Preoperative neurological, respiratory, glucose, renal, and cardiovascular optimization.
• Detailed documentation of left-hand power 2/5 and all baseline sensory/motor deficits.
• Arterial line, two reliable IVs, crossmatched blood as indicated.
• Controlled general anesthesia with a cervical-protective airway technique. Consider awake fiberoptic intubation if imaging/examination suggests high instability or severe airway difficulty.
• Avoid succinylcholine due to chronic motor denervation/myelopathy and hyperkalemia risk.
• Use low-dose titrated non-depolarizing relaxant with quantitative monitoring. Avoid further paralysis if MEP/EMG monitoring is needed.
• TIVA if SSEP/MEP monitoring is planned.
• Maintain neutral neck, meticulous prone/supine positioning, and protect all pressure points.
• Prevent hypotension. In significant cervical myelopathy, aim for MAP approximately 80-90 mmHg unless patient-specific factors require another target.
• Strict glucose monitoring and avoidance of hypoxia, hypercarbia, anemia, hypothermia, and hypovolemia.
• Extubate only after complete recovery and satisfactory airway/respiratory assessment. Low threshold for ICU/HDU observation and delayed extubation.
• Immediate postoperative neurological comparison with the documented baseline.