An 84-yr-old woman with a history of ankylosing spondylitis was scheduled for lymph node biopsy under general anesthesia. Preoperative anesthestic assessment mentioned a potential difficult intubation owing to a rigid cervical flexion deformity with limited range of motion. The patient was alert with a normal neurologic exam. Preoperative imaging showed evidence of bamboo spine without any underlying fracture (panel A). Both videolaryngoscopy and fiberoptic intubation were considered for airway management.

Videolaryngoscopy was preferred because the operator was more familiar with this technique. The videolaryngoscope was inserted using an in-line traction. The operator did not succeed in introducing the tracheal tube because of cervical rigidity and difficulties in exposing the epiglottis. Using a bougie, the patient was intubated after two attempts.

During the postoperative course, hypotension and acute respiratory failure occurred. Neurologic exam showed a left hemiparesis. A...

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