We thank Drs. Hindman and Dexter and Dr. Cometa  for their interest in our image in clinical medicine relaying a cervical spine injury secondary to videolaryngoscopy. 

The main purpose of this image is educative, highlighting airway management in patients with ankylosing spondylitis as well as limits of the use of videolaryngoscopy. In the last decade, the use of videolaryngoscopy has been generalized to operating rooms and intensive care units worldwide. Its use has been widely recommended for use in difficult airway management, and it is now the first choice of most anesthesiologists, due to its accessibility.

We agree with Drs. Hindman and Dexter that although videolaryngoscopy improves visualization of the glottis, it may not facilitate catheterization of the trachea and may cause the operator to apply more force than intended. Moreover, it is important to note that even manual inline stabilization does not preclude the motion of an unstable cervical segment.

Because of this, all anesthesiologists should train and be comfortable with fiberoptic intubation, which may be more appropriate in some cases, as underscored by Dr. Cometa’s comments. Training for fiberoptic intubation should begin during residency but should be pursued and developed further in each anesthesiologist’s practice. Indeed, an initial training that is not followed by regular use of fiberoptic intubation could lead an anesthesiologist to inappropriately choose videolaryngoscopy if that is a more familiar technique. We believe that certain situations—such as those occurring in patients with ankylosing spondylitis—benefit from a choice in intubation technique, determined during the preanesthesia evaluation and with a formal indication discussed and agreed upon by the full anesthesiology team. As highlighted by Dr. Cometa, severe complications would not occur as a consequence of a single operator’s preference, or based upon the availability and ease of use of videolaryngoscopy compared to fiberoptic intubation.  In conclusion, in selected cases of spine fragility (e.g., in patients with ankylosing spondylitis), the ready availability and ease of use of videolaryngoscopy may actually be a poisoned gift.