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1. A short neck and fused cervical vertebrae may contribute to difficulties in tracheal intubation.

2. In some patients with upper cervical spine abnormalities, hypermobility may be associated with neurological complications (Pizzutillo et al 1994, Baba et al 1995). By contrast, decreased motion of the lower cervical spine predisposed to degenerative disease. If cervical instability is present, there is a risk of spinal cord injury. Quadriplegia has been reported after minor trauma (Elster 1984). In one patient, paraesthesia and weakness occurred on neck extension (Hall et al 1990). Magnetic resonance imaging of the spinal canal undertaken in 20 children showed stenoses of 9 mm or less in 25% of patients (Ritterbusch et al 1991), and subluxation of

5 mm or greater in 25%. Several children had spinal cord abnormalities in addition.

3. Sleep apnoea from craniocervical compression may be misdiagnosed as being secondary to tonsillar enlargement (Rosen et al 1993).A child underwent adenotonsillectomy for severe sleep apnoea. Polysomnography 6 days later showed no improvement and, in view of the presence of neurological signs, tracheostomy was planned. However, before this could be undertaken, the child had a respiratory arrest during sleep, and autopsy showed syringobulbomyelia and displacement of the odontoid process against the medulla and upper cervical cord. In a second child with similar symptoms,Arnold—Chiari malformation was detected, by chance before tonsillectomy, and subsequent suboccipital craniectomy resulted in improvement in sleep apnoea.

4. The trachea may be short (15 or fewer rings compared with the normal 17). This increases the risk of accidental bronchial intubation (Wells et al 1989).

5. Kyphoscoliosis may reduce respiratory reserve.

6. A single case of muscle rigidity and rhabdomyolysis after halothane induction followed by suxamethonium has been reported, in which the CK increased to 20 470 iu l-1 (Khalil et al 1999).The significance of this is unknown.

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