From Nitrous to Nerves: MTHFR, CRPS & Cervical Collars Unpacked | Office Hours

[00:24] Dr. Linda Bluestein: And I hear from patients all the time, "Well, but I've been tested for inflammation and the tests were negative." Usually, if somebody has neuroinflammation, they might be having a lot of pain. They might be having maybe some psychiatric symptoms, insomnia, all kinds of things going on, but we don't really have good ways to test for neuroinflammation yet.
[00:58] Welcome back, every bendy body, to the Bendy Bodies Podcast. I'm your host, Dr. Linda Bluestein, the Hypermobility MD, a Mayo Clinic-trained expert in Ehlers-Danlos syndromes dedicated to helping you navigate connective tissue disorders and live your best life.
In today's Office Hours episode, I'll be answering some of your most pressing questions. We're going to be talking about wearing cervical collars for surgery, nitrous oxide, CRPS, specific surgeries with EDS, and so much more. If you're watching the video right now, you're going to see a couple of new faces. We have two of the amazing human content producers joining us today, Tessa and Shanti. We thought it would be super fun to give a behind-the-scenes look for this Office Hours episode, and they are actually wearing some of our VIP merch. So check that out. Let us know if you would like your own VIP merch, and we'll see what we can do. As you know, there's merch available right now at the Bendy Bodies Boutique, but these are special designs that we have for the team right now.
[01:56] Stick around until the very end so you don't miss any of our special hypermobility hacks. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Here we go.
[02:10] Okay, so we have some great questions that we're going to be addressing today. Which one of you is going to read the first question?
[02:16] Okay, so this first question is from Anne. Love this question because it's actually from an internal medicine physician. She is a medical physician in Juneau, Alaska. I'm looking for help in finding a surgeon in the Pacific Northwest who's experienced with patients with EDS. One of my patients who has EDS is considering breast reduction surgery, and we'd like to make this as safe as possible for her. What should I look for in a surgeon? What questions should I ask? And do you have any resources to share?
[02:47] Fantastic. I love Anne's question. This is such an important topic. So first, you want to see if they have experience with connective tissue disorders. Now, pretty much every surgeon who's operated on enough people will have operated on people with connective tissue disorders. But do they know and understand these conditions? So ideally, you're looking for someone who's operated on EDS or other connective tissue disorders like Marfan syndrome or Loeys-Dietz syndrome. And ideally, they understand fragility, poor healing, and bruising tendencies. And we'll get to some of the specific questions that you should ask in just a little bit.
You want a board-certified plastic surgeon in this case, of course, ideally one with reconstructive as well as cosmetic training. You want to take a collaborative approach. You want to be looking for a surgeon who is open to consulting with your EDS-knowledgeable physician, anesthesiologist, or pain specialist. You want somebody who takes a conservative, safety-first philosophy. You want to avoid surgeons who promise quick recovery or minimal scarring without addressing the unique risks of EDS. You also want somebody who does individualized techniques where they are very careful to do closures with less tension, layering suturing, longer follow-up, and meticulous wound support.
Here are some specific questions to ask. Number one: have you operated on patients with EDS before? If not, are you open to reviewing information or collaborating with my EDS physician? And then the more important question: how will you modify your technique for my fragile tissues? If they say, "I just treat everyone the same," then that's a red flag. You want to see what they say about closure. Do they use multiple layers? Do they use deeper sutures? Do they possibly use longer-lasting absorbable or non-absorbable sutures to reduce dehiscence, which is when the wound opens back up — and we're going to be talking about that more in just a little bit. And what is your wound support plan? Do you use Steri-Strips, silicone tape? There are special kinds of glue that they can use, compression garments, or delayed suture removal, which is often needed for EDS skin.
[04:53] What will you do to minimize bruising and hematomas? People with EDS often bleed easily. Do they handle tissues gently? What do they do about drains and post-operative monitoring? I would ask, how do you manage post-operative pain control given that some people with EDS have local anesthesia resistance? You want to discuss multimodal pain management like nerve blocks — and nerve blocks use local anesthetics, so of course if you have local anesthetic resistance, nerve blocks could be particularly tricky. But we talked about that in part one of this two-part series, so be sure to check that out as well. Things like non-opioid analgesics like ketamine can be really helpful, or clonidine and preoperative coordination with your pain physician.
[05:35] Also ask, what is your approach to scars? Because EDS scars can stretch or widen, and you want to make sure that they take a very thoughtful approach to scar care protocols like silicone gel, taping, or laser follow-up. Will you coordinate with anesthesia about positioning and joint protection? We'll talk about this more later, but it's really, really important to consider the cervical spine or the neck, the risk of subluxation of the shoulders — because shoulders are more inherently unstable joints. And what about management of POTS and mast cell activation syndrome before and after the surgery? What is your follow-up plan, and how long do you monitor healing for? People with EDS often need more frequent visits and longer restrictions.
[06:23] Some additional questions that are specific to this breast reduction surgery: what techniques do you use — Wise Pattern, vertical, or liposuction-assisted? EDS tissue often stretches, so technique choice can influence scar quality and long-term shape. How will you minimize wound tension at the T-junction and nipple area? They usually do have a junction where they have this T-like type incision. And ask about drain placement, tension-reducing sutures, and staged closures if needed.
[06:55] You also want to ask, do you expect higher rates of delayed healing or wound separation in EDS? A good surgeon should acknowledge this and have a plan for prevention and management. Will nipple sensation and blood flow be monitored? Microvascular fragility raises the risk of ischemia or loss of blood flow, and then where the tissues die. So gentle dissection and careful flap handling are essential. How will you handle potential scar stretching or bottoming out over time? You want to ask about internal support techniques like dermal slings, absorbable mesh, or internal bra methods, and realistic expectations for long-term results.
[07:32] What is your policy on post-op compression garments and how long they should be worn? Proper support can reduce swelling and protect the healing tissue. If revision is necessary, how soon can that safely be done? Healing in EDS can take months, and early revision can actually worsen scarring. You can also ask how they address POTS or dysautonomia before, during, and after surgery, and ask this about MCAS as well. Discuss IV fluids, gradual mobilization, and temperature regulation.
[07:59] Some other red flags to watch for: number one, if they're dismissive of EDS or say, "I treat everyone the same way." If they guarantee perfect scars or quick recovery. If they rush through your questions or seem impatient with complexity. And if they refuse to coordinate with your other clinicians.
So the take-home messages here are: preparation and communication are everything. Bring documentation of your EDS subtype, current medications, and prior surgical experiences. Longer recovery and modified expectations are normal and healthy. And you want to choose a surgeon who values precision, patience, and partnership over promises of perfection.
[08:39] Okay, next question.
[08:41] Yeah, so the next question is from Kimberly, and I think, Dr. Bluestein, you're also familiar with this name.
[08:49] Yes. She sent us her whole story, which we so, so appreciate the context, but we've shortened it a bit for brevity. Kimberly wrote in asking about the effects of nitrous oxide. She says, after my partner's complicated hospital stay involving nitrous oxide, he began having severe full-body spasms. Could those spasms come from nitrous exposure or from advanced hypermobile EDS? And more broadly, how can patients get the right help at the right time to avoid this kind of suffering, especially for those of us already coping with trauma and PTSD?
Okay. That's a great question. So first we're going to talk about what nitrous oxide is. Nitrous oxide, N2O, commonly known as laughing gas, is a colorless gas that's used for its analgesic or pain-reducing properties, anxiolytic or anti-anxiety properties, and mild sedative effects. It's frequently used in dentistry, minor medical procedures, and childbirth because it acts quickly, it's easily reversible, and has minimal cardiovascular or respiratory depression compared to other sedatives. It's typically inhaled through a mask and is often mixed with oxygen, providing short-term relaxation and pain relief. The effects occur within minutes and wear off very quickly after stopping the gas.
[10:04] What's nice about it is this can be used without any intravenous catheter, and it usually can be titrated quite easily. So nitrous oxide is considered a low-risk option for anxiety or mild pain control in healthy individuals, and it can be used for minor procedures and in dentistry. And I have to say, I've had an IUD placed and removed. Now, the removal was really easy and definitely did not need anything for that. But for the placement, it would have been nice if my OB-GYN's office had used nitrous. I've heard some people say that they do have nitrous in their GYN's office, and I think that would be a really cool thing because those procedures can be quite painful.
[10:46] So nitrous oxide is often used as an adjunct during general anesthesia. A lot of people don't realize that general anesthesia usually involves a whole bunch of different medications. It's not one medication. Usually we're putting medications in the IV, and then you're also inhaling these more potent volatile anesthetics like sevoflurane, desflurane, or isoflurane, all of which have their own side effects. But if we use a little bit of desflurane, and you're also breathing oxygen, and we use a little nitrous oxide, those will actually work synergistically and we can use less of each one and still achieve a really nice anesthetic. So they kind of share the load.
[11:22] So the nitrous oxide lowers what's called the minimum alveolar concentration, or MAC, of volatile anesthetics, meaning that less gas is needed to maintain the same depth of anesthesia because they work synergistically. This results in faster induction and emergence. And emergence is the part at the end of the procedure where you're waking up. Nowadays, especially because we're fast-tracking everything, we like people to wake up as quickly as possible, which also helps reduce the cost and gets you home quicker, or to your room if you're staying overnight in the hospital.
[11:54] Nitrous oxide also helps with having potentially fewer cardiovascular depressant effects compared to higher concentrations of volatile anesthetics alone. However, we should use nitrous oxide cautiously in people with EDS or MTHFR variants, as we will discuss, due to effects on methylation or neurologic sensitivity.
[12:14] So people with EDS can have increased joint laxity, cervical instability, or autonomic dysfunction like POTS. That can make positioning and breathing responses less predictable during sedation. We need to be extra careful with airway management — things like neck hyperextension, which we're going to talk about more. Manipulating the jaw can worsen subluxations or TMD, or temporomandibular joint pain. The blood pressure and heart rate always need to be monitored closely because of dysautonomia and variable responses to sedatives or stress. Some individuals with EDS will report paradoxical reactions like agitation, dystonia — which is abnormal muscle movements — or tremor after nitrous oxide exposure.
[12:58] But what about nitrous oxide, MTHFR variants, and B12 pathways? So nitrous oxide inactivates vitamin B12 by oxidizing the cobalt atom in methylcobalamin, leading to temporary or prolonged impairment of the methylation cycle. This raises homocysteine levels, impairs DNA methylation, neurotransmitter balance, and myelin maintenance. MTHFR variants are more common in some EDS populations and reduce the body's ability to recycle homocysteine. If you combine MTHFR variants and nitrous oxide exposure, you can further impair methylation, which can possibly lead to neurologic symptoms such as muscle stiffness, dystonia, or cognitive fog, especially with repeated or prolonged exposure. And it sounds like that's the case that Kimberly is describing, where there was prolonged and repeated exposure.
[13:49] What about dysautonomia and neurologic concerns? Nitrous oxide has been associated in case reports with acute dystonic reactions, tremors, or myoclonus, particularly in those with B12 deficiency or MTHFR-related methylation deficits. We talked about MTHFR in a previous episode, so we definitely want you to check that out as well. These effects may appear hours or days later and can mimic anxiety or unusual sensations after procedures.
High-risk groups include those with known MTHFR or B12 metabolism variants. People who are vegetarian or vegan often have lower B12 intake. People who are on PPIs might also have lower B12 levels because of decreased absorption. People with EDS will have neurologic hypersensitivity and might have prior dystonic reactions.
Okay, so here are some practical tips for people with EDS and clinicians. First of all, discuss history of EDS, dysautonomia, and any known MTHFR or B12 issues before using nitrous oxide. You want to pre-screen labs — check a serum B12, methylmalonic acid, and homocysteine if you have any concern about deficiency. You want to consider B12 supplementation with methylcobalamin or hydroxocobalamin before and after procedures involving nitrous oxide. You want to use the lowest effective dose and shortest duration possible. You want to monitor post-procedure symptoms like fatigue, mood changes, stiffness, dystonia, and neuropathy.
[16:47] If problems arise, treat that promptly with B12 repletion and evaluate for elevated homocysteine. Consider alternative anxiolytics like oral benzodiazepines or guided relaxation that might be safer for those with known methylation issues or previous adverse reactions.
So Kimberly, I hope this is helpful. Nitrous oxide could be helpful for short-term pain and anxiety control, but should be used cautiously in people with EDS, especially for those with dysautonomia, dystonia, POTS, or MTHFR variants. Understanding its impact on B12 and methylation can help clinicians and patients alike make safer, individualized choices. Hopefully that helps Kimberly, and we will move on to our next question.
[17:31] So we got a question in from Daniel about CRPS and EDS. He asks, I recently found out that complex regional pain syndrome is a comorbidity of EDS. Can you tell us more about this overlap?
[17:44] Yes, absolutely. So there is a significant amount of overlap between CRPS and MCAS, and we often see that cluster together. So again, lots of acronyms — EDS, CRPS, and mast cell activation syndrome often go together. There are some shared themes here such as tissue fragility, autonomic dysfunction — for example, POTS — neuroinflammation or central sensitization, and small fiber neuropathy.
[18:09] So we know that mast cells and nerves interact. Mast cell mediators like histamine, tryptase, and prostaglandins can sensitize nociceptors or pain-sensing neurons and promote neurogenic inflammation that we often see in CRPS. Neuropeptides like substance P can further activate mast cells and cause a feedforward loop. And I hear from patients all the time, "Well, but I've been tested for inflammation and the tests were negative." Usually, if somebody has neuroinflammation, they might be having a lot of pain. They might be having some psychiatric symptoms, insomnia, all kinds of things going on, but we don't really have good ways to test for neuroinflammation yet. So it's not surprising that your CRP and sed rate — those kinds of inflammatory markers that we test for in the blood — are completely normal.
[18:57] Connective tissue laxity in EDS also causes microinstability and recurrent minor trauma and impaired fascial support, which can lead to peripheral nociceptive input that can trigger and maintain CRPS and also provoke MCAS flares. We know that a lot of people with EDS and MCAS also have dysautonomia and autonomic dysregulation that can lead to altered microvascular tone, color and temperature changes, edema, and allodynia, which is typical of CRPS.
[19:26] Allodynia is when something that is normally not painful is painful. So if somebody touches you lightly — I used to be so hypersensitive to my husband touching me — that's allodynia. Something that's normally not painful is painful. And also if we have CRPS, we often have something called hyperalgesia, and that is where things that are normally only a little bit painful are a lot painful. If we have allodynia and hyperalgesia, those are signs of central sensitization.
[19:52] We can also see small fiber nerve changes reported in all three of these conditions, and that can cause dysesthesias, burning pain, dysautonomia, and itch flushing overlap.
[20:08] So what are some patterns to look for? Features of CRPS include disproportionate pain, allodynia, and hyperalgesia, skin color or temperature change, swelling, pseudomotor changes. We'll see changes with sweating and things like that after minor injury or surgery, or even after immobilization. It's much more common after procedures on the extremities, so wrist surgery, hand surgery, injuries to the ankles — things in the periphery are much more likely to trigger CRPS.
[20:39] And I had a family member who was not having that severe of pain but was told to immobilize a joint and use a knee scooter, and they got CRPS within a matter of days simply from the immobilization. So it's really important to be aware of these things. They're very commonly missed.
[20:59] We can get trigger stacking, so we can get heat, friction, adhesives, infection, stress, medications, etc. that can trigger an MCAS flare, and that causes pain amplification and dysautonomia, which worsens CRPS symptoms. A lot of medication sensitivities are actually reactions to dyes, excipients, opioids, etc., and local anesthetic variability is found to be more common. So you definitely want to plan ahead if you're having any kind of surgery.
[21:27] Some practical pearls: we want to always screen for POTS and dysautonomia and MCAS symptoms if we're experiencing CRPS because we know there's more of an overlap. We want to be looking for any neuropathic signs in CRPS cases with hypermobility. Consider small fiber nerve testing like a QSART test or a skin biopsy when symptoms suggest small fiber neuropathy. And we also want to treat coexisting myofascial drivers because myofascial pain is extremely common in EDS and HSD.
[21:58] What are some implications when it comes to management? We want to calm the biology. We want to use H1 and H2 blockers, cromolyn, and trigger avoidance for MCAS. We want to use graded desensitization and mirror therapy. Early mobilization is very important for CRPS. Stability-focused physical therapy is also really important. Low-load closed-chain exercises and pacing. We want to support the autonomic nervous system with fluids, salt, compression, sleep work, vagal work, et cetera, to reduce sympathetic overdrive.
[22:28] Consider a variety of options for analgesia, including non-opioid multimodality regimens. Consider low-dose naltrexone, topical anesthetics, and where appropriate, carefully selective nerve blocks with ultrasound and buffering agents like bicarbonate, as we talked about in part one. Peri-procedure tips for dental work, surgery, injections, et cetera: you want to pre-plan your medications to reduce MCAS flares. You want to encourage your surgeon to handle your tissues very gently, avoid prolonged immobilization, protect your skin and joints, and monitor closely for early CRPS signs.
[23:05] Some clinicians use vitamin C pre- and post-surgery as a low-risk preventative measure. And I will tell you that I use this myself when I have had surgery as a way of possibly preventing CRPS. The dose that I often recommend is 500 milligrams twice a day, but I know some people do go higher than that. Believe it or not, there are some studies that support the use of vitamin C before surgery to help reduce the risk of CRPS, and it's generally very safe.
[23:32] Psychosocial layers are very important. You want to do pain education, reassurance, graded exposure to reduce central sensitization. You want to consider things like CBT and pacing to prevent boom-and-bust cycles.
[23:44] When to escalate your care: if you're getting rapid progression of color and temperature asymmetry, severe allodynia, or progressive weakness, you might need urgent CRPS-directed care. If you're having recurrent anaphylactoid symptoms, syncope, or uncontrolled flushing, then it would be important to reconsider your MCAS plan, and maybe you need to go into your rescue-type MCAS plan.
So the take-home message here for this listener is: EDS, CRPS, and MCAS can definitely amplify each other through mast cell-nerve-autonomic crosstalk. Best outcomes come from early recognition, trigger control, and coordinated gentle multidisciplinary care rather than single-modality fixes.
[24:29] Okay. I think we have another question or two. So we got in a few questions about cervical collars and surgery. One of the questions was: many people with EDS worry about neck instability during anesthesia, but who really needs a cervical collar and when might it do more harm than good? What is the right balance between protecting fragile tissues and keeping the airway safe during anesthesia? And if you're hypermobile but not formally diagnosed with EDS, how do you know whether you should take the same precautions as someone who is diagnosed?
[25:03] Okay. I love these questions because airway management is so important. I did it for over 20 years in the operating room, and in a crisis when someone is coding or about to code, it's airway, breathing, circulation — and of course neck protection is right up there too. But the airway is extremely important. If you don't maintain a good airway when you're inducing general anesthesia, bad things can happen. So we really want to keep all of this in mind and make sure that we're coming up with a good plan for people.
[25:34] So, first, some considerations. People with joint hypermobility or connective tissue fragility are at increased risk of atlantoaxial — or C1 to C2 — or craniocervical instability. They're also at risk of TMJ subluxation and airway trauma during intubation or positioning. There are a lot of things that we do in anesthesia to manage your airway, such as a chin lift, head tilt, jaw thrust. We do laryngoscopy where we put a device down your throat in order to place a breathing tube — that can sublux or overly stretch cervical structures or structures in the neck, which can lead to postoperative pain, headache, dizziness, or even neurologic symptoms.
[26:11] The combination of ligamentous laxity — and ligaments are what connect bone to bone — and dysautonomia and soft tissue fragility requires gentle and individualized handling by the anesthesia team.
[26:29] It's really important to communicate well with your team. Tell the anesthesia team about your diagnoses. If you have any symptoms of neck instability or any prior imaging showing that you have instability in your cervical spine, you want to ask what type of anesthesia you will be having, because this is very relevant. Are you having a general anesthetic? And if you are, are you having an endotracheal tube or are you having a laryngeal mask airway? Because both of those devices require a little bit different techniques. Are you having a regional anesthetic, like an epidural or a spinal? Are you having a MAC anesthetic, which is monitored anesthesia care? Or maybe you're having surgery and you're just having local anesthesia and that's all.
[27:11] Ask what position you'll be in for the surgery and how they plan to position you. I talked about this a lot in my chapter on anesthesia and surgery for EDS in the Disjointed book, so you'll want to check out that chapter as well. If they're going to be moving you into different positions for different portions of the surgery, ask if they'll be doing that after you're anesthetized or if there's a way to do that before they induce general anesthesia so you can give them feedback about how you feel in that particular position.
[27:39] When it comes to neck positioning in general, we do try to maintain neutral alignment. If there are any anesthesiologists listening right now, of course, we need to remember to avoid excessive flexion, extension, or rotation. There are fortunately newer strategies such as video laryngoscopy that can minimize neck movement during intubation. We can also consider fiber optic laryngoscopy, and that's where we have a long tube that's completely flexible. We're looking at one end, and then the other end has a light so we can see through those fibers, and we don't have to move the neck at all. So that's another technique that can be really helpful.
[28:16] Usually though, we do that with people awake — and when I say awake, I should say awake but sedated — but still, that requires extra time and some people, although they're sedated, might have recall of that experience.
We want to support the joints and the skin. We want to use padding under the shoulders, neck, and pressure points to prevent injury. In general, we can use smaller endotracheal tubes, and we want to really consider the size of the LMA to reduce airway trauma. If we go too small on the laryngeal mask airway, it's not going to work effectively. So we need to make sure that we're choosing the correct size and using adequate lubrication so that we can place it smoothly and easily. If we're doing mask ventilation — and that's where we have our hand on your face and we're squeezing a bag to get air into your lungs — we want to avoid aggressive jaw thrust because that can sublux the temporomandibular joint.
[29:12] So what about cervical collars? When should we use those and why? A cervical collar might be appropriate for individuals diagnosed with craniocervical or atlantoaxial instability by imaging or a specialist. Or those who have symptoms of instability like neck pain, headaches, vertigo, or a bobblehead sensation, or neurologic symptoms with motion. Patients who normally use a collar for daily stability and who have been advised by their specialist to wear one during transfers or positioning also might be appropriate candidates.
[29:43] If you have generalized hypermobility without confirmed instability, or localized joint hypermobility, or asymptomatic joint hypermobility, a collar is typically not needed. If you have a mild case of EDS without neck symptoms or instability on imaging, you might not need a collar. Patients who have not been evaluated or prescribed a collar but use one "just in case" can sometimes cause more harm than benefit.
[30:10] Pros and cons of wearing a cervical collar to your actual surgery. Potential benefits: it helps remind the anesthesia and surgical team to handle your neck carefully. It might help prevent sudden or extreme movement during transfers, induction, or intubation. It can provide subjective comfort and security if you have known instability. It can be useful for pre- or post-induction transport when neck support is necessary.
[30:36] What are some potential drawbacks? Collars can obscure airway landmarks, making intubation or mask ventilation more difficult. You can imagine if you're having a mask and you have to create a seal over the mouth and over the nose, and the collar goes basically up over your chin, they're basically meeting at the same point. So it's very, very difficult to do mask ventilation while someone is wearing a hard cervical collar. That can be really challenging. Rigid collars also limit neck extension, which can complicate emergency airway access or even routine airway access. If worn unnecessarily, cervical collars can create muscle stiffness or discomfort or give false reassurance about safety. Cervical collars can also increase intracranial pressure slightly in some cases if they're too tight or poorly positioned.
[31:24] So if you normally wear a collar, bring it to the hospital and consider wearing it, and tell the team when you typically use it. Ask your neurosurgeon or EDS specialist in advance for documentation or written guidance about collar use during anesthesia. In the pre-surgical area, wearing your collar can prompt the right conversation. The anesthesiologist can assess whether to remove it just before induction and reapply after positioning. If it's removed, ensure neck stabilization during transfers and intubation using manual inline stabilization or a foam head cradle. These are a couple of things that we do to help protect the neck and make sure that we keep it in the proper position.
[32:00] So key takeaways: cervical collars can be valuable for EDS patients with documented or symptomatic craniocervical instability, or those who are at high risk for it. The safest approach is a personalized one. Collar decisions should be made ahead of time with the treating specialist and communicated clearly to the anesthesia team.
[32:18] What about hypermobility without an EDS diagnosis? What does that mean? As I've mentioned before on the show, I have some friends that are hypermobile, and they're in their 60s, and they're doing great. They have some joints that have greater than normal range of motion, but they don't meet the criteria for EDS, and they're not having any problems. People like that, I definitely don't think should wear a cervical collar when they go in for surgery.
What about people who have some joint hypermobility and they might have some symptoms, and so they may fall into the category of hypermobility spectrum disorders? They might have symptoms like pain, a little bit of instability or fatigue, but they don't have a formal diagnosis. We still don't know how their tissues are going to behave. Things like ligaments and fascia could be more elastic and joints might sublux more easily. Some people do have preclinical EDS or are on the hypermobility spectrum, so the same precautions would apply, especially if they've had any prior dislocations, surgical complications, or unexplained pain.
[33:17] Let's discuss some airway and positioning implications. Neck, jaw, and shoulder hypermobility can still increase risk during airway management or positioning. Even if you don't have cervical instability, excessive neck extension or rotation can strain ligaments or cause muscle spasm. TMJ subluxation is common, so you want to avoid aggressive jaw thrust or mouth opening during intubation. Loose skin and mucosa may increase the risk of small tears or bruising during airway manipulation.
[33:45] So cervical collar guidance for joint hypermobility without EDS: many of these patients do not need to wear a cervical collar to surgery unless they experience symptomatic neck instability — so if they experience things like dizziness or pain with motion or subluxations — or if they've been evaluated and prescribed a collar by a clinician familiar with hypermobility or connective tissue disorders. If somebody simply knows that they're flexible but has no symptoms at all or no history of instability, a collar is probably not necessary. Careful positioning and awareness by the anesthesia team are enough. And please feel free to point out to them that you do have some hypermobile joints.
[34:21] Okay, so I just want to quickly review some pros of wearing a cervical collar. It can provide gentle support and reassurance if neck pain exists or if instability symptoms are present. It can serve as a visual cue to the staff that the patient needs careful handling.
[34:35] Some cons for cervical collars and generalized hypermobility: unneeded collars may limit airway access and complicate intubation, may create dependence or stiffness if worn unnecessarily, and can increase anxiety or signal instability that doesn't exist, leading to overcautious or uncomfortable handling.
[34:54] So best practices: communicate clearly with the anesthesia team any history of subluxations, dizziness, or pain with neck movement. If no symptoms are present, focus on neutral positioning, padding, and gentle transfers rather than bracing. For those who are unsure about instability, preoperative evaluation by a knowledgeable physical therapist, PM&R, or EDS specialist can help determine whether support is warranted or not. Bring documentation if you do normally use a collar, brace, or special support device so the surgical team understands when and why you use it.
[35:22] So in conclusion, not everyone with hypermobility needs the same surgical precautions, but respecting tissue fragility and joint laxity matters a lot. I know Dr. Chopra was researching this topic specifically and has a paper in progress, so we will really look forward to seeing that paper about some patients who went in for surgery without known CCI and then came out with actual craniocervical instability. So that's really important to be aware of, but I also think that we need to be very thoughtful in how we apply the strategy of wearing a cervical collar.
[35:58] Okay. Hopefully that was helpful information, and thank you so much to Tessa and Shanti for being here today. It was super fun. We're going to do the hypermobility hack and then we're going to wrap up.
[36:09] Thanks so much for having us on. It was so fun to be in front of the camera this time. And I also want to tell your listeners that we see all your questions coming in and they're so, so appreciated. So please do keep submitting at bendybodiespodcast.com.
[36:25] Thank you, Tessa. So the hack for today is about spitting sutures, which I am literally dealing with right now as we speak in my forehead. If you've ever had a stitch work its way to the surface after surgery or even after a small biopsy, you are not imagining it. People with EDS, HSD, and MCAS experience spitting sutures at a higher rate because of a few things.
[36:45] Number one, fragile collagen and delayed healing causes slower absorption of dissolvable sutures. Overactive mast cells create local inflammation, itching, or irritation around the suture site. Then reactive skin may literally push the suture out instead of remodeling over it.
[37:03] So you may have noticed that I was wearing a headband for a while, and at this point I'm supposed to keep my forehead uncovered as much as possible. I am six weeks and two days out of my surgery and my incision is still a little bit open. But it's closing more and more every day. I had Mohs surgery for the third time for my eighth basal cell skin cancer. So this is also a shout-out for sunscreen. Wear your sunscreen. You do not want to have parts of your face hacked off like I've had.
[37:35] And I also definitely had an allergic reaction to the first type of bandage that I was putting on my face because I would take that off and the whole area of the square that I had on my forehead was super, super red and irritated. So that's the other thing I've discovered: having it open to air and having just the ointment on there is helping it heal a lot faster.
[37:57] So enough about me, back to the hack. If you notice redness, itching, or a tiny thread poking out, in general, don't pick it or pull it. Now, there was a point at which I could see a little bit of the suture sticking out, and my dermatologist did tell me that I could take a tweezers. I cleaned it with an alcohol wipe first — and I have a very, very powerful magnifying mirror — so I would look in there and then very, very gently grab the end of the stitch and just kind of pull gently. The idea is that your body is wanting to get rid of it, so the sooner you get it out, the better. But initially I was pulling, pulling, pulling, and it just didn't want to let go yet. There was too much of the knot; it wasn't dissolved enough. So don't pull hard because then you're really going to reopen the wound. But you can also go back to your surgeon and let them either trim it or potentially pull it depending on what's happening.
[38:50] In general, it's really important to keep the area clean, dry, and initially you want to keep it covered. Although, as I said, at this point for me it's important that I keep petroleum jelly on it and keep it uncovered. My dermatologist — I've been sending him pictures every single week — and I'm also now taking antihistamines, not topically, I'm taking them orally. Cool compresses can also help with the itching if mast cells are contributing.
[39:18] We're going to talk more in a future episode about why this happens, how you can prevent it, and what suture types or closure methods work best. So stay tuned.
[39:30] Okay, that's your hack for the day. Thank you so much for listening to this week's episode of the Bendy Bodies Podcast with the Hypermobility MD. You can help us spread the word about joint hypermobility and related conditions by leaving a review and sharing the podcast. This really helps raise awareness about these multidimensional conditions.
[39:47] Did you know that I offer one-on-one support for both clients and healthcare professionals? Whether you're living with a connective tissue disorder or caring for people who are, I've got your back. Check out my coaching and mentorship options on the services page of my website at hypermobilitymd.com. You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, Twitter, TikTok, or LinkedIn at HypermobilityMD.
[40:09] You can find Human Content, my amazing producing team — two of whom you met today, Tessa and Shanti — at Human Content Pods on TikTok and Instagram. You can find full video episodes up every week on YouTube at Bendy Bodies Podcast.
[40:24] I'm so glad you're enjoying the Bendy Bodies Podcast. We love bringing on guests with unique perspectives to share. However, these unscripted discussions do not reflect the views or opinions held by me or the Bendy Bodies team. Although we may share healthcare perspectives on the podcast, no statements shared on Bendy Bodies should be considered medical advice. Please always consult a qualified healthcare provider for your own care.
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