Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study

doi:10.1016/j.spinee.2006.02.024

The Spine Journal

Volume 7, Issue 2, March–April 2007, Pages 141-147

https://doi.org/10.1016/j.spinee.2006.02.024 Get rights and content

Abstract

Background context

Severe and disabling dysphagia is a relatively uncommon complication of anterior cervical spine surgery. However, the incidence of dysphagia ranges widely (2% to 60%). Furthermore, risk factors that contribute to the development of dysphagia have not been well identified.

Purpose

The purpose of this study was to evaluate the prevalence of dysphagia after anterior cervical spine surgery, and to identify any risk factors associated with increased dysphagia.

Study design

This study is a prospective cohort study designed to evaluate the prevalence of dysphagia at 1, 2, 6, 12, and 24 months. Patients were prospectively interviewed at 1, 2, 6, 12, and 24 months regarding the presence and subjective severity of dysphagia.

Patient sample

Between the period of 1999 and 2002, 348 cervical spine surgeries were performed using the anterior Smith Robinson approach. 310 of these patients were available for 2-year follow-up.

Outcomes measure

Using the dysphagia grading system defined by Bazaz et al. (Spine 2002), we prospectively evaluated patients' postoperative dysphagia.

Methods

The presence and severity of dysphagia were reported during the telephone interviews performed at 1, 2, 6, 12, and 24 months after the procedure.

Proportion analysis (χ-square or a Fisher Exact Test), prevalence ratios, and 95% confidence intervals were used to compare the prevalence of dysphagia with age, gender, type of surgery (eg, discectomy vs. corpectomy, primary vs. revision), use of instrumentation, number and location of surgical levels.

Results

The overall prevalences for dysphagia at 1, 2, 6, 12, and 24 months were 54.0%, 33.6%, 18.6%, 15.2%, and 13.6%. The prevalence of dysphagia was found to be significantly higher in women (18.3%) than men (9.9%) 2 years after the surgery. Revision surgery patients (27.7%) also had a significantly higher prevalence of dysphagia than primary surgery (11.3%) patients 2 years after the surgery. Pateints who underwent more than two-level surgery (19.3%) also had significantly higher rates of dysphagia 2 years after their procedures than patients who had two or less levels (9.7%) operated on.

Conclusion

Overall the incidence of dysphagia 2 years after anterior cervical spine surgery was 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus discectomy did not significantly increase the prevalence of dysphagia.

Introduction

Severe and disabling dysphagia is a relatively uncommon complication of anterior cervical spine surgery. However, the prevalence of dysphagia ranges widely (2% to 60%) [1], [2], [3], [4], [5] and most studies are retrospective. The identification of adverse reactions after surgery in a retrospective fashion may not be entirely accurate [6]. Furthermore, risk factors that contribute to the development of dysphagia have not been well identified. This study is a prospective cohort study designed to evaluate the prevalence of dysphagia at 1, 2, 6, 12, and 24 months. Also, factors such as age, gender, type of surgery (eg, discectomy vs. corpectomy, primary vs. revision), use of instrumentation, and number and location of surgical levels are analyzed for the development of dysphagia.

Section snippets

Materials and methods

Between 1999 and 2002, 348 cervical spine surgeries were performed using the anterior Smith Robinson approach. The study was approved by the Institutional Review Board of University Hospitals of Cleveland. All patients with preoperative dysphagia were excluded from the study. Three fellowship trained orthopedic spine surgeons, and one senior spine surgeon at a single institution performed all the procedures. Anesthetic care included the use of an inflated endotracheal cuff and an esophageal

Incidence of risk factors

Female gender and surgeries involving at least three levels were previously found to be significant risk factors for the development of dysphagia [5]. The incidences of these risk factors were separately evaluated within each subgroup. There were no significant differences in the gender makeup of each subgroup. However, the corpectomy group had significantly higher number of surgeries involving at least three levels than the discectomy group (p<.01), and the noninstrumented group had

Discussion

The development of dysphagia after anterior cervical spine surgery is being recognized as common. The purpose of this study was to identify risk factors for developing dysphagia after anterior cervical spine procedures. In addition, another goal was to determine the prevalence and severity of dysphagia.

Widely ranging prevalences of dysphagia after anterior spine surgery have been reported. However, most of these studies are retrospective. There are few prospective studies examining dysphagia

Conclusion

The etiology of dysphagia in the postoperative period is likely multifactorial. Other possible factors not examined in this study include: duration of operation, manual versus self-retaining retraction, prolonged intubation, and amount of intravenous fluids during the operation. Postsurgical edema is probably the strongest contributor to dysphagia in the early postoperative period (1 and 2 months). However, in the later recovery period (1 and 2 years), the amount of scar tissue likely plays a

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Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures
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Dysphonia and dysphagia following the anterior approach to the cervical spine
Arch Otolaryngol Head Neck Surg
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Intraoperative Protection of Pharyngeal Autonomic Nerves: Preventing Dysphagia After Anterior Cervical Decompression and Fusion Surgery
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The study aims to investigate whether intraoperative protection of the pharyngeal autonomic nerve can effectively reduce the incidence of postoperative dysphagia following anterior cervical decompression and fusion surgery (ACDF).
A retrospective analysis was conducted on 130 cases that underwent ACDF from January 2018 to June 2022 at our hospital. Divided into nonautonomic neuroprotection (NANP) group and autonomic neuroprotection group based on whether receive protective measures for the pharyngeal autonomic nerve during surgery. General data were recorded and compared between the 2 groups. Postoperative outcomes were evaluated using Neck Disability Index, Japanese Orthopaedics Association (JOA) score, and JOA improvement rate. The incidence and severity of postoperative dysphagia were assessed using Bazaz dysphagia assessment criteria and swallowing-quality of life questionnaire.
There were no significant differences in general data (P > 0.05). The average operation time and intraoperative blood loss also showed no significant differences (P > 0.05). Both groups showed significant improvements in Neck Disability Index and JOA scores at all follow-up time points compared to preoperative scores (P < 0.01). The incidence of postoperative dysphagia in the autonomic neuroprotection group was significantly lower than that in the NANP group at all follow-up time points (P < 0.05). Both group showed a significant reduction in scores 3 days postoperatively compared to preoperative scores (P < 0.01), and the NANP group also showed significant reductions in scores at 3 month and 1 year postoperative follow-up time points compared to preoperative scores (P < 0.01).
The adoption of pharyngeal autonomic nerve protective measures during ACDF can effectively lower the probability of postoperative dysphagia.
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Anterior cervical discectomy and fusion (ACDF) is among the most common spine procedures. Adjacent segment disease (ASD), characterized by degenerative disease at an adjacent spinal level to a prior fusion, is a well-recognized and significant sequela following ACDF. Adjacent segment ACDF may be considered after the failure of non-surgical options for patients with symptomatic ASD. This study aimed to assess the incidence of dysphagia and other complications as well as radiographic outcomes in adult patients who have undergone ACDF with an integrated interbody spacer device for symptomatic ASD.
This was a retrospective review of patients who underwent ACDF for symptomatic ASD with commercially available integrated interbody spacers by three spine surgeons at an academic institution from March 2018 to April 2022. Demographic, radiographic, and postoperative data were collected, including dysphagia, device-related complications, and the need for revision surgery.
There were 48 patients (26 male, 22 female) who met inclusion criteria (mean age 59.7 years, mean body mass index 19.5 kg/m²) who underwent ACDF for symptomatic ASD (1one-level, n = 44; 2-level, n = 4). Overall, 12 patients (25%) experienced dysphagia postoperatively before the first follow-up appointment. Nine of 44 (20.4%) of 1-level ACDF patients experienced dysphagia, and 3 of 4 (75%) of 2-level ACDF patients experienced dysphagia. Three patients had severe dysphagia which prompted an otolaryngology referral. Two of those patients remained symptomatic at 6 weeks postoperatively. Of 43 patients with prior plate cage systems, none required hardware removal at the time of surgery. Preoperative global and segmental lordosis were 9.07° ± 8.36° (P = 0.22) and 3.58° ± 4.57° (P = 0.14), respectively. At 6 weeks postoperatively, global and segmental lordosis were 11.44° ± 9.06° (P = 0.54) and 5.11° ± 4.44° (P = 0.44), respectively. This constitutes a change of +2.37° and +1.53° in global and segmental lordosis, respectively. The mean anterior disc height change between preoperative and immediate postoperative time points was 6.3 ± 3.1 mm. Between the immediate postoperative and 6-week postoperative time points, the mean anterior disc height change was –1.5 ± 2.7 mm. Between the immediate postoperative and 3-month postoperative time points, the mean anterior disc height change was –3.7 ± 5.0 mm. The posterior disc height changes at the same time points were 2.5 ± 1.7 mm, –0.4 ± 1.8. and –0.5 ± 1.4 mm, respectively. This fusion rate was 50% and 70% at 6 months and 1 year post-surgery, respectively.
ACDF with integrated spacer is a viable alternative to traditional plate-cage systems for symptomatic ASD. An advantage over traditional plate-cage systems is that the removal of prior instrumentation is not needed in order to place implants. Based on a review of the literature, these standalone systems allowed for a shorter operative time and had less incidence of dysphagia than plate-cage systems for ASD after ACDF. The different standalone and plate-cage systems used in treating ASD after ACDF surgeries should be compared in prospective studies.
Analysis of swallowing function after anterior/posterior surgery for cervical degenerative disorders and factors related to the occurrence of postoperative dysphagia
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Dysphagia is one of the postoperative complications of cervical degenerative disorders. However, few studies have evaluated the pre- and postoperative swallowing function in detail.
To analyze pre- and postoperative swallowing dynamics kinetically and investigate factors associated with postoperative dysphagia in patients with cervical degenerative disorders.
Retrospective review of prospectively collected data.
A total of 41 consecutive patients who underwent an anterior approach (anterior cervical discectomy/corpectomy and fusion (ACDF, ACCF), hybrid surgery (ACDF+ACCF) and total disc replacement) and 44 consecutive patients who underwent a posterior approach (laminoplasty and laminoplasty/laminectomy with fusion).
We compared the pre- and postoperative functional oral intake scale (FOIS), dysphagia severity scale (DSS), esophageal dysphagia, anterior/superior hyoid movement, upper esophageal sphincter (UES) opening, pharyngeal transit time, bolus residue scale (BRS), and the number of swallows.
Videofluoroscopy was performed on the day before surgery and within two weeks after surgery. Data related to age, gender, disease, surgical procedure, surgical site, operative time, and blood loss were collected from the medical records. Pre- and postoperative data were compared for each item in the anterior and posterior approaches. The odds ratio of dysphagia after an anterior approach was also calculated.
In the anterior approach, DSS, FOIS, the anterior and superior hyoid movements, maximum UES opening, BRS, and number of swallows worsened postoperatively (p<.05, respectively). In the posterior approach, DSS, FOIS, the anterior hyoid movement, and BRS worsened postoperatively (p<.05, respectively). The factors associated with dysphagia were a proximal surgical site above C3 (OR: 14.40, CI: 2.84−73.02), blood loss >100 mL (OR: 9.60, CI: 2.06−44.74), an operative time >200 minutes (OR: 8.18, CI: 1.51−44.49), and an extensive surgical field of more than three intervertebral levels (OR: 6.72, CI: 1.50−30.07). The decline in swallowing function after the posterior approach was related to aging (p=.045).
Each approach may decrease swallowing function, especially because of the limitation on the anterior hyoid movement. Dysphagia after anterior approaches was associated with the operative site, operative time, and blood loss.
Upper Instrumented Vertebrae, Number of Levels Fused, and Plate Morphology Do Not Affect Severity of Chronic Dysphagia After Anterior Cervical Spine Surgery
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Disordered swallowing, or dysphagia, is the most common complication after anterior cervical spine (ACS) surgery. Many operative factors are associated with development of dysphagia. The aim of this study was to explore how number of levels instrumented, specific levels fused, and plate morphology affect chronic dysphagia after ACS surgery.
Consecutive patients referred to a tertiary center for otolaryngology evaluation for chronic dysphagia after ACS surgery between 2012 and 2017 were enrolled. Basic demographic data were obtained. Plain radiographs were reviewed for number of levels fused, upper instrumented vertebrae, and plate morphology. Plate morphology was categorized as a closed, small window, large window, or no profile plate. The 10-item Eating Assessment Tool (EAT-10) was used to assess dysphagia severity.
Of 171 patients referred for dysphagia, 126 met inclusion criteria; 54% were female, with a mean age of 63 years (range, 32–88 years). Mean EAT-10 score was 18.5 ± 10.1. Mean time from spine surgery to videofluoroscopic swallow study for dysphagia was 58.3 months. Mean number of levels fused was 2.2 ± 0.9. There were no significant differences in EAT-10 scores in single-level versus multilevel fusion (19.0 vs. 18.4, P = 0.76) as well as with regard to upper instrumented vertebrae or plate morphology.
In this series of patients with chronic dysphagia following ACS surgery, the severity of dysphagia as measured by the EAT-10 was not affected by upper instrumented vertebrae, number of levels fused, or plate morphology.
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Cervical spondylotic myelopathy (CSM) is an acquired degenerative condition of insidious deterioration of neurologic function due to chronic compression of the cervical spinal cord. Patients commonly require a decompressive surgical procedure to relieve the pressure on the spinal cord and nerve roots, with goals of halting the progressive neurologic deficits and rehabilitating toward improvement. Cervical spine decompression can be achieved both anteriorly and posteriorly. This chapter focuses on anterior surgical approaches to the cervical spine for patients with CSM. Knowledge of pertinent surgical anatomy and surgical technique are key essentials to achieving adequate decompression while maintaining low operative morbidity. This chapter also draws comparisons to the multiple grafts and devices that are used during surgery for these patients.
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Dysphagia, mostly resulting from prevertebral soft tissue swelling (PSTS), is a common and refractory complication of anterior cervical discectomy and fusion (ACDF). Although the symptoms are mild and moderate in most cases, severe dysphagia can incur significant mental burdens and morbidity in some patients. This retrospective study aims to analyze the effect of absorbable collagen sponge and steroid injection (ACS-SI) for patients with ACDF.
A total of 150 patients in the ACS-SI group and 175 in the ACDF without absorbable collagen sponge and steroid injection (ANCS-SI) group were enrolled in this study from the Affiliated Lihuili Hospital of Ningbo University from January 2018 to November 2020. Baseline characteristics and operation parameters were collected from medical records. Swallowing function was evaluated by the Swallowing-Quality of Life (SWAL-QOL) survey, odynophagia was assessed by visual analog scale (VAS), and prevertebral soft tissue swelling index (PSTSI) was measured.
There was no significant difference in baseline characteristics and operation parameters between the 2 groups. The improvement of PSTSI and recovery of swallowing function in the ACS-SI group was better than that in the ANCS-SI group at 1 day and 1-month follow-up visit (P < 0.05). The VAS score was significantly higher at 2 and 7 days after operation in the ANCS-SI group than that in the ACS-SI group (6.61 ± 0.68 vs. 5.52 ± 0.74 and 4.23 ± 0.90 vs. 2.08 ± 0.56, P < 0.05). There was no significant difference in clinical outcomes between the 2 groups after 1 month (P > 0.05).
The use of ACS-SI is beneficial to relieve postoperative odynophagia, reduce PSTS, and recover swallow function.

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Clinical StudyRisk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study

Abstract

Background context

Purpose

Study design

Patient sample

Outcomes measure

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Incidence of risk factors

Discussion

Conclusion

Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures

Spine

Swallowing performance following anterior cervical spine surgery

Br J Neurosurg

Dysphonia and dysphagia following the anterior approach to the cervical spine

Arch Otolaryngol Head Neck Surg

Clinical Study
Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study