Delayed Recurrent Laryngeal Nerve Palsy Following Anterior Cervical Discectomy and Fusion

Recurrent Laryngeal Nerve Injury During Anterior Cervical Discectomy and Fusion (ACDF): A Case Presentation and Review of the Literature

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure used to manage spine pathology including disc herniation, spondylosis, and myelopathy. During the operation, the vertebral segment of interest is accessed via the anterior neck and the disc space is fully resected along with osteophytes to relieve the compression along the affected nerve. While the procedure is regarded as being highly effective in improving symptoms, there are several complications associated with the surgery that patients should be cautioned about. We present a case of a patient with oropharyngeal and cervical esophageal dysphagia and left vocal cord paralysis following a C5/C6, C6/C7, and C7/T1 ACDF for multilevel cervical stenosis and disc herniation. Otolaryngology evaluation confirmed vocal cord paralysis from recurrent laryngeal nerve palsy (RLNP) and the patient's symptoms were managed with a vocal cord injection and speech therapy. This report explores the surgical approach for ACDF along with its complications and postoperative care.

A systematic review of risk factors and adverse outcomes associated with anterior cervical discectomy and fusion surgery over the past decade

Background

Anterior cervical discectomy and fusion (ACDF) is one of the most frequently performed cervical surgeries in the world, yet there have been several reported complications.

Objective

To determine the actual incidence of complications related to ACDF as well as any risk variables that may have been identified in earlier research.

Methods

To evaluate the origin, presentation, natural history, and management of the risks and the complications, we conducted a thorough assessment of the pertinent literature. An evaluation of clinical trials and case studies of patients who experienced one or more complications following ACDF surgery was done using a PubMed, Cochrane Library, and Google Scholar search. Studies involving adult human subjects that were written in the English language and published between 2012 and 2022 were included in the search. The search yielded 79 studies meeting our criteria.

Results

The overall rates of complications were as follows: Dysphagia 7.9%, psudarthrosis 5.8%, adjacent segment disease (ASD) 8.8%, esophageal perforations (EPs) 0.5%, graft or hardware failure 2.2%, infection 0.3%, recurrent laryngeal nerve palsy 1.7%, cerebrospinal fluid leak 0.8%, Horner syndrome 0.5%, hematoma 0.8%, and C5 palsy 1.9%.

Conclusion

Results showed that dysphagia was a common postoperative sequelae with bone morphogenetic protein use and a higher number of surgical levels being the major risk factors. Pseudarthrosis rates varied depending on the factors such as asymptomatic radiographic graft sinking, neck pain, or radiculopathy necessitating revision surgery. The incidence of ASD indicated no data to support anterior cervical plating as more effective than standalone ACDF. EP was rare but frequently fatal, with no correlation found between patient age, sex, body mass index, operation time, or number of levels.

Symptoms and coping of patients with dysphagia after anterior cervical spine surgery: a qualitative study

AIM

To explore the subjective symptoms, psychological characteristics and coping strategies of patients with dysphagia after anterior cervical spine surgery, so as to provide the basis for formulating strategies to help patients with dysphagia solve clinical practice problems and to improve their quality of life after surgery.

METHODS

Using the phenomenological research method and the purpose sampling method, semi-structured interviews were conducted with 22 participants with dysphagia at 3-time points after anterior cervical spine surgery (7 days, 6 weeks, and 6 months).

RESULTS

A total of 22 (10 females and 12 males) patients, with years old ranging between 33 and 78 years were interviewed. When analysing the data, the following 3 categories were extracted from the participant interviews: "Subjective symptoms, Coping style and impact on social life". The 3 categories consist of 10 sub-categories.

CONCLUSIONS

The results showed that swallowing-related symptoms may occur after anterior cervical spine surgery. Many patients had developed compensatory strategies to manage or reduce the burden of these symptoms, but lacked professional guidance from health care professionals. Moreover, dysphagia after neck surgery has its unique characteristics, involving the interaction of physical, emotional and social factors, which requires early screening.Healthcare professionals should provide better psychological support in the early or late postoperative period to ensure the improvement of health outcomes and patients' quality of life.

A scoping review of the methods used to capture dysphagia after anterior cervical discectomy and fusion: the need for a paradigm shift

OBJECTIVE

Dysphagia is the most commonly reported complication of annterior cervical discectomy and fusion (ACDF) surgery. However, the incidence of dysphagia post-ACDF varies widely-partly attributable to differing outcome measures used to capture dysphagia. Our objective was to conduct a scoping review of the literature to quantify which dysphagia outcome measures have been employed post-ACDF and examine trends by study design, year, and location.

METHODS

After removing duplicates, 2396 abstracts were screened for inclusion. A total of 480 studies were eligible for full-text review. After applying exclusion criteria, data was extracted from 280 studies. We extracted the dysphagia outcome measure(s), study design (prospective vs retrospective), year, and location (country). Approximately 10% of studies were repeated for intra-rater agreement.

RESULTS

In total, 317 dysphagia outcome measures were reported in 280 studies (primarily retrospective-63%). The largest proportion of outcome measures were categorized as "unvalidated patient-reported outcome measures" (46%), largely driven by use of the popular Bazaz scale. The next most common categories were "insufficient detail" and "validated patient-reported outcome measures" (both 16%) followed by "chart review/database" (13%) and instrumental assessment (7%). Studies examining dysphagia post-ACDF steadily increased over the years and the use of validated measures increased in the past 10 years.

CONCLUSIONS

This scoping review of the literature highlights that nearly half of the ACDF dysphagia literature relies on unvalidated patient-reported outcome measures. The current understanding of the mechanism, timeline, and presentation of dysphagia post-ACDF are likely limited due to the metrics that are most commonly reported in the literature.

The pharyngeal plexus: an anatomical review for better understanding postoperative dysphagia

The pharyngeal plexus is an essential anatomical structure, but the contributions from the glossopharyngeal and vagus nerves and the superior cervical ganglion that give rise to the pharyngeal plexus are not fully understood. The pharyngeal plexus is likely to be encountered during various anterior cervical surgical procedures of the neck such as anterior cervical discectomy and fusion. Therefore, a detailed understanding of its anatomy is essential for the surgeon who operates in and around this region. Although the pharyngeal plexus is an anatomical structure that is widely mentioned in literature and anatomy books, detailed descriptions of its structural nuances are scarce; therefore, we provide a comprehensive review that encompasses all the available data from this critical structure. We conducted a narrative review of the current literature using databases like PubMed, Embase, Ovid, and Cochrane. Information was gathered regarding the pharyngeal plexus to improve our understanding of its anatomy to elucidate its involvement in postoperative spine surgery complications such as dysphagia. The neural contributions of the cranial nerves IX, X, and superior sympathetic ganglion intertwine to form the pharyngeal plexus that can be injured during ACDF procedures. Factors like surgical retraction time, postoperative hematoma, surgical hardware materials, and profiles and smoking are related to postoperative dysphagia onset. Thorough anatomical knowledge and lateral approaches to ACDF are the best preventing measures.

Complications of anterior cervical spine surgery: a systematic review of the literature

The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.

A Review of Complication Rates for Anterior Cervical Diskectomy and Fusion (ACDF)

Background:

There are multiple complications reported for anterior cervical diskectomy and fusion (ACDF), one of the most common cervical spine operations performed in the US (e.g. estimated at 137,000 ACDF/year).

Methods:

Multiple studies analyzed the risks and complications rates attributed to ACDF.

Results:

In multiple studies, overall morbidity rates for ACDF varied from 13.2% to 19.3%. These included in descending order; dysphagia (1.7%-9.5%), postoperative hematoma (0.4%-5.6% (surgery required in 2.4% of 5.6%), with epidural hematoma 0.9%), exacerbation of myelopathy (0.2%-3.3%), symptomatic recurrent laryngeal nerve palsy (0.9%-3.1%), cerebrospinal fluid (CSF) leak (0.5%-1.7%), wound infection (0.1-0.9%-1.6%), increased radiculopathy (1.3%), Horner’s syndrome (0.06%-1.1%), respiratory insufficiency (1.1%), esophageal perforation (0.3%-0.9%, with a mortality rate of 0.1%), and instrument failure (0.1%-0.9%). There were just single case reports of an internal jugular veing occlusion and a phrenic nerve injury. Pseudarthrosis occurred in ACDF and was dependant on the number of levels fused; 0-4.3% (1-level), 24% (2-level), 42% (3 level) to 56% (4 levels). The reoperation rate for symptomatic pseudarthrosis was 11.1%. Readmission rates for ACDF ranged from 5.1% (30 days) to 7.7% (90 days postoperatively).

Conclusions:

Complications attributed to ACDF included; dysphagia, hematoma, worsening myelopathy, recurrent laryngeal nerve palsy, CSF leaks, wound infection, radiculopathy, Horner’s Syndrome, respiratory insufficiency, esophageal perforation, and instrument failure. There were just single case reports of an internal jugular vein thrombosis, and a phrenic nerve injury. As anticipated, pseudarthrosis rates increased with the number of ACDF levels, ranging from 0-4.3% for 1 level up to 56% for 4 level fusions.