Quantitative Risk Factor Analysis of Postoperative Dysphagia After Anterior Cervical Discectomy and Fusion (ACDF) Using the Eating Assessment Tool-10 (EAT-10)

Does Operative Level Impact Dysphagia Severity After Anterior Cervical Discectomy and Fusion?: A Multicenter Prospective Analysis

STUDY DESIGN

Prospective multicenter cohort study.

OBJECTIVE

To explore the association between operative level and postoperative dysphagia after anterior cervical discectomy and fusion (ACDF).

BACKGROUND

Dysphagia is common after ACDF and has several risk factors, including soft tissue edema. The degree of prevertebral soft tissue edema varies based on the operative cervical level. However, the operative level has not been evaluated as a source of postoperative dysphagia.

PATIENTS AND METHODS

Adult patients undergoing elective ACDF were prospectively enrolled at 3 academic centers. Dysphagia was assessed using the Bazaz Questionnaire, Dysphagia Short Questionnaire, and Eating Assessment Tool-10 (EAT-10) preoperatively and at 2, 6, 12, and 24 weeks postoperatively. Patients were grouped based on the inclusion of specific surgical levels in the fusion construct. Multivariable regression analyses were performed to evaluate the independent effects of the number of surgical levels and the inclusion of each particular level on dysphagia symptoms.

RESULTS

A total of 130 patients were included. Overall, 24 (18.5%) patients had persistent postoperative dysphagia at 24 weeks and these patients were older, female, and less likely to drink alcohol. There was no difference in operative duration or dexamethasone administration. Patients with persistent dysphagia were significantly more likely to have C4-C5 included in the fusion construct (62.5% vs . 34.9%, P = 0.024) but there were no differences based on the inclusion of other levels. On multivariable regression, the inclusion of C3-C4 or C6-C7 was associated with more severe EAT-10 (β: 9.56, P = 0.016 and β: 8.15, P = 0.040) and Dysphagia Short Questionnaire (β: 4.44, P = 0.023 and (β: 4.27, P = 0.030) at 6 weeks. At 12 weeks, C3-C4 fusion was also independently associated with more severe dysphagia (EAT-10 β: 4.74, P = 0.024).

CONCLUSION

The location of prevertebral soft tissue swelling may impact the duration and severity of patient-reported dysphagia outcomes at up to 24 weeks postoperatively. In particular, the inclusion of C3-C4 and C4-C5 into the fusion may be associated with dysphagia severity.

Ultrasonographic Evaluation of Upper Esophageal Sphincter for Dysphagia During the Acute Postoperative Phase of Anterior Cervical Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

To verify the pathophysiology of dysphagia during the acute postoperative phase of anterior cervical surgery and to identify its predictive features, using ultrasonographic (US) examination for upper esophageal sphincter (UES).

SUMMARY OF BACKGROUND DATA

There are no clinical studies investigating dysphagia after anterior cervical surgery, using US examination for UES.

MATERIALS AND METHODS

We enrolled patients who underwent anterior cervical spine surgery between August 2018 and March 2022. Dysphagia was evaluated using the Eating Assessment Tool-10 (EAT-10) questionnaires. The US examination was performed preoperatively and 2 weeks postoperatively. Three US parameters for morphologic measurements (outer diameter, inner diameter, and muscle thickness) and 4 for functional measurements (displacement, time to relax, passing duration, and time to contract) were assessed. To verify the pathophysiology of postoperative dysphagia, we examined the change in the ratios of US parameters (=US parameter 2 weeks postoperatively /US parameter at baseline ) and the existence of significant correlations with change in the EAT-10 score (=EAT-10 2 weeks postoperatively -EAT-10 at baseline ). To identify the predictive features, the baseline US parameters were compared between dysphagia (+) and dysphagia (-) groups.

RESULTS

A total of 46 patients (mean age, 61.3 y; 78.3% male) were included for analysis. A greater increase of the EAT-10 score after surgery was positively correlated with change ratios of the muscle thickness and time to contract and negatively with change ratio of the inner diameter. The dysphagia (+) group exhibited significantly greater inner diameter and smaller muscle thickness at baseline than the dysphagia (-) group.

CONCLUSION

Dysphagia during the acute postoperative phase of anterior cervical surgery is caused by the physical narrowing of the inner lumen due to muscle thickening of the UES and sphincter contractile dysfunction. In addition, a baseline UES morphology characterized by a greater inner diameter and a thinner muscle layer is predictive of postoperative dysphagia.

Lateral Deviation of the Hyoid Bone and Thyroid Cartilage Influences Prevertebral Soft-Tissue Swelling and Dysphagia After Anterior Cervical Diskectomy and Fusion

BACKGROUND AND OBJECTIVES

Prevertebral soft-tissue swelling (PSTS) after anterior cervical diskectomy and fusion (ACDF) is known to be influenced by several factors. We considered the effect of lateral deviation on the traction force and attempted to find a relationship with the PSTS. This study was designed to evaluate the preoperative lateral deviation of the hyoid bone and thyroid cartilage and its effect on PSTS, airway collapse, and clinical outcomes after ACDF.

METHODS

Preoperative lateral deviations of the hyoid bone and thyroid cartilage at the superior cornu and inferior cornu were measured. To assess the effect of lateral deviation, patients who underwent 1 or 2 level ACDF with the left-sided approach were divided into a deviation group (left-sided deviation >5 mm or >10 mm) and a nondeviation group (left-sided deviation <5 mm or <10 mm). Difference of preoperative and postoperative PSTS (dPSTS), airway collapse, dysphagia score, and Neck Disability Index were compared between the 2 groups.

RESULTS

Lateral deviation was measured in 290 patients, and 145 were enrolled to assess the effect of lateral deviation. Left-sided deviation was more common than right-sided deviation in all 3 structures (the hyoid bone, superior cornu, and inferior cornu of the thyroid cartilage). The deviation group demonstrated a significantly larger dPSTS at the C3 and C4 levels, more airway collapse at the C4 level, and a higher dysphagia score. There was no significant difference in the Neck Disability Index between the 2 groups. Lateral deviation significantly correlated with dPSTS (C3, C4, C5, and C6 levels) and airway collapse (C3 and C4 levels).

CONCLUSION

A left-sided deviation of more than 5 mm of the hyoid bone or thyroid cartilage discouraged the left-sided approach for ACDF because of the aggravation of dPSTS, airway collapse, and dysphagia postoperatively.

Intraoperative Protection of Pharyngeal Autonomic Nerves: Preventing Dysphagia After Anterior Cervical Decompression and Fusion Surgery

OBJECTIVE

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).

METHODS

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.

RESULTS

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).

CONCLUSIONS

The adoption of pharyngeal autonomic nerve protective measures during ACDF can effectively lower the probability of postoperative dysphagia.

Application of Intraoperative Neurophysiological Monitoring (IONM) for Preventing Dysphagia After Anterior Cervical Surgery: A Prospective Study

OBJECTIVE

To evaluate the clinical value of intraoperative nerve monitoring (IONM) for dysphagia after anterior cervical surgery with and without IONM.

METHODS

A prospective, randomized, controlled study was conducted on 46 patients who underwent anterior cervical spine surgery by an experienced orthopaedic surgeon. Twenty-three patients who underwent anterior cervical surgery did not undergo IONM (non-IONM group), while the other 23 patients who underwent anterior cervical surgery did ("IONM group"). The swallowing function of patients was evaluated using the EAT-10 and endoscopic evaluation of swallowing (FEES) after surgery.

RESULTS

There was no difference in the incidence of swallowing difficulties between the intervention group and the control group on the third day or sixth week after surgery. At the 12th week after surgery, the incidence of swallowing difficulties in the intervention group and the control group was significantly different (43.5% vs. 13.0%, P = 0.024).

CONCLUSIONS

IONM is a promising tool for identifying and protecting the spinal cord and nerves during anterior cervical surgery. Our research revealed that IONM significantly reduced the occurrence of swallowing disorders 12 weeks after surgery, but the effect was not significant at the third or sixth week after surgery.

Factors Influencing Early Diagnosis and Poor Prognosis of Dysphagia After Senile Ischemic Stroke

Dysphagia is often a long-term problem after ischemic stroke, which are often accompanied by complications and results in poor outcome. This study aimed to investigate the influencing factors associated with the prognosis of dysphagia after senile ischemic stroke and evaluate the diagnostic performance of crucial factors. A total of 192 elderly ischemic stroke patients (96 patients without dysphagia with average age of 69.81 ± 4.61 years and 96 patients with dysphagia with average of 70.00 ± 6.66 years) were enrolled in the retrospective study. The clinical factors of the patients were collected and recorded for chi-square analysis and logistic analysis. The receiver operating characteristic (ROC) curve was performed to evaluate the diagnostic performance of international normalized ratio (INR) and homocysteine (Hcy) in senile ischemic stroke patients. The age, cough reflex, history of stroke, mechanical ventilation, eating posture, insufficient elevation of the larynx, standard swallowing assessment (SSA) score, Hcy value, and INR were closely related to endpoint events of patients with dysphagia. The joint model (combined INR and Hcy value) can increase the area under the curve (AUC) value (0.948) with higher sensitivity and specificity for predicting patients with dysphagia occurred endpoint events. The influencing factors for older ischemic stroke patients with dysphagia include age, cough reflex, history of stroke, mechanical ventilation, eating posture, insufficient elevation of the larynx, SSA score, Hcy value, and INR. INR and Hcy were independent risk factors for prognosis and diagnostic markers for patients with dysphagia after senile ischemic stroke.

Impact of Frailty and Cervical Radiographic Parameters on Postoperative Dysphagia Following Anterior Cervical Spine Surgery

STUDY DESIGN

Retrospective review of a prospectively collected registry.

OBJECTIVE

The purpose of the present study was to investigate the impact of frailty and radiographical parameters on postoperative dysphagia after anterior cervical spine surgery (ACSS).

SUMMARY OF BACKGROUND DATA

There is a growing body of literature indicating an association between frailty and increased postoperative complications following various surgeries. However, few studies have investigated the relationship between frailty and postoperative dysphagia after anterior cervical spine surgery.

MATERIALS AND METHODS

Patients who underwent anterior cervical spine surgery for the treatment of degenerative cervical pathology were included. Frailty and dysphagia were assessed by the modified Frailty Index-11 (mFI-11) and Eat Assessment Tool 10 (EAT-10), respectively. We also collected clinical demographics and cervical alignment parameters previously reported as risk factors for postoperative dysphagia. Multivariable logistic regression was performed to identify the odds ratio (OR) of postoperative dysphagia at early (2-6 weeks) and late postoperative time points (1-2 years).

RESULTS

Ninety-five patients who underwent ACSS were included in the study. Postoperative dysphagia occurred in 31 patients (32.6%) at the early postoperative time point. Multivariable logistic regression identified higher mFI-11 score (OR, 4.03; 95% CI: 1.24-13.16; P =0.021), overcorrection of TS-CL after surgery (TS-CL, T1 slope minus C2-C7 lordosis; OR, 0.86; 95% CI: 0.79-0.95; P =0.003), and surgery at C3/C4 (OR, 12.38; 95% CI: 1.41-108.92; P =0.023) as factors associated with postoperative dysphagia.

CONCLUSIONS

Frailty, as assessed by the mFI-11, was significantly associated with postoperative dysphagia after ACSS. Additional factors associated with postoperative dysphagia were overcorrection of TS-CL and surgery at C3/C4. These findings emphasize the importance of assessing frailty and cervical alignment in the decision-making process preceding ACSS.

Evaluation of outcome measures for post-operative dysphagia after anterior cervical discectomy and fusion

PURPOSE

The goal is to conduct a review of the current literature to determine and evaluate the current classification metrics available for quantifying post-operative dysphagia.

METHODS

We surveyed the literature for the subjective and objective measures used to classify dysphagia, and further described and analyzed them in the context of post-operative dysphagia (PD) after anterior cervical spine surgery, with a focus on anterior cervical discectomy and fusion (ACDF). We searched PubMed from the years 2005-2021 using the terms "anterior cervical discectomy and fusion" and "dysphagia or postoperative dysphagia." We included papers that were meta-analyses, systemic reviews, prospective, or retrospective studies. Our selection was further consolidated via abstract and title screening. Ultimately, nineteen articles were included and had full-text reviews.

RESULTS

EAT-10 tool was shown to be more valid and reliable than the commonly used Bazaz grading system. HSS-DDI was found to have a high diagnostic accuracy in stratifying mild, moderate, and severe PD. A shortened 16-item version of the original 44-item SWAL-QOL was found to be statistically and clinically significant. When compared to PROMs, objective tests more accurately diagnose PD.

CONCLUSION

We found that the most valuable subjective tests were the EAT-10 and HSS-DI because they are quick, sensitive, and correlated strongly with the well-established measurements of PD. The MBS and FEES provided accurate measurements of the severity of PD, but they required more time and equipment than the surveys. In some patient populations, such as those with pre-surgical dysphagia, objective testing should always be done.

Development and Validation of a Predictive Model to Evaluate the Risk of Dysphagia Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

A retrospective study.

OBJECTIVE

To investigate the potential risk factors of dysphagia after anterior cervical discectomy and fusion (ACDF) and to establish and validate a prediction model.

METHODS

The clinical data of 252 patients who underwent anterior cervical discectomy and fusion in our hospital from January 2018 to October 2020 were retrospectively analyzed and divided into the dysphagia group and the non-dysphagia group according to whether dysphagia occurred after surgery. Age, gender, body mass index, smoking and drinking history, hypertension history, diabetes history, disease duration, placement of Hemovac negative pressure drain, number of segments involved in surgery, whether C4-5/C5-6 segment surgery, incision length, incision position, level of preoperative EAT-10 score, whether preoperative tracheal exercise, and changes in cervical curvature before and after surgery were recorded in both groups. Risk factors for postoperative dysphagia were identified and nomogram prediction models were developed.

RESULTS

A total of 252 patients were included in the study, 115 of whom presented with dysphagia within 1 week after anterior cervical fusion. The results of multivariate logistic regression analysis indicated that male gender (OR = .045, 95% CI .223-.889) and whether preoperative tracheal exercise (OR = .260, 95% CI .107-.633) were independent risk factors associated with reduced incidence of postoperative dysphagia.

CONCLUSION

The incidence of dysphagia symptoms after anterior cervical decompression and fusion gradually decreased with the extension of follow-up time, and preoperative tracheal exercise and shortening the operation time may help to reduce the occurrence of postoperative dysphagia.

Predictive Factors for Dysphagia After Anterior Cervical Spine Surgery: A Prospective Multicenter Study

OBJECTIVE

To identify the incidence and predictors of postoperative dysphagia in patients who undergo anterior cervical spine surgery (ACSS) by utilizing the Eating Assessment Tool (EAT-10).

METHODS

A multicenter prospective study was undertaken at three hospitals to evaluate patients undergoing ACSS between January 2021 and January 2023. Included patients were aged 18-80 years and were undergoing primary or revision ACSS. Dysphagia was assessed using the validated EAT-10 questionnaire. Patients with dysphagia were included in the observation group, and those without dysphagia were included in the control group.

RESULTS

Of the 343 patients enrolled, 50 patients (14.6%) had EAT-10 scores of 3 or more at the 6-month follow-up. In the univariate analysis, patients with dysphagia at 7 days had a longer operative time, were current smokers, had involvement of vertebral bodies at C4 and above, and underwent intraoperative neurophysiological monitoring. Patients with dysphagia at 6 months had involvement of vertebral bodies at C4 and above and underwent intraoperative neurophysiological monitoring. In the multivariate analysis to determine associations with prolonged dysphagia, only the involvement of vertebral bodies at C4 and above (odds ratio 3.883, 95% confidence interval 1.847-8.165, P = 0.001) and intraoperative neurophysiological monitoring (odds ratio 0.273, 95% confidence interval 0.080-0.931, P = 0.038) remained significant.

CONCLUSIONS

Dysphagia is common after ACSS, affecting more than 67.5% of patients at 7 days postoperatively, but over time, the incidence of dysphagia gradually decreases. Involvement of the vertebral bodies at C4 and above is a risk factor for dysphagia after ACSS, and intraoperative neurophysiological monitoring is a protective factor.

The Impact of Preoperative Myelopathy on Postoperative Outcomes among Anterior Cervical Discectomy and Fusion Procedures in the Nonelderly Adult Population: A Propensity-Score Matched Study

STUDY DESIGN

Retrospective cohort study.

PURPOSE

Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for patients diagnosed with cervical degenerative diseases with or without myelopathy. A thorough understanding of outcomes in patients with and without myelopathy undergoing ACDF is required because of the widespread utilization of ACDF for these indications.

OVERVIEW OF LITERATURE

Non-ACDF approaches achieved inferior outcomes in certain myelopathic cases. Studies have compared patient outcomes across procedures, but few have compared outcomes concerning myelopathic versus nonmyelopathic cohorts.

METHODS

The MarketScan database was queried from 2007 to 2016 to identify adult patients who were ≤65 years old, and underwent ACDF using the international classification of diseases 9th version and current procedural terminology codes. Nearest neighbor propensity-score matching was employed to balance patient demographics and operative characteristics between myelopathic and nonmyelopathic cohorts.

RESULTS

Of 107,480 patients who met the inclusion criteria, 29,152 (27.1%) were diagnosed with myelopathy. At baseline, the median age of patients with myelopathy was higher (52 years vs. 50 years, p <0.001), and they had a higher comorbidity burden (mean Charlson comorbidity index, 1.92 vs. 1.58; p <0.001) than patients without myelopathy. Patients with myelopathy were more likely to undergo surgical revision at 2 years (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.54-1.73) or are readmitted within 90 days (OR, 1.27; 95% CI, 1.20-1.34). After patient cohorts were matched, patients with myelopathy remained at elevated risk for reoperation at 2 years (OR, 1.55; 95% CI, 1.44-1.67) and postoperative dysphagia (2.78% vs. 1.68%, p <0.001) compared to patients without myelopathy.

CONCLUSIONS

We found inferior postoperative outcomes at baseline for patients with myelopathy undergoing ACDF compared to patients without myelopathy. Patients with myelopathy remained at significantly greater risk for reoperation and readmission after balancing potential confounding variables across cohorts, and these differences in outcomes were largely driven by patients with myelopathy undergoing 1-2 level fusions.

Comparing Clinical and Radiographic Outcomes Between the Self-locking Stand-alone Cage and Conventional Cage-plate Construct: A Five-year Retrospective Cohort Study

STUDY DESIGN/SETTING

A retrospective cohort study.

OBJECTIVE

To evaluate the clinical efficacy of the self-locking stand-alone (SA) cage and conventional cage-plate construct (CPC) in treating degenerative cervical spondylosis with a five-year follow-up.

SUMMARY OF BACKGROUND DATA

The SA approach was designed to reduce complications associated with traditional anterior cervical discectomy and fusion. These techniques have been shown to have satisfactory short-term clinical outcomes. Literature describing the mid-term clinical outcomes of SA cage is limited.

MATERIALS AND METHODS

We retrospectively analyzed patients with cervical spondylosis who had received an SA device or CPC between 2014 and 2016 at the Xijing Hospital. Participants were matched for sex, age, and operative level. Differences in clinical and radiographic outcomes and the occurrence of postoperative complications between the two groups were analyzed.

RESULTS

In total, 207 patients were included (101 with SA and 106 with CPC), the median follow-up for both groups were 60.2 and 60.9 months. Both groups exhibited significant improvements in all measured values compared with the preoperative values. The SA group had a shorter operation time, less intraoperative blood loss, and a significantly lower incidence of dysphagia after surgery than the CPC group ( P <0.05). At the last visit, cage subsidence was 6.9% and 3.8% in the SA and CPC groups, respectively ( P =0.365). The radiographic adjacent segment degeneration (ASD) was significantly lower in the SA group than in the CPC group (6.9% vs. 27.4%, P <0.01). No symptomatic ASD was observed in the SA group, and six (5.7%) cases occurred in the CPC group ( P =0.029).

CONCLUSIONS

In this study, the SA cage showed similar efficacy to that of the conventional CPC in treating cervical spondylosis using anterior cervical discectomy and fusion, with a significant reduction in the incidence of immediate postoperative dysphagia and mid-term ASD.

Anterior cervical spine surgery and dysphagia

PURPOSE OF REVIEW

The purpose of this review is to summarize current evidence regarding dysphagia in anterior cervical spine surgeries (ACSS) and to present recent advances in evaluation and surgical technique.

RECENT FINDINGS

Various risk factors for dysphagia have been identified, and they include female sex, smoking history, prior surgery and cervical lordotic angle. EAT-10 is a validated tool for the assessment of individuals with dysphagia post-ACSS. Local intraoperative corticosteroid application significantly reduced the incidence and magnitude of dysphagia in four out of five studies that were reviewed. Individuals who had undergone cervical disc replacement (CDR) and revision surgery by a zero-profile anchored spacer (ROI-C) device experienced less dysphagia than those who had anterior cervical discectomy with fusion (ACDF). Videofluoroscopic swallow study (VFSS) after ACSS demonstrated pharyngeal weakness and increased posterior pharyngeal wall thickness, while no other abnormality was found.

SUMMARY

Different technique variations can reduce dysphagia severity in individuals undergoing ACSS. Surgeons are encouraged to continue performing randomized control studies to assist in choosing the most favourable technique for the patient.

Realistic long-term dysphagia rates after anterior cervical discectomy with fusion: is there a correlation with postoperative sagittal alignment and lordosis at a minimum 2-year follow-up?

OBJECTIVE

Postoperative dysphagia after anterior cervical discectomy and fusion (ACDF) has many contributing factors, and long-term data are sparse. The authors evaluated dysphagia after ACDF based on levels fused and cervical sagittal parameters.

METHODS

Patients who underwent ACDF between 2009 and 2018 at the University of California, San Francisco (UCSF), were retrospectively studied. Dysphagia was evaluated preoperatively, immediately postoperatively, and at last follow-up using the UCSF dysphagia score. Dysphagia was categorized as normal (level 7), mild (levels 5 and 6), moderate (levels 3 and 4), and severe (levels 1 and 2). The UCSF mild dysphagia score was further classified as "minimal dysphagia," while moderate and severe dysphagia were classified as "significant dysphagia." "Any dysphagia" included any dysphagia, regardless of grade. Cervical sagittal parameters were measured preoperatively, immediately postoperatively, and at last follow-up.

RESULTS

A total of 131 patients met inclusion criteria. The mean follow-up was 43.89 (24-142) months. Seventy-eight patients (59.5%) reported dysphagia immediately postoperatively, and 44 patients (33.6%) reported some dysphagia at last follow-up (p < 0.001). The rates of moderate dysphagia were 13.0% immediately postoperatively and 1.5% at the last follow-up (p < 0.001). Twenty-two patients (16.8%) had significant dysphagia immediately postoperatively, and 2 patients (1.5%) had significant dysphagia at last follow-up (p < 0.001). Patients with immediate postoperative dysphagia had less C2-7 preoperative lordosis (-9.35°) compared with patients without (-14.15°, p = 0.029), but there was no association between C2-7 lordosis and dysphagia at last follow-up (p = 0.232). The prevalence rates of immediate postoperative dysphagia and long-term dysphagia were 87.5% and 58.3% in ≥ 3-level ACDF; 64.0% and 40.0% in 2-level ACDF; and 43.9% and 17.5% in 1-level ACDF, respectively (p < 0.001).

CONCLUSIONS

The realistic incidence of any dysphagia after ACDF was 59.5% immediately postoperatively and 33.6% at the minimum 2-year follow-up, higher than previously published rates. However, most dysphagia was not severe. The number of fused levels was the most important risk factor for long-term dysphagia, but not for immediate postoperative dysphagia. Loss of preoperative C2-7 lordosis was associated with immediate postoperative dysphagia, but not long-term dysphagia. ACDF segmental lordosis and cervical sagittal vertical axis were not associated with long-term dysphagia in ACDF.

Predictors of Dysphagia After Anterior Cervical Discectomy and Fusion: A Prospective Multicenter Study

STUDY DESIGN

Multicenter prospective study.

OBJECTIVE

Our aim was to evaluate the incidence and predictors of postoperative dysphagia in patients undergoing anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Dysphagia is a common complication after ACDF that can have significant effect on patients' quality of life, but the frequency of occurrence and potential risk factors are not known.

METHODS

A multicenter prospective study was undertaken at three academic sites to evaluate patients undergoing ACDF between September 2018 and September 2020. Included patients were aged 18 to 80 years and were undergoing primary or revision ACDF for a degenerative condition. Dysphagia was assessed using the validated Eating Assessment Tool (EAT-10) questionnaire, with dysphagia defined as EAT-10 ≥ 3.

RESULTS

A total of 170 patients (53.5% female; mean age at surgery 55.0 yr) were included. At preoperative baseline, 23 patients (13.5%) had dysphagia. Rates of dysphagia increased to 45.3% at 2 weeks postoperatively but gradually decreased to 15.3% at 24weeks. On univariate analysis, patients with dysphagia at 2weeks had longer operations (113.1 ± 58.4 vs. 89.0 ± 39.8 minutes, P   =  0.003) and higher baseline dysphagia rates (18.2% vs. 6.2%, P   =  0.018) and were more likely to be female (66.2% vs. 45.7%, P   =  0.009). Patients with prolonged dysphagia had more levels fused (2.1 ± 1.0 vs. 1.7 ± 0.7, P   =  0.020), longer operations (131.8 ± 63.1 vs. 89.3 ± 44.3 min-minutes, P   <  0.001), and higher baseline dysphagia rates (32% vs. 7.1%, P   <  0.001) and were more likely to be smokers (24% vs. 8%, P   =  0.021). On multivariate analysis to determine associations with prolonged dysphagia, only smoking status (OR 6.2, 95% CI 1.57-24.5, P   =  0.009) and baseline dysphagia (OR 5.1, 95% CI 1.47-17.6, P   =  0.01) remained significant.

CONCLUSION

Dysphagia is common immediately after ACDF, but rates of prolonged dysphagia are similar to preoperative baseline rates. We identified dysphagia rates over time and several patient factors associated with development of short- and long-term postoperative dysphagia.Level of Evidence: 3.

Ramifications of Postoperative Dysphagia on Health Care Resource Utilization Following Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate patient risk factors and health care resource utilization associated with postoperative dysphagia following elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

There is a paucity of data on factors predisposing patients to dysphagia and the burden this complication has on health care resource utilization following ACDF.

METHODS

A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016 to 2017. All adult (above 18 y old) patients undergoing ACDF for cervical spondylotic myelopathy were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then categorized by whether they had a recorded postoperative dysphagia or no dysphagia. Weighted patient demographics, comorbidities, perioperative complications, length of hospital stay (LOS), discharge disposition, and total cost of admission were assessed. A multivariate stepwise logistic regression was used to determine both the odds ratio for risk-adjusted postoperative dysphagia as well as extended LOS.

RESULTS

A total of 17,385 patients were identified, of which 1400 (8.1%) experienced postoperative dysphagia. Compared with the No-Dysphagia cohort, the Dysphagia cohort had a greater proportion of patients experiencing a complication (P=0.004), including 1 complication (No-Dysphagia: 2.9% vs. Dysphagia: 6.8%), and >1 complication (No-Dysphagia: 0.3% vs. Dysphagia: 0.4%). The Dysphagia cohort experienced significantly longer hospital stays (No-Dysphagia: 1.9±2.1 d vs. Dysphagia: 4.2±4.3 d, P<0.001), higher total cost of admission (No-Dysphagia: $19,441±10,495 vs. Dysphagia: $25,529±18,641, P<0.001), and increased rates of nonroutine discharge (No-Dysphagia: 16.5% vs. Dysphagia: 34.3%, P<0.001). Postoperative dysphagia was found to be a significant independent risk factor for extended LOS on multivariate analysis, with an odds ratio of 5.37 (95% confidence interval: 4.09, 7.05, P<0.001).

CONCLUSION

Patients experiencing postoperative dysphagia were found to have significantly longer hospital LOS, higher total cost of admission, and increased nonroutine discharge when compared with the patients who did not.

LEVEL OF EVIDENCE

Level III.

Dysphagia Weakly Correlates With Other Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion

Introduction

Dysphagia is a common complication after anterior cervical discectomy and fusion (ACDF), but it is not a routinely asked question in legacy patient-reported outcome measures (PROMs). This study analyzes whether there are associations between dysphagia and legacy outcome measures.

Methods

We retrospectively reviewed 168 patients who underwent ACDF surgery from 2017 to 2019 at a single institution. Demographics, anthropometric data, Neck Disability Index (NDI), Visual Analog Scale (VAS)-Arm and VAS-Neck Pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical and PROMIS-Mental scores, Charlson Comorbidity Index (CCI), and Eating Assessment Tool-10 (EAT-10) were obtained for each patient preoperatively and at one, three, six, and 12 months postoperatively. Pearson’s correlation coefficients were used to evaluate the bivariate correlations between legacy, PROMIS, and EAT-10 measures.

Results

Significant but weak correlations existed between NDI and EAT-10 at one, three, and six months postoperatively (correlation coefficient (R) = 0.31, 0.42, and 0.34 at one, three, and six months, p < 0.001) and VAS-Neck Pain and EAT-10 scores at one, three, and six months postoperatively (R = 0.27, 0.30, and 0.28 at one, three, and six months, p ≤ 0.004). Both PROMIS-Physical and PROMIS-Mental scores showed significant but weak correlations with EAT-10 scores at three and six months postoperatively (R = -0.29 and -0.25, p ≤ 0.01, at three months and R = -0.25 and -0.28, p < 0.01, at six months). In all comparisons of EAT-10 scores with legacy outcome measures, the significance of correlations disappeared by 12 months postoperatively. In addition, there was a positive association between CCI and EAT-10 score (β = 0.37, p < 0.05).

Conclusion

Weak correlations exist between self-reported dysphagia scores and legacy patient-reported outcome measures in patients undergoing ACDF. The correlation strength decreases over time; therefore, dysphagia scores should be reported separately when looking at outcomes after ACDF. Patients with more comorbidities are also at increased risk for dysphagia.

Post-Operative Dysphagia in Anterior Cervical Discectomy and Fusion

OBJECTIVE

We sought to identify risk factors associated with long-term dysphagia, characterize changes in dysphagia over time, and evaluate the incidence of otolaryngology referrals for patients with long-term dysphagia following anterior cervical discectomy with fusion (ACDF).

METHODS

About 56 patients who underwent ACDF between May 2017 to February 2019 were included in the study. All patients were assessed for dysphagia using the Eating Assessment Tool (EAT-10) survey preoperatively and late postoperatively (≥1 year). Additionally, 28 patients were assessed for dysphagia early postoperatively (2 weeks-3 months). Demographic data, medical comorbidities, intraoperative details, and post-operative otolaryngology referral rates were collected from electronic medical records.

RESULTS

Of the 56 patients enrolled, 21 patients (38%) had EAT-10 scores of 3 or more at long-term follow-up. None of the demographics, comorbidities, or surgical factors assessed were associated with long-term dysphagia. Patients who reported no long-term dysphagia had a mean EAT-10 score of 6.9 early postoperatively, while patients with long-term symptoms had a mean score of 18.1 (P = .006). Of the 21 patients who reported persistent dysphagia symptoms, 3 (14%) received dysphagia testing or otolaryngology referrals post-operatively.

CONCLUSION

Dysphagia is a notable side effect of ACDF surgery, but there are no significant demographics, comorbidities, or surgical risk factors that predict long-term dysphagia. Early postoperative characterization of dysphagia using the EAT-10 questionnaire can help predict long-term symptoms. There is inadequate screening and otolaryngology follow-up for patients with post-ACDF dysphagia.

Perioperative and swallowing outcomes in patients undergoing 4- and 5-level anterior cervical discectomy and fusion

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) is a common and robust procedure performed on the cervical spine. Literature on ACDF for 4 or more segments is sparse. Increasing the number of operative levels increases surgical complexity, tissue retraction, and risks of complications, particularly dysphagia. The overall risks of these complications and rates of dysphagia are not well studied for surgery on 4 or more segments. In this study, the authors evaluated their institution's perioperative experience with 4- and 5-level ACDFs.

METHODS

The authors retrospectively reviewed patients who underwent 4- or 5-level ACDF at their institution over a 6-year period (May 2013-May 2019). Patient demographics, perioperative complications, readmission rates, and swallowing outcomes were recorded. Outcomes were analyzed with a multivariate linear regression.

RESULTS

A total of 174 patients were included (167 had 4-level and 7 had 5-level ACDFs). The average age was 60.6 years, and 54.0% of patients (n = 94) were men. A corpectomy was performed in 12.6% of patients (n = 22). After surgery, 56.9% of patients (n = 99) experienced dysphagia. The percentage of patients with dysphagia decreased to 22.8% (37/162) at 30 days, 12.9% (17/132) at 90 days, and 6.3% (5/79) and 2.8% (1/36) at 1 and 2 years, respectively. Dysphagia was more likely at 90 days postoperatively in patients with gastroesophageal reflux (OR 4.4 [95% CI 1.5-12.8], p = 0.008), and the mean (± SD) lordosis change was greater in patients with dysphagia than those without at 90 days (19.8° ± 13.3° vs 9.1° ± 10.2°, p = 0.003). Dysphagia occurrence did not differ with operative implants, including graft and interbody type. The mean length of time to solid food intake was 2.4 ± 2.1 days. Patients treated with dexamethasone were more likely to achieve solid food intake prior to discharge (OR 4.0 [95% CI 1.5-10.6], p = 0.004). Postsurgery, 5.2% of patients (n = 9) required a feeding tube due to severe approach-related dysphagia. Other perioperative complication rates were uniformly low. Overall, 8.6% of patients (n = 15) returned to the emergency department within 30 days and 2.9% (n = 5) required readmission, whereas 1.1% (n = 2) required unplanned return to surgery within 30 days.

CONCLUSIONS

This is the largest series of patients undergoing 4- and 5-level ACDFs reported to date. This procedure was performed safely with minimal intraoperative complications. More than half of the patients experienced in-hospital dysphagia, which increased their overall length of stay, but dysphagia decreased over time.

Anterior Approach to the Subaxial Cervical Spine: Pearls and Pitfalls

Since its introduction by Smith and Robinson, the anterior approach to the subaxial cervical spine has become one of the standard procedures for numerous cervical spine pathologies, including, but not limited to degenerative disease, trauma, tumor, deformity, and instability. Along with its increasing popularity and improvements in anterior instrumentation techniques, a comprehensive knowledge of the surgical anatomy during the anterior exposure is critical for trainees and experienced spine surgeons alike to minimize the infrequent but potentially devastating risks associated with this approach. Understanding the anatomy and techniques to minimize damage to relevant structures can reduce the risks of developing notable postoperative complications and morbidity.

Comparison of Clinical Outcomes and Sagittal Alignment After Different Levels of Anterior Cervical Discectomy and Fusion in Patients With Cervical Spondylotic Myelopathy: From One-level to Three-level

STUDY DESIGN

A nonrandomized and prospective study.

OBJECTIVE

The aim of this study was to compare clinical outcomes and sagittal alignment after one-level, two-level, and three-level anterior cervical discectomy and fusion (ACDF) in patients with cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

ACDF is a widely used surgical approach for CSM. It remains controversial regarding to whether corrected lordosis can be maintained over time after different levels ACDF.

METHODS

A total of 175 patients with cervical spondylotic myelopathy who underwent ACDF were enrolled in this retrospective study. The neurofunctional assessment was performed with the Japanese Orthopedic Association (JOA) score and the recovery rate of JOA score. Radiographic parameters included C2-C7 lordosis, fused segments lordosis, T1 slope, the cervical sagittal vertical axis (cSVA).

RESULTS

Patients with more fusion levels had more operative time and blood loss and higher rate of complications. All patients showed a larger cervical lordosis than that preoperatively and the restored lordosis increased with more segments involved. The restored lordosis had little change during the whole follow-up in one-level and two-level group. CL decreased from 25.65 ± 9.31° on the third postoperative day to 20.25 ± 10.03° at the final follow-up in three-level group (P = 0.001). Only T1 slope in three-level increased significantly from preoperative 26.55 ± 9.36° to 29.06 ± 7.54° on the third postoperative day (P = 0.011) and decreased to 26.89 ± 7.22° (P = 0.043) at final follow-up. The JOA score all increased significantly at the last follow-up in each group, but the recovery rate of the JOA score in each group was similar (P = 0.096).

CONCLUSION

ACDF with different levels had similar postoperative clinical outcomes. Three-level ACDF has an apparent advantage in restoring lordosis, a poor ability to maintain lordosis, and a higher incidence of complications compared to one-level or two-level ACDF.Level of Evidence: 3.

Application of Zero-profile Spacer in the Treatment of Three-level Cervical Spondylotic Myelopathy: 5-year Follow-up Results

STUDY DESIGN

A retrospective study.

OBJECTIVE

To assess the long-term results of zero-profile spacer for 3-level anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Although widely used, there are still controversies about the long-term results of zero-profile spacer, especially in multilevel cases.

METHODS

Cases received 3-level ACDF for cervical spondylotic myelopathy (CSM) using either zero-profile spacer (n = 27) (ZP Group), or plate and cages (n = 34) (PC Group), and with 5-year follow-up were reviewed. Neurological function and life quality were assessed by modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), and Short-Form 36 (SF-36) score. Disc height, cervical lordosis, fusion rate, and surgical complications were observed.

RESULTS

Neurological recovery and life quality improvement were similar in both groups. Disc height and cervical lordosis (C2-7 Cobb angle) were well restored after operations, but lost in both groups during follow-up. Loss of correction (LOC) in disc height was larger in ZP Group (11.38% vs 5.71%, P < 0.05) at 5-year follow-up. LOC of cervical lordosis in ZP group constantly grew from 11.28% to 48.13% during 5-year follow-up, significantly higher than that in the PC group (from 7.43% to 14.01%) (P < 0.05). The rate of postoperative dysphagia was no statistical difference between the two groups, and symptoms were all disappeared within 1 year. There were 10 levels of adjacent segment degeneration (1 in ZP Group, and 10 in PC Group, P = 0.02). Cage subsidence (11 of 81 levels, 13.58%) and screw migration (2 of 81 levels, 2.47%) were only observed in the ZP Group. The migrated screws in one case were surgically removed. Fusion was achieved in all cases.

CONCLUSIONS

In long-term follow-up of 3-level ACDF for CSM, zero-profile spacer has the similar clinical results, but loss of correction of disc height and cervical alignment were significantly higher, compared with anterior plate and cages.

LEVEL OF EVIDENCE

3.

Effect of the Presence and Type of Plate Augmentation on Postoperative Dysphagia Among Adult Patients Undergoing Elective Anterior Cervical Discectomy and Fusion for Spondylosis: A Randomized Trial

OBJECTIVE

To determine the effect of anterior plating on postoperative dysphagia (POD) among adult patients undergoing elective anterior cervical discectomy and fusion (ACDF) for cervical spondylosis and determine the potential role of demographic and clinical characteristics in the development of POD.

METHODS

Consecutive adults undergoing an elective, single-level, ACDF were randomly assigned to receive a stand-alone CoRoent Cage or a CoRoent Cage with a Helix, or HelixMini plate. Patients with a history of cervical spine surgery were excluded. M. D. Anderson Dysphagia Inventory and Bazaz questionnaires were completed at regular intervals for 12 months postoperatively.

RESULTS

Twenty-five patients were recruited over a 2-year period, with 8 allocated to receive a stand-alone cage, 5 to receive a cage and Helix Mini plate, and 12 to receive a cage and Helix plate. The POD rate was 68% at 48 hours, before falling to 16% at 6 and 12 months. A longer retraction time was observed in the Helix plate group compared to the stand-alone cage group (7.88; 95% confidence interval, 0.12-15.63; p = 0.046), although there was no difference in the incidence or severity of dysphagia between cohorts at any timepoint. With the exception of body mass index, there was no difference in patients with and without dysphagia, and each of the interventions was equally efficacious with respect to clinical and radiological endpoints.

CONCLUSION

Dysphagia is a common consequence of ACDF and, while the placement of a large plate results in longer retraction time, it was not associated with higher rates of dysphagia. Further research is required to identify both patient-specific and surgical contributors to this complication.

Effect of local retropharyngeal steroids on fusion rate after anterior cervical discectomy and fusion

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) is considered the gold standard surgical intervention for cervical myelopathy and radiculopathy. Obtaining a solid fusion is an important goal of ACDF, and doing so has correlated with favorable clinical outcomes. A common complication after surgery is postoperative dysphagia. Multiple techniques have been utilized in attempt to prevent and treat dysphagia, including use of retropharygeal steroids.

PURPOSE

To examine the effects of retropharyngeal steroids on fusion rate in ACDF.

STUDY DESIGN

Case control METHODS: Forty-two patients who received local retropharyngeal steroids during ACDF surgery were the sample patient population. The control group consisted of matched cases based on number of spinal levels treated and age at approximately 1:2 case to control ratio. Data were collected on demographic variables, as well as operative and postoperative courses. Radiographic data were collected and fusion determined by <2 mm motion on flexion/extension views and bridging bone. Data were compared between case and control populations. Continuous variables were compared using Student's t test and nominal/ordinal values were compared using Z-test. Fusion status was assessed using Pearson chi-squared test.

RESULTS

A total of 121 patients were reviewed based on matching status and sufficient follow-up. The case and control groups were successfully matched based on age, spinal levels treated, and smoking status. The case group had an overall fusion rate of 64.7%, whereas the control group had a fusion rate of 91%. When analyzed at each level of attempted fusion, the case group had a fusion rate of 81% compared to 93% in the control group. There was a single patient in the case group that developed esophageal rupture and retropharygeal abscess requiring surgical intervention with irrigation, debridement and repair at 8 months after index operation.

CONCLUSIONS

The use of retropharyngeal steroids to mitigate postoperative dysphagia is associated with a decreased rate of radiographic fusion in ACDF surgery.