Atrophy of the Posterior Cricoarytenoid Muscle as an Indicator of a Recurrent Laryngeal Nerve Injury History Before Revision Anterior Cervical Spine Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVES

In our recent study, we observed some cases of symptomatic normal vocal cord motility instead of asymptomatic vocal cord palsy (VCP) in preoperative laryngoscopy of a revision anterior cervical spine surgery (ACSS) cohort. We assumed the intrinsic muscle atrophy caused by recurrent laryngeal nerve injury could cause vocal cord-related symptoms. Thus, radiological examinations were reviewed in relation to the posterior cricoarytenoid (PCA) muscle, one of the intrinsic muscles.

METHODS

We retrospectively analyzed 64 patients who underwent a revision ACSS. Patients with vocal cord-related symptoms were classified as symptomatic group (group S, n = 11), and those without symptoms as asymptomatic group (group AS, n = 53). The bilateral size and signal intensity of the PCA muscles in these patients were measured in the axial view with preoperative computed tomography (CT) and magnetic resonance imaging (MRI) evaluations. Since the size and signal intensity values were different on each image, the ratios of the contralateral and ipsilateral muscle values were analyzed for each modality.

RESULTS

There was no VCP on laryngoscopy study. However, the mean ratio of the PCA muscle size on CT was 1.40 ± .37 in group S and 1.02 ± .12 in group AS (P = .007). These values on the MRI were 1.49 ± .45 in group S and 1.02 ± .14 in group AS, which was also a significant difference (P = .008).

CONCLUSIONS

Evaluating the size of the PCA muscle before revision ACSS may predict a previous recurrent laryngeal nerve injury. Careful planning for the appropriate approach should be undertaken if vocal cord-related symptoms and atrophy of PCA muscle are evident.

Bilateral recurrent laryngeal nerve palsy following anterior cervical surgery subsequent to contralateral apical lung radiotherapy

Unilateral recurrent laryngeal nerve palsy is a potential complication of the anterior approach for cervical surgery. It is a rare complication of radiotherapy to the neck. Only one case has been reported following radiotherapy apical lung cancer. It can result in unilateral vocal cord paralysis. We report a patient who demonstrated bilateral vocal cord paralysis immediately following right-sided anterior cervical surgery, with significant consequences, including aphonia, respiratory distress and subsequent takotsubo cardiomyopathy. She was diagnosed with acute, (temporary) post-operative right recurrent laryngeal nerve palsy, on the background of undetected and previously asymptomatic left recurrent laryngeal nerve palsy following radiotherapy for left apical lung cancer. The possibility of recurrent laryngeal nerve palsy should be considered in patients with previous apical lung cancer and/ or radiotherapy. Patents undergoing subsequent anterior cervical surgery should be considered for the appropriate precautions in the form of same-side surgery or pre-operative investigation for vocal cord paralysis.

Laryngoscopic Screening Before Revision Anterior Cervical Spine Surgery: Is Vocal Cord Palsy a Relevant Factor in Deciding the Approach Direction?

STUDY DESIGN

Retrospective study.

OBJECTIVES

The aim was to evaluate the exact incidence of vocal cord palsy (VCP) caused by previous anterior cervical spine surgery (ACSS) and aid surgeons in deciding the approach direction in revision ACSS.

SUMMARY OF BACKGROUND DATA

The incidence of VCP detected by preoperative laryngoscopic screening before revision ACSS appeared to be much higher in previous reports than in our experience.

MATERIALS AND METHODS

We reviewed the data of 64 patients who underwent revision ACSS. Preoperative laryngoscopy was performed in all patients to detect VCP and/or structural abnormalities of the vocal cords. The patients' characteristics, laryngoscopy results, and symptoms before revision surgery that were potentially caused by previous recurrent laryngeal nerve injuries (voice change, foreign body sensation, and chronic aspiration) were recorded.

RESULTS

Laryngoscopy demonstrated no complete VCP or decreased vocal cord motility. Eleven patients (17.2%) showed vocal cord-related symptoms and 13 patients (20.3%) showed abnormal laryngoscopic findings without VCP. Four patients (6.2%) showed vocal cord-related symptoms and abnormal laryngoscopic findings simultaneously. At the initial operative level, no significant differences in vocal cord-related symptoms were observed between the upper and lower levels (C3-4-5 vs. C5-6-7). However, the frequency of vocal cord-related symptoms was significantly high at the larger number of levels (≥3 segments) (P=0.010).

CONCLUSIONS

In contrast to previous reports, this study demonstrated that VCP is rarely detected before revision ACSS. Therefore, deciding the approach direction with only vocal cord motility can be dangerous, and more attention is required in setting the approach direction in patients who show both vocal cord-related symptoms and abnormal laryngoscopic finding. In other cases, a contralateral approach which has a low risk of bilateral VCP could be utilized if necessary.

Assessment of Acoustic Voice Parameters After Anterior Cervical Discectomy and Fusion

Background

Anterior cervical discectomy and fusion (ACDF) is a surgical treatment approach for cervical spine diseases. Alteration in voice quality is a commonly encountered concern after perilaryngeal neck surgeries. Vocal cord paralysis is a known complication of ACDF. In this study, we aimed to investigate the effect of ACDF on acoustic voice parameters and to compare ACDF with posterior cervical discectomy and fusion (PCDF).

Methodology

In this study, we investigated 52 patients admitted to the hospital with symptoms related to cervical spinal cord compression and underwent spine surgery in the Neurosurgery Clinic (26 underwent ACDF and 26 underwent PCDF). For standardization, 25 healthy age and gender-matched volunteers were evaluated as the control group. The voices of the patients were analyzed digitally preoperatively and at first and third months postoperatively. As acoustic parameters, jitter, shimmer, basal frequency, and normalized noise energy were recorded. All patients were examined preoperatively and postoperatively for laryngeal pathology and were asked to fill the Voice Handicap Index-10 (VHI-10).

Results

The changes in four of the five acoustic parameters from baseline to postoperative first-month assessment in the ACDF group were significant (p < 0.05). These parameters almost approached normal values in the analysis performed at three months. In the PCDF group, no significant differences were seen in the acoustic analysis of the patients in comparison to the preoperative and the first and third-month assessments. The VHI-10 values were not significantly different among the patients who underwent ACDF or PCDF or control patients at any postoperative time point.

Conclusions

Our study demonstrated that voice parameters in patients who underwent ACDF worsened significantly after the surgery compared with patients who underwent PCDF; however, these changes recovered within three months postoperatively. The possible causes for these findings include the retraction of the vagus and the recurrent laryngeal nerve, postoperative edema of strap muscles, intubation trauma to the vocal folds, and other laryngeal structures.

Correlation of Voice Hoarseness and Vocal Cord Palsy: A Prospective Assessment of Recurrent Laryngeal Nerve Injury Following Anterior Cervical Discectomy and Fusion

BACKGROUND

Injury to the recurrent laryngeal nerve (RLN) has been implicated as a common complication following anterior cervical discectomy and fusion (ACDF) surgery. The purpose of this study is to determine the true incidence of voice hoarseness and RLN palsy following ACDF surgery, to determine the reliability of symptoms in the diagnosis of RLN injury, and to evaluate factors related to the development of these symptoms.

METHODS

All patients undergoing elective (primary or secondary) ACDF surgery at a single institution consented to and enrolled in the present study. All approaches were through the left side. Enrolled patients received both preoperative and postoperative (within 1 month following surgery) laryngoscopy by a fellowship-trained ENT physician for evaluation of RLN function. Patients also responded as to whether they were experiencing postoperative symptoms of dysphagia, aspiration, and voice changes.

RESULTS

In total, 108 patients were included in this study. Mean age of the population was 59.2 ± 10.7 years and mean body mass index was 31.2 ± 7.1 kg/m². Three patients had previously undergone a thyroidectomy, whereas 20 patients had undergone a previous ACDF. Average intubation time for ACDF surgery was 121.6 ± 38.5 minutes. After surgery and excluding patients who were experiencing preoperative symptoms, 19 patients (20.4%) complained of dysphagia, 2 patients (1.9%) complained of aspiration symptoms, and 5 patients (4.6%) complained of voice hoarseness. There was no incidence of vocal cord palsy from postoperative laryngoscopy. From multivariate analysis, endotracheal cuff pressure after retractor placement was correlated to postoperative voice hoarseness, dysphagia, and aspiration symptoms.

CONCLUSIONS

From the results of this prospective study, the RLN remained functional even a month after surgery despite several cases of postoperative dysphagia, aspiration, and voice changes. Endotracheal cuff pressure, number of vertebral levels, body mass index, and intubation time were important variables related to postoperative symptoms.

CLINICAL RELEVANCE

Voice hoarseness does not necessarily indicate recurrent laryngeal nerve injury after ACDF but may be caused by compressive forces on laryngeal tissue during retraction or intubation. Laryngoscopy should be performed in cases with high clinical suspicion.

LEVEL OF EVIDENCE

2.

Recurrent laryngeal nerve injury following single- and multiple-level anterior cervical discectomy and fusion: a meta-analysis

Background

Recurrent laryngeal nerve (RLN) palsy is a common and potentially debilitating complication of anterior cervical discectomy and fusion (ACDF). The relationship between the risk of RLN palsy and the number of operated levels remains unclear, and no previous studies address potential differences between short- and long-term RLN injury following ACDF.

Methods

Electronic searches of PubMed, Cochrane, ScienceDirect and Google Scholar were performed from database inception to June 2019. Relevant studies reporting the rate of RLN palsy for patients undergoing ACDF for cervical spine pathology were identified according to predetermined inclusion and exclusion criteria. Statistical analysis was performed using fixed effects and random effects modelling. I2 and Q statistics were used to explore heterogeneity.

Results

Five studies with a total of 3,514 patients were included in the meta-analysis. The incidence of RLN palsy was found to be 1.2%. There were no statistically significant differences in the rate of RLN palsy between multiple- and single-level ACDF [odds ratio (OR) 1.04; 95% CI: 0.56-1.95; P=0.891, I2=0%]. There were similarly no statistically significant differences in RLN palsy rates for multiple- and single-level ACDF when patients were stratified based on length of follow-up of less than or greater than 12 months.

Conclusions

This analysis suggests that there is no statistically significant association between the number of ACDF operative levels and the risk of short- or long-term RLN palsy.

Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery

OBJECTIVE

To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI.

RESULTS

The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; P = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; P = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, P = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, P = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant.

CONCLUSION

Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.

Assessment of the Reliability of the Fiberoptic Endoscopic Evaluation of Swallowing as an Outcome Measure in Patients Undergoing Revision Anterior Cervical Discectomy and Fusion

BACKGROUND

Dysphagia is one of the most common complications of anterior cervical spine surgery, and there is a need to establish that the means of testing for it are reliable and valid. The objective of this study was to measure observer variability of the fiberoptic endoscopic evaluation of swallowing (FEES) test, specifically when used for evaluation of dysphagia in patients undergoing revisionary anterior cervical decompression and fusion (ACDF).

METHODS

Images from patients undergoing revision ACDF at a single institution were collected from May 1, 2010, through July 1, 2014. Two senior certified speech pathologists independently evaluated the swallowing function of patients preoperatively and at 2 weeks postoperatively. Their numeric evaluations of the Rosenbeck Penetration-Aspiration Scale and the Swallowing Performance Scale during the FEES were then compared for interrater reliability.

RESULTS

Positive agreement between raters was 94% for the preoperative Penetration-Aspiration Scale (prevalence-adjusted bias-adjusted κ, 0.77). The postoperative Penetration-Aspiration Scale showed reliability coefficients for κ, Kendall's W, and intraclass correlation coefficient (ICC) of 0.34 (fair agreement), 0.70 (extremely strong agreement), and 0.35 (poor agreement), respectively. The preoperative Swallowing Performance Scale showed strong agreement, with a Kendall's W coefficient of 0.68, and fair reliability, with an ICC of 0.40. The postoperative Swallowing Performance Scale indicated extremely strong agreement between raters, with a Kendall's W of 0.82, and good agreement, with an ICC of 0.53.

CONCLUSIONS

The FEES test appears to be a reliable assessor of dysphagia in patients undergoing ACDF and may be a useful measure for exploring outcomes in this population.

Voice and swallowing outcomes following reoperative anterior cervical discectomy and fusion with a 2-team surgical approach

OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors' knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.

Indications for Direct Laryngoscopic Examination of Vocal Cord Function Prior to Anterior Cervical Surgery

Recurrent laryngeal nerve palsy (RLNP) is among the most common complications in both thyroid surgeries and anterior approaches to the cervical spine, having both a diverse etiology and presentation. Most bilateral paresis, with subsequent devastating impact on patients, are due to failure to recognize unilateral recurrent laryngeal nerve paralysis and, although rare, are entirely preventable with appropriate history and screening. Recurrent laryngeal nerve palsy has been shown to present asymptomatically in as high as 32% of cases, which yields limitations on exclusively screening with physical examination. Based on the available literature, diagnosis of unilateral RLNP is the critical factor in preventing the occurrence of bilateral RLNP as the surgeon may elect to operate on the injured side to prevent bilateral paresis. Analysis of incidence rates shows postoperative development of unilateral RLNP is 13.1 (95% confidence interval [CI]: 6.1-28.1) and 13.90 (95% CI: 6.6-29.3) times more likely in anterior spine and thyroid surgery, respectively, in comparison with intubation. Currently, there is no consensus on when to order a preoperative laryngoscopic examination prior to anterior cervical spine surgery. The importance of patient history should be emphasized, as it is the basis for indications of preoperative laryngoscopy. Efforts to minimize postoperative complications must be made, especially when considering the rising rate of cervical fusion. This study presents a systematic review of the literature defining key causes of RLNP, with a probability-based protocol to indicate direct laryngoscopy prior to anterior cervical surgery as a screening tool in the prevention of bilateral RLNP.

Complications of Anterior and Posterior Cervical Spine Surgery

Cervical spine surgery performed for the correct indications yields good results. However, surgeons need to be mindful of the many possible pitfalls. Complications may occur starting from the anaesthestic procedure and patient positioning to dura exposure and instrumentation. This review examines specific complications related to anterior and posterior cervical spine surgery, discusses their causes and considers methods to prevent or treat them. In general, avoiding complications is best achieved with meticulous preoperative analysis of the pathology, good patient selection for a specific procedure and careful execution of the surgery. Cervical spine surgery is usually effective in treating most pathologies and only a reasonable complication rate exists.

Recurrent laryngeal nerve injury following reoperative anterior cervical discectomy and fusion: a meta-analysis

OBJECTIVE Recurrent laryngeal nerve (RLN) injury is one of the most frequent complications of anterior cervical discectomy and fusion (ACDF) procedures. The frequency of RLN is reported as 1%-11% in the literature. (4 , 15) The rate of palsy after reoperative ACDF surgery is not well defined. This meta-analysis was performed to review the current medical evidence on RLN injury after ACDF surgery and to determine a relative rate of RLN injury after reoperative ACDF. METHODS MEDLINE, PubMed, and Google Scholar searches were performed using several key words and phrases related to ACDF surgery. Included studies were written in English, addressed revisionary ACDF surgery, and studied outcomes of RLN injury. Statistical analysis was then performed using a random-effects model to calculate a pooled rate of RLN injury. The heterogeneity of the studies was assessed using Cochran's Q statistic and I(2) statistic, and a funnel plot was constructed to evaluate publication bias. RESULTS The search initially identified 345 articles on this topic. Eight clinical articles that met all inclusion criteria were included in the meta-analysis. A total of 238 patients were found to have undergone reoperative ACDF. Thirty-three of those patients experienced an RLN injury. This analysis identified a rate of RLN injury in the literature after reoperative ACDF of 14.1% (95% confidence interval [CI] 9.8%-19.1%). CONCLUSIONS The rate of RLN palsy of 14.1% was greater than any published rate of RLN injury after primary ACDF operations, suggesting that there is a greater risk of hoarseness and dysphagia with reoperative ACDF surgeries than with primary procedures as reported in these studies.

A Tunneled Subcricoid Approach for Anterior Cervical Spine Reoperation: Technical and Safety Results

OBJECTIVE

Anterior cervical spine decompression and fusion are common neurosurgical operations. Reoperation of the anterior cervical spine is associated with increased morbidity. The authors describe a novel subcricoid approach to protect the recurrent laryngeal nerve in a cuff of tissue while facilitating surgical access to the anterior cervical spine.

METHODS

Single institution, consecutive case review of 48 patients undergoing reoperation in the anterior cervical region including the level of C5 and below. Univariable and multivariable regression analysis was used to determine predictors of postoperative morbidity.

RESULTS

No intraoperative complications were reported. Estimated blood loss for the approach was 13.6 ± 3.1 mL. Nine of 48 patients developed immediate postoperative complications, including vocal cord paresis (10.4%), moderate-to-severe dysphagia (10.4%), and neck edema requiring intubation (2.1%). No postoperative hematomas or death occurred. All complications occurred with 4 or more levels of exposure (1-3 disc levels, 0%, vs. ≥ 4 disc levels, 31%). Extension of the exposure to the upper thoracic spine was associated with odds for postoperative complications (adjusted odds ratio, 6.50; 95% confidence interval, 1.14-37.03) and prolonged hospital stay (adjusted increase 4.23 days, P < 0.01).

CONCLUSION

The tunneled subcricoid approach is a relatively safe corridor to reapproach the anterior cervical spine at the level of C5 and below. However, caution must be exercised when using this approach to expose 4 or more disc levels and with extension of the exposure to the upper thoracic spine. Future comparative studies are needed to establish patient selection criteria in determining the use of this technique compared with classic approaches.

Revision surgery for failed cervical spine reconstruction: review article

BACKGROUND

As the number of cervical spine procedures performed continues to increase, the need for revision surgery is also likely to increase. Surgeons need to understand the etiology of post-surgical changes, as well as have a treatment algorithm when evaluating these complex patients.

QUESTIONS/PURPOSES

This study aims to review the rates and etiology of revision cervical spine surgery as well as describe our treatment algorithm.

METHODS

We used a narrative and literature review. We performed a MEDLINE (PubMed) search for "cervical" and "spine" and "revision" which returned 353 articles from 1993 through January 22, 2014. Abstracts were analyzed for relevance and 32 articles were reviewed.

RESULTS

The rates of revision surgery on the cervical spine vary by the type and extent of procedure performed. Patient evaluation should include a detailed history and review of the indication for the index procedure, as well as lab work to rule out infection. Imaging studies including flexion/extension radiographs and computed tomography are obtained to evaluate potential pseudarthrosis. Magnetic resonance imaging is helpful to evaluate the disc, neural elements, soft tissue, and to differentiate scar from infection. Sagittal alignment should be corrected if necessary.

CONCLUSIONS

Recurrent or new symptoms after cervical spine reconstruction can be effectively treated with revision surgery after identifying the etiology, and completing the appropriate workup.

Vocal cord palsy after anterior cervical spine surgery: a qualitative systematic review

BACKGROUND CONTEXT

Vocal cord palsy (VCP) is a known complication of anterior cervical spine surgery. However, the true incidence and interventions to minimize this complication are not well studied.

PURPOSE

To conduct a systematic review to identify the incidence, risk, and interventions for VCP after anterior cervical spine surgery.

STUDY DESIGN

This is a qualitative systematic literature review.

SAMPLE

Prospective and retrospective trials of patients undergoing anterior cervical spine surgery that reported on postoperative VCP or recurrent laryngeal nerve palsy.

OUTCOME MEASURES

Primary: incidence of VCP after anterior cervical spine surgery; secondary: risk factors and interventions for prevention of VCP after anterior cervical spine surgery.

METHODS

Electronic searches were conducted on Ovid Medline, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systemic Reviews for clinical studies reporting VCP in anterior cervical spine surgery, limited to studies published between 1995 and June 2013 in English and French languages. After selection of studies independently by two review authors, data on incidence, risk, and interventions were extracted. Qualitative analysis was performed on three domains: quality of studies, strength of evidence, and impact of interventions.

RESULTS

Our search has identified 187 abstracts, and 34 studies met our inclusion criteria. The incidence of VCP ranges from 2.3% to 24.2%. Significant heterogeneity in study design and definition of VCP were used in the published studies. There is good evidence that reoperation increases the risk of VCP. One study of moderate strength suggests that operating from the right side may increase the risk of VCP. Among the interventions studied, endotracheal tube (ETT) cuff pressure monitoring with deflation during retraction has shown to reduce the incidence from 6% to 2%, but this result was not confirmed by randomized control trials. Limited evidence exists for other interventions of intraoperative electromyographic monitoring and methylprednisolone.

CONCLUSIONS

Vocal cord palsy is a significant morbidity after anterior cervical surgery with incidence up to 24.2% in the immediate postoperative period, with a higher risk in reoperation of the anterior cervical spine. Moderate evidence exists for ETT cuff pressure adjustment in preventing this complication.

Preoperative laryngoscopic examination in patients undergoing repeat anterior cervical discectomy and fusion

STUDY BACKGROUND

Patients who experience a recurrent laryngeal nerve injury (RLI) after undergoing an Anterior Cervical Discectomy and Fusion (ACDF) procedure may eventually become asymptomatic. If patients with an asymptomatic vocal cord abnormality undergo a subsequent ACDF they may be at risk for developing bilateral vocal cord paralysis (VCP). Bilateral VCP is a potentially life threatening problem, requiring emergent tracheotomy in some cases. A program of referring patients for preoperative laryngoscopic examinations (PLE) who were being considered for a revision ACDF was instituted. This study reviews the results of these examinations and determines if the information gained impacted management.

METHODS

Patients who were referred for PLE prior to revision ACDF were identified from a prospectively maintained database during the period 2004 - 2010. All patients underwent examinations by an Otorhinolaryngologist specialist (ENT) using a nasopharyngoscope in combination with video stroboscopic examination.

RESULTS

23 patients were identified as having a PLE and subsequent revision ACDF. 18 patients underwent a single level ACDF and 5 patients underwent a previous 2 level surgery. Significant findings were found in 4 patients. 2 patients presented with asymptomatic VCP and 2 patients with chronic hoarseness. One was found with VCP and the other with a vocal cord mass. The revision procedures were performed on the same side as the previous ACDF.

CONCLUSIONS

17.3% of patients undergoing PLE exhibited abnormalities, affecting decision-making regarding side of approach for revision ACDF. PLE is a simple and effective way of screening patients for abnormalities prior to revision ACDF surgery.