National Trends and Correlates of Dysphagia After Anterior Cervical Discectomy and Fusion Surgery

Comparison of the efficacy of ROI-C cage with Zero-P device in anterior cervical discectomy and fusion of cervical degenerative disc disease: a two-year follow-up study

Background

This study aimed to compare the clinical outcomes of Zero-P and ROI-C devices applied to anterior cervical discectomy and fusion (ACDF) surgery of cervical degenerative disc disease (CDDD).

Methods

From January 2020 and December 2020, 56 patients with CDDD who underwent ACDF using Zero-P or ROI-C were included in this retrospective study. The outcomes included visual analogue scale (VAS) score, Japanese Orthopedic Association (JOA) score, neck disability index (NDI) score, Cobb angle, dysphagia, and bone fusion rate. Dysphagia was assessed using the Bazaz grading system. The comparison of outcomes between the two groups was based on the 2-year follow-up time point, which was defined as the last follow-up visit.

Results

The Zero-P group included 16 males and 14 females, with a mean age of 56.2 (range, 35-65) years. The ROI-C group included 11 males and 15 females, with a mean age of 57.4 (range, 36-67) years. There was no significant difference in gender and mean age between the two groups. There were no significant differences in VAS score, JOA score, NDI score, Cobb angle, dysphagia, and bone fusion rate between two groups at the last follow up visit. In the Zero-P group, the duration of surgeries involving C3-4 or C6-7 segments was significantly longer than those including C4-5 or C5-6 segments (135.0 ± 19.0 vs. 105.6 ± 17.5 min, P < 0.05). In surgeries involving C3-4 or C6-7 segments, the operation time of ROI-C was significantly shorter than that of Zero-P (106.5 ± 19.5 vs.112.2 ± 20.5 min, P < 0.05). There were no significant differences in the dysphagia or cage subsidence rates between the Zero-P and ROI-C groups (P > 0.05). The Cobb angle in the last follow-up visit in the Zero-P group (24.4 ± 4.5°) was significantly higher than that in the ROI-C group (18.1 ± 2.3°) (P < 0.05).

Conclusions

ACDF using ROI-C device showed an efficacy similar to the Zero-P device, as well as a shorter operation time for surgeries involving C3-4 or C6-7 segments. However, ROI-C could cause more loss of Cobb angle over time, which could lead to uncomfortable symptoms.

The Effect of the Coronavirus Disease 2019 Pandemic on Pituitary Surgery

OBJECTIVE

As the coronavirus disease 2019 (COVID-19) pandemic spread to the United States in 2020, there was an impetus toward postponing or ceasing nonurgent transsphenoidal pituitary surgeries to prevent the spread of the virus. Some centers encouraged transcranial approaches for patients with declining neurologic function. However, no large-scale data exist evaluating the effects that this situation had on national pituitary practice patterns.

METHODS

Pituitary surgeries in the National Inpatient Sample were identified from 2017 to 2020. Surgeries in 2020 were compared with the 3 years previously to determine any differences in demographics, surgical trends/approaches, and perioperative outcomes.

RESULTS

In 2020, there was a decline in overall pituitary surgeries (34.2 vs. 36.3%; odds ratio (OR), 0.88; P < 0.001) yet transsphenoidal approaches represented a higher proportion of interventions (69.0 vs. 64.9%; P < 0.001). Neurosurgical complications were higher (51.9 vs. 47.4%; OR, 1.13; P < 0.001) and patients were less likely to be discharged home (86.4 vs. 88.5%; OR, 0.84; P < 0.001). This finding was especially true in April 2020 during the first peak in COVID-19 cases, when transcranial approaches and odds of mortality/complications were highest.

CONCLUSIONS

In 2020, transsphenoidal surgery remained the preferred approach for pituitary tumor resection despite initial recommendations against the approach to prevent COVID-19 spread. Pituitary surgeries had a higher risk of periprocedural complications despite accounting for preoperative comorbidities, COVID-19 infection status, and surgical approach, suggesting that an overwhelmed hospital system can negatively influence surgical outcomes in noninfected patients.

Evaluating the Effect of Gastroesophageal Reflux Disease on Postoperative Dysphagia Following Anterior Cervical Spine Surgery-A Prospective, Multicenter Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The purpose of this study was to prospectively evaluate the impact of a preoperative diagnosis of gastroesophageal reflux disease on the incidence and severity of postoperative dysphagia in a multicenter population.

METHODS

After Institutional Review Board approval, written informed consent was obtained from all participating patients. Patients over 18 years of age who underwent an elective anterior cervical discectomy and fusion for a degenerative condition were prospectively enrolled at two academic centers from the years 2018 to 2020. Patients were separated into two groups: those with and without a preoperative diagnosis of GERD. Continuous variables were assessed using either an independent t-test or Mann Whitney U-test for parametric and non-parametric data. All categorical variables were compared using a chi-square test.

RESULTS

A total of 116 patients met study criteria and were subsequently enrolled. Overall rates of postoperative dysphagia increased to 47.3% (n = 53) at 2-weeks but eventually decreased towards the preoperative prevalence of 25.0% at the 24-week mark. Patients with preoperative diagnosis of GERD had lower dysphagia severity scores on a continuous variable analysis in both the DSQ and EAT-10 surveys at 2-week follow-up in addition to the Bazaz survey at 24-week follow-up. Our follow up at 24-weeks was 85.7%.

CONCLUSIONS

Our study shows that having a preoperative diagnosis of GERD has no significant effect on the incidence of dysphagia following ACDF. Nevertheless, having a preoperative diagnosis of GERD does seem to provide some protective effect on the severity of dysphagia that this patient population develops at multiple intervals over a 24-week postoperative period.

The efficacy of post-operative drains for anterior cervical discectomy and fusion: a systematic review and meta-analysis

BACKGROUND

Controversy remains with the use of post-operative subfascial drains for anterior cervical discectomy and fusion, with limited guidelines and a paucity of conclusive evidence. Thus, the aim of this meta-analysis was to analyse and collate an evidence summary to determine the efficacy of such drains.

METHODS

A systematic search of Medline (2002-2022.11), PubMed (2003-2022.11), Scopus (2002-2022.11), Cochrane Library (2015-2022.11) databases and reference lists of articles was conducted as per Cochrane systematic reviews standards. All relevant RCTs and NRCTs were included in this study. Data was extracted in a standardised form and analysed with RevMan version 5.4.1. Bias was assessed with RoB2 tool for RCTs and ROBINS-E tool for NRCTs.

RESULTS

Two RCTs (136 patients) and five NRCTs (7563 patients) were included. These had a moderate to high risk of bias, except for one very high-risk article. Meta-analysis results showed no significant differences for post-operative haematoma (P = 0.31), surgical site infection (P = 0.84), take back to theatre (P = 0.27), length of stay (P = 0.34), and estimated blood loss (P = 0.09). Dysphagia (P = 0.002) and median operative time (P = 0.02) were significantly increased in the drain cohort.

CONCLUSION

The low quality of available data in the included studies is insufficient to estimate the effect of post-operative drains for elective spondylotic ACDF. The findings suggest that if the decision to leave a drain in is left to the surgeon, then there is no difference in the rates of POH, SSI, LOS, or take back to the theatre. The significant association of dysphagia and increased operative time with drains, and the non-significant trend towards increased EBL with drains, must be considered in the context in which procedures may influence the decision to place drains. The results could not be stratified by various confounders that affect the decision-making process, including the number of levels operated. Due to the decreased quality and amount of evidence available, large-scale RCTs that adequately account for confounders should be performed.

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.

Comparing zero-profile and conventional cage and plate in anterior cervical discectomy and fusion using finite-element modeling

Conventional cage and plate (CCP) implants usually used in ACDF surgery, do have limitations such as the development of postoperative dysphagia, adjacent segment degeneration, and soft tissue injury. To reduce the risk of these complications, zero-profile stand-alone cage were developed. We used finite-element modeling to compare the total von Mises stress applied to the bone, disc, endplate, cage and screw when using CCP and ZPSC implants. A 3-dimensional FE (Finite element) analysis was performed to investigate the effects of the CCP implant and ZPSC on the C3 ~ T1 vertebrae. We confirmed that the maximum von Mises stress applied with ZPSC implants was more than 2 times greater in the endplate than that applied with CCP implants. The 3D analysis of the ZPSC model von Mises stress measurements of screw shows areas of higher stress in red. Although using ZPSC implants in ACDF reduces CCP implant-related sequalae such as dysphagia, we have shown that greater von Mises stress is applied to the endplate, and screw when using ZPSC implants. This may explain the higher subsidence rate associated with ZPSC implant use in ACDF. When selecting an implant in ACDF, surgeons should consider patient characteristics and the advantages and disadvantages of each implant type.

Nationwide sample data analysis of additional surgery rate after anterior or posterior cervical spinal surgery

Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40-1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.

Safety and Efficacy of Local Steroid Application on Dysphagia Following Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

To evaluate the safety and efficacy of local steroid application (LSA) on dysphagia after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Dysphagia is one of the most common adverse events in the early postoperative period of ACDF. LSA is reported as an effective method to reduce the swelling of soft tissues, thereby decreasing the incidence of dysphagia. However, the safety and efficacy of LSA on dysphagia after ACDF need to be systematically reviewed and analyzed.

METHODS

A comprehensive literature search was carried out in the database PubMed, Web of Science, EMBASE, Clinical key, Cochrane library, and Wiley Online Library to screen papers that report LSA in ACDF surgery. The Cochrane Collaboration tool and a methodological index for nonrandomized studies were used for the assessment of study quality. Data were analyzed with the Review Manager 5.3 software.

RESULTS

A total of 10 studies were included. The results revealed no significant differences between the steroid group and the control group in ACDF regarding postoperative drainage, estimated blood loss, and neck disability index score (P > 0.05). LSA significantly alleviates visual analog scale score for neck pain (or odynophagia) (P < 0.05), reduces the length of hospital stay (weighted mean difference, -1.00 (-1.05 to -0.95); P < 0.001), and mitigates dysphagia rate and prevertebral soft-tissue swelling in the early postoperative period (P < 0.05). There seemed to be no significant increase in the complication rate and steroid-related adverse events in the steroid group compared with the control group (P < 0.05).

CONCLUSIONS

LSA shows advantages in reducing the length of hospital stay, decreasing dysphagia rate, and mitigating prevertebral soft-tissue swelling in the early postoperative period of ACDF. Further large-scale studies are urgently required for the development of a standard protocol for LSA and further analysis of potential delay complications.

Anterior cervical discectomy and fusion, open-door laminoplasty, or laminectomy with fusion: Which is the better treatment for four-level cervical spondylotic myelopathy?

Four-level cervical spondylotic myelopathy (CSM) is a common disease affecting a large number of people, with the optimal surgical strategy remaining controversial. This study compared the clinical outcomes, radiological parameters, and postoperative complications of primarily performed surgical procedures such as anterior cervical discectomy and fusion (ACDF), open-door laminoplasty (LAMP), and laminectomy with fusion (LF) in treating four-level CSM. A total of 116 patients who received ACDF (38 cases), LAMP (45 cases), and LF (33 cases) were followed up for a minimum of 24 months were enrolled in this study and retrospectively analyzed. Clinical outcomes were evaluated using the Japanese Orthopedic Association (JOA) scoring system, the Neck Disability Index (NDI), and the Visual Analogue Scale (VAS). Changes in the curvature of the cervical spine were determined using the cervical curvature index (CCI) and the C2-C7 Cobb angle. Cervical mobility was evaluated using the C2-C7 range of motion (ROM) and active cervical ROM (aROM). Complications were recorded and compared among the three groups. All patients achieved significant improvement in JOA, NDI, and VAS scores at the final follow-up (P < 0.05), whereas no remarkable difference was found among the groups (P > 0.05). In addition, both C2-7 ROM and aROM were significantly reduced in the three groups and LAMP showed the least reduction relatively. As for complications, LAMP showed the lowest overall incidence of postoperative complications, and patients in the ACDF group were more susceptible to dysphagia, pseudoarthrosis than LAMP and LF. Considering improvements in clinical symptoms and neurological function, no remarkable difference was found among the groups. Nevertheless, LAMP had advantages over the other two surgical procedures in terms of preserving cervical mobility and reducing postoperative complications.

Leveraging HFRS to assess how frailty affects healthcare resource utilization after elective ACDF for CSM

BACKGROUND CONTEXT

Frailty is a common comorbidity associated with worsening outcomes in various medical and surgical fields. The Hospital Frailty Risk Score (HFRS) is a recently developed tool which assesses frailty using 109 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) comorbidity codes to assess severity of frailty. However, there is a paucity of studies utilizing the HFRS with patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

PURPOSE

The aim of this study was to investigate the impact of HFRS on health care resource utilization following ACDF for CSM.

STUDY DESIGN

A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016-2019.

PATIENT SAMPLE

All adult (≥18 years old) patients undergoing primary, ACDF for CSM were identified using the ICD-10 CM codes.

OUTCOME MEASURES

Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total admission costs were assessed.

METHODS

The 109 ICD-10 codes with pre-assigned values from 0.1 to 7.1 pertaining to frailty were queried in each patient, with a cumulative HFRS ≥5 indicating a frail patient. Patients were then categorized as either Low HFRS (HFRS<5) or Moderate to High HFRS (HFRS≥5). A multivariate stepwise logistic regression was used to determine the odds ratio for risk-adjusted extended LOS, non-routine discharge disposition, and increased hospital cost.

RESULTS

A total of 29,305 patients were identified, of which 3,135 (10.7%) had a Moderate to High HFRS. Patients with a Moderate to High HFRS had higher rates of 1 or more postoperative complications (Low HFRS: 9.5% vs. Moderate-High HFRS: 38.6%, p≤.001), significantly longer hospital stays (Low HFRS: 1.8±1.7 days vs. Moderate-High HFRS: 4.4 ± 6.0, p≤.001), higher rates of non-routine discharge (Low HFRS: 5.8% vs. Moderate-High HFRS: 28.2%, p≤.001), and increased total cost of admission (Low HFRS: $19,691±9,740 vs. Moderate-High HFRS: $26,935±22,824, p≤.001) than patients in the Low HFRS cohort. On multivariate analysis, Moderate to High HFRS was found to be a significant independent predictor for extended LOS [OR: 3.19, 95% CI: (2.60, 3.91), p≤.001] and non-routine discharge disposition [OR: 3.88, 95% CI: (3.05, 4.95), p≤.001] but not increased cost [OR: 1.10, 95% CI: (0.87, 1.40), p=.418].

CONCLUSIONS

Our study suggests that patients with a higher HFRS have increased total hospital costs, a longer LOS, higher complication rates, and more frequent nonroutine discharge compared with patients with a low HFRS following elective ACDF for CSM. Although frail patients should not be precluded from surgical management of cervical spine pathology, these findings highlight the need for peri-operative protocols to medically optimize patients to improve health care quality and decrease costs.

A Bibliometric Analysis of the Top 100 Cited Articles in Anterior Cervical Discectomy and Fusion

Study design

A bibliometric analysis.

Objective

To identify and analyze the top 100 cited articles in anterior cervical discectomy and fusion.

Summary of Background Data

Anterior cervical discectomy and fusion (ACDF) is one of the most routine surgical procedures in spine surgery. Many surgeons and academics have researched ACDF thoroughly and published numerous articles. However, there is no relevant bibliometric analysis. Therefore, our study aims to identify and analyze the top 100 cited articles in ACDF to identify the research trends.

Methods

We searched the Web of Science (WOS) Core Collection database with restrictions and identified the top 100 cited publications in ACDF for analysis.

Results

The citation counts of the top 100 cited publications ranged from 37 to 361 (mean 67.42). All studies were published between 2008 and 2019, with 2013 and 2015 the most prolific years. The journals Spine and Journal of Neurosurgery-Spine provided the majority of the articles. Overall, the 100 articles came from 12 countries, with the United States being the top producer, followed by China and South Korea. The most frequent keywords were "spine", "anterior cervical discectomy and fusion", "interbody fusion", 'arthrodesis', "follow-up", "decompression", and "ACDF".

Conclusion

ACDF has been regarded as a classical gold standard in anterior cervical surgery, and the emergence of new surgical procedures has not affected its status. Cervical disc arthroplasty still needs further research and development. As the first bibliometric analysis of ACDF, this bibliometric study is meant to provide guidance for clinicians and scholars to research the development trend of this field.

Frailty as a Superior Predictor of Dysphagia and Surgically Placed Feeding Tube Requirement After Anterior Cervical Discectomy and Fusion Relative to Age

Frailty is a measure of physiological reserve that has been demonstrated to be a discriminative predictor of worse outcomes across multiple surgical subspecialties. Anterior cervical discectomy and fusion (ACDF) is one of the most common neurosurgical procedures in the United States and has a high incidence of postoperative dysphagia. To determine the association between frailty and dysphagia after ACDF and compare the predictive value of frailty and age. 155,300 patients with cervical stenosis (CS) who received ACDF were selected from the 2016-2019 National Inpatient Sample (NIS) utilizing International Classification of Disease, tenth edition (ICD-10) codes. The 11-point modified frailty index (mFI-11) was used to stratify patients based on frailty: mFI-11 = 0 was robust, mFI-11 = 1 was prefrail, mFI-11 = 2 was frail, and mFI-11 = 3 + was characterized as severely frail. Demographics, complications, and outcomes were compared between frailty groups. A total of 155,300 patients undergoing ACDF for CS were identified, 33,475 (21.6%) of whom were frail. Dysphagia occurred in 11,065 (7.1%) of all patients, and its incidence was significantly higher for frail patients (OR 1.569, p < 0.001). Frailty was a risk factor for postoperative complications (OR 1.681, p < 0.001). Increasing frailty and undergoing multilevel ACDF were significant independent predictors of negative postoperative outcomes, including dysphagia, surgically placed feeding tube (SPFT), prolonged LOS, non-home discharge, inpatient death, and increased total charges (p < 0.001 for all). Increasing mFI-11 score has better prognostic value than patient age in predicting postoperative dysphagia and SPFT after ACDF.

Bibliometric and visualized analysis of the top 100 most-cited articles on anterior cervical surgery

Anterior cervical surgery (ACS) owes its development to various pioneering individuals whose revolutionary works form key advances and guide current medical decisions. This bibliometric study aimed to identify, analyse and visualize the main features of the most-cited papers in ACS.

The citation count for the top 100 most-cited articles ranged from 148 to 1,197, and citations per year ranged from 3.1 to 89.8. The articles were published from 1958 to 2016, with the 2000s being the most active decade. There was an inverse correlation between the average citations per year since publication and article age.

The oldest as well as most-cited two articles were both published in 1958 by Smith and Robinson, and Cloward, respectively. In their studies, the authors individually described the technique of anterior cervical discectomy with fusion (ACDF).

The most popular keywords were: ‘fusion’ (22), ‘spine’ (20), ‘cervical spine’ (16), ‘complications’ (15), ‘arthrodesis’ (13), ‘interbody fusion’ (13), ‘bone morphogenetic protein’ (13), and ‘radiculopathy’ (12).

ACDF was the most frequent surgical procedure (80%), while cervical disc arthroplasty is of gradual greater impact.

The surgical techniques of ACDF have remained unaltered for over 60 years. More attempts are needed to promote its development.

Cite this article: EFORT Open Rev 2021;6:1203-1213. DOI: 10.1302/2058-5241.6.210074