A Comparison of Patient-Centered Outcome Measures to Evaluate Dysphagia and Dysphonia After Anterior Cervical Discectomy and Fusion

A Novel Method for Tracking Neck Motions Using a Skin-Conformable Wireless Accelerometer: A Pilot Study

Introduction

Cervical spine disease is a leading cause of pain and disability. Degenerative conditions of the spine can result in neurologic compression of the cervical spinal cord or nerve roots and may be surgically treated with an anterior cervical discectomy and fusion (ACDF) in up to 137,000 people per year in the United States. A common sequelae of ACDF is reduced cervical range of motion (CROM) with patient-based complaints of stiffness and neck pain. Currently, tools for assessment of CROM are manual, subjective, and only intermittently utilized during doctor or physical therapy visits. We propose a skin-mountable acousto-mechanic sensor (ADvanced Acousto-Mechanic sensor; ADAM) as a tool for continuous neck motion monitoring in postoperative ACDF patients. We have developed and validated a machine learning neck motion classification algorithm to differentiate between eight neck motions (right/left rotation, right/left lateral bending, flexion, extension, retraction, protraction) in healthy normal subjects and patients.

Methods

Sensor data from 12 healthy normal subjects and 5 patients were used to develop and validate a Convolutional Neural Network (CNN).

Results

An average algorithm accuracy of 80.0 ± 3.8% was obtained for healthy normal subjects (94% for right rotation, 98% for left rotation, 65% for right lateral bending, 87% for left lateral bending, 89% for flexion, 77% for extension, 50% for retraction, 84% for protraction). An average accuracy of 67.5 ± 5.8% was obtained for patients.

Discussion

ADAM, with our algorithm, may serve as a rehabilitation tool for neck motion monitoring in postoperative ACDF patients. Sensor-captured vital signs and other events (extubation, vocalization, physical therapy, walking) are potential metrics to be incorporated into our algorithm to offer more holistic monitoring of patients after cervical spine surgery.

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.

Evaluating Dysphagia Duration and Severity After ACDF in Patients With Underlying Dysphagia - A Prospective, Multicenter Study

STUDY DESIGN

Prospective Cohort Study.

OBJECTIVES

The purpose of this study was to prospectively evaluate the impact of preoperative dysphagia on the postoperative incidence and severity of dysphagia in patients undergoing ACDF at multiple institutions.

METHODS

After IRB approval, patients over 18 years of age who underwent an elective ACDF for degenerative conditions were prospectively enrolled at two academic centers from 2018 to 2021. Preoperative dysphagia was self-reported by patients through a pre-operative questionnaire on a binary basis. Patients completed dysphagia surveys (Bazaz, Dysphagia Short Questionnaire, 10-item Eating Assessment Tool) to assess dysphagia severity during their preoperative visit, and these dysphagia surveys were repeated immediately postoperatively, at two weeks and again at six, 12, and 24 weeks postoperatively. Patients were stratified into three subgroups based on dysphagia status preoperatively and immediately postoperatively and compared using ANOVA tests or Kruskal-Wallis tests for continuous variables and Pearson chi-square analysis or Fisher's Exact test for categorical variables.

RESULTS

A total of 168 patients (23 with preoperative dysphagia, 145 without preoperative dysphagia) met study criteria and were enrolled in the study. Patients with preoperative dysphagia had less frequent alcohol consumption (23.8% vs 53.7%, P = .0210), and higher rates of dysphagia at 2-weeks (77.8% vs 38.7%, P = .004) and 24-weeks (43.8% vs 14.8%, P = .010) postoperatively. These patients also had higher severity scores for dysphagia on the Bazaz (P = .001), DSQ (P = .012), EAT10 (P = .022) questionnaires at the 2-week follow-up period, higher DSQ scores (P = .036) at the 6-week follow-up period, higher EAT-10 scores (P = .009) at the 12-week follow-up period, and higher Bazaz (P = .001), DSQ (P = .002), and EAT-10 (P = .005) scores at the 24-week follow-up period. There were no differences in demographic, medical history, surgical variables, rates of ENT consultation, length of stay, or other in-hospital events between groups.

CONCLUSIONS

Patients undergoing ACDF who had preoperative dysphagia have prolonged postoperative dysphagia and greater dysphagia severity. Surgeons should be aware of the risk of prolonged dysphagia severity that may persist past 24 weeks after surgery when discussing clinical decisions with patients.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dysphagia after cervical spine surgery: a review of risk factors and preventative measures

Dysphagia is a regular occurrence after cervical spine surgery, and the development of dysphagia postoperatively is associated with worsened quality of life for patients. Despite the frequency and negative implications of this adverse outcome, there is no clear consensus for defining dysphagia within the spinal literature. Numerous patient-reported outcomes questionnaires are currently used to elucidate the presence and severity of postoperative dysphagia, several of which are not validated instruments. This variability in reporting creates difficulty when trying to determine the prevalence of dysphagia and any potential mitigating factors. In the current review, the authors discuss the causes of postoperative dysphagia after cervical spine surgery, metrics for evaluating postoperative dysphagia, risk factors for the development of this adverse outcome, and strategies for preventing its development. Readers will be able to use this information to improve patient outcomes after cervical spine surgery.

The Quality of Life in Citizens with Oropharyngeal Dysphagia—A Cross-Sectional Study

Dysphagia is a risk factor that impaires an individual’s experience of mealtimes. Few studies contribute to the knowledge on the health-related quality of life (HRQoL) of citizens with oropharyngeal dysphagia (OD) living independently. The aim of this study involves evaluating the HRQoL in citizens living independently and suffering from OD. This cross-sectional study was performed in seven municipalities in Denmark between March 2019 and December 2020. The 90 citizens included (54% female, mean age 76.6 years (SD 0.8)) were ≥18 years, as well as diagnosed with OD using the volume-viscosity swallow test and Minimal Eating Observation Form version II. The Dysphagia Handicap Index-DK, Barthel 20, and European Quality of Life-5 Dimensions were fulfilled. Of the participating citizens, 66% of them needed additional time to eat, 64% coughed while eating, and 58% coughed while drinking. Additionally, 60% reported having a dry mouth, 62% needed to drink to succeed with swallowing foods, and 57% had to swallow multiple times. About one-third felt embarrassed when eating with others. They could not enjoy eating in the same manner as they had previously, and/or felt handicapped or limited. OD was shown to have had a high impact on the QoL in citizens with OD living independently. Focus is needed on xerostomia, as well as on the psychological aspects pertainings to mealtimes for citizens with OD.

Dysphagia as a Postoperative Complication of Anterior Cervical Discectomy and Fusion

Anterior cervical discectomy and fusion (ACDF), despite its possible complications, remains the gold standard for the surgical treatment of patients with radiculopathy and/or myelopathy caused by cervical intervertebral disc herniation or spondylosis. Despite its high rate of incidence, postoperative dysphagia following ACDF is still poorly understood; its pathogenesis remains relatively unknown, and its risk factors are still a subject of debate.

The aim of this study is to review the incidence, pathogenesis, diagnosis, and methods of prevention of dysphagia in ACDF patients. To this end, a literature review was conducted based on the PubMed internet database. Article titles were searched by using the following keywords: “dysphagia” and “anterior cervical discectomy and fusion” or “ACDF”. The search was limited to prospective clinical studies evaluating dysphagia after ACDF surgery. Studies published in non-English languages, retrospective studies, cadaveric studies, reviews, case reports, study protocols, and commentary studies were excluded.

Initially, 335 studies were identified after a primary search. After the application of the exclusion criteria, 73 studies remained for the final analysis. This literature review focused on identifying the rate of dysphagia and the various risk factors leading to this complication by comparing and evaluating the current literature with a wide spectrum of heterogeneity concerning patients, surgeons, and surgical techniques. A mean dysphagia rate of 19.4% (95% CI: 9.6%-29.1%) based on the findings of the included studies correlating dysphagia directly with ACDF procedures was calculated. Various established risk factors leading to dysphagia include the female sex, smoking, the surgical approach, rhBMP-2 use, and multilevel surgery, while zero-profile devices seem to reduce dysphagia risk. The diagnosis is based on clinical and radiological findings, especially prevertebral soft-tissue swelling. However, videofluoroscopic and endoscopic studies have been recently used for the evaluation of dysphagia. The role of local administration of steroids in the prevention of dysphagia has not yet been clarified. This review underscores the prevailing rudimentary understanding of the problem of dysphagia after ACDF procedures and highlights the need for more sensitive, factor-specific studies for understanding the impact of various risk factors on the incidence rate of dysphagia.

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.

Combined Anterior Osteophytectomy and Cricopharyngeal Myotomy for Treatment of DISH-Associated Dysphagia

STUDY DESIGN

Retrospective observational case series.

OBJECTIVE

To assess the outcome of patients with diffuse idiopathic skeletal hyperostosis (DISH) with dysphagia who underwent cricopharyngeal myotomy (CPM) in conjunction with anterior osteophytectomy (OP).

METHODS

This is a retrospective observational study of 9 patients that received combined intervention by neurosurgeons and otolaryngologists. Inclusion criteria for surgery consisted of patients who failed to respond to conservative treatments for dysphagia and had evidence of both upper esophageal dysfunction and osteophyte compression. We present the largest series in literature to date including patients undergoing combined OP and CPM.

RESULTS

A total of 88.9% (8/9) of the patients who underwent OP and CPM showed improvement in their symptoms. Of the aforementioned group, 22.2% of these patients had complete resolution of their symptoms, 11.1% did not improve, and only 2 patients showed recurrence of their symptoms. None of the patients in whom surgery was performed required reoperation or suffered serious complication related to the surgical procedures.

CONCLUSION

Based on the literature results, high rate of improvements in dysphagia, and low rate of complications, combined OP and CPM procedures may be beneficial to a carefully selected group of patients.

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.

The Role of Cricopharyngeal Myotomy After Anterior Cervical Decompression and Fusion Operations

BACKGROUND

Anterior cervical spine surgeries have low morbidity, sufficient surgical corridor, and quick recovery times. Although largely considered a safe and effective procedure to address cervical myelopathy, radiculopathy, and deformity, dysphagia is a frequent yet poorly understood adverse event. One treatment is cricopharyngeal myotomy (CPM), which aids in swallowing for patients with refractory issues after anterior cervical decompression and fusion (ACDF).

CASE DESCRIPTION

Here we describe our experience with 6 patients requiring revision ACDF with preoperative dysphagia who were treated with concurrent revision and CPM. Our series demonstrated that CPM is an effective and safe procedure used in combination with an ACDF. In our series, we had 6 patients with dysphagia preoperatively who were all able to undergo ACDF without worsening of their dysphagia despite having risk factors predisposing them to this complication. In our series, 83% of patients either improved or experienced resolution of their symptoms with only 1 patient failing to improve.

CONCLUSIONS

Given its efficacy and safety, patients planned for ACDF with preoperative dysphagia should be evaluated by ENT for potential CPM.