Dysphagia as a Postoperative Complication of Anterior Cervical Discectomy and Fusion

Abstract

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.

The Incidence and Risk Factors Related to Post Operative Dysphagia After Anterior Cervical Spine Surgery: A Prospective Study

“…(14) Older patients (aged > 60 years) are at increased risk for postoperative dysphagia. (7) Although authors of several studies found no correlation between age and dysphagia (3,6,11,14,17), study by Kalb et al found that the mean age of dysphagic and nondysphagic patients was signi cantly different (55 and 50 years, respectively, P = 0.05). (9) This could be explained by anatomic and physiological changes seen in elderly patients like weakening of swallowing muscles, decrease in salivary secretions and decrease in elasticity of oesophagus.…”

“…(6) Dysphagia can prolong the period of hospital stay and also in uence the standard of life of patients in terms of food which patient can eat and di culty in talking to another person to which has a greater effect on quality of life and psychology of patients. (7) However, the pathophysiology of dysphagia after has not been well understood. There are various factors which lead to dysphagia after ACSS which include operative time, use of instrumentation, design and thickness of plate, extent and duration of intraoperative retraction, endotracheal tube cuff pressure, use of steroids, number of levels operated, revision versus primary surgery leading to wide variation in incidence rates of dysphagia.…”

Short-term and Long-term Complications of Cervical Disk Arthroplasty

“…Previous studies have compared the incidence of dysphagia in CDA versus ACDF patients; however, the results have been inconclusive, with authors reporting both higher, lower, or equal rates of dysphagia in arthroplasty versus fusion 24–27 . Some studies in the ACDF literature report the use of intraoperative steroids as a method of reducing risk of dysphagia due to decreases in soft tissue swelling; however, the results have been inconsistent and yet to be shown in the CDA literature 20–22 …”

“…[24][25][26][27] Some studies in the ACDF literature report the use of intraoperative steroids as a method of reducing risk of dysphagia due to decreases in soft tissue swelling; however, the results have been inconsistent and yet to be shown in the CDA literature. [20][21][22]…”

“…31,32 In a meta-analysis by Zavras et al, 31 which included results from a single academic institution with 169 patients as well as 3976 total patients from systematic review reports an incidence of gross device extrusion of 1.2% and 0.3%, respectively. Failure of osseointegration leading to extrusion may also be related to inadequate preparation of the vertebral endplates before Difficulty swallowing 13,18,19 Some studies support the use of IV or local steroids intraoperatively to prevent soft tissue swelling [20][21][22] Laryngeal nerve injury 0-1.25 23 Hoarseness, dysphonia, risk for aspiration 16,23 Careful dissection and retraction of the longus colli muscle [24][25][26][27] Horner syndrome ~0.06 28 Ptosis, anhidrosis, and miosis 28 Careful dissection and retraction of the longus colli muscle 24-27 Hematoma ~0.1 29 May lead to airway compromise or compression of nearby neural structures 29,30 Meticulous hemostasis and caution around vascular structures 29,30 Gross extrusion 0.3 31 Failure of implant osseointegration, risk of device migration and potential esophageal perforation 31,32 Early detection of abnormal postoperative radiographs 33 IV indicates intravenously.…”