Swallowing Characteristics in Zenker's‐like Diverticulum After Anterior Cervical Spine Surgery

Abstract

Objectives: A Zenker's diverticulum (ZD) is a hypopharyngeal pulsion diverticula caused by dysfunction of the cricopharyngeus muscle with herniation of hypopharyngeal mucosa through Killian's dehiscence. Anterior cervical spine surgery (ACSS) can cause a Zenker's-like traction diverticulum (ZTD) with a similar presentation but different pathophysiology. The purpose of this investigation was to compare the fluoroscopic parameters and surgical outcomes of ZTD after ACSS to those of typical ZD.Study Design: Case-control study. Methods: The charts of patients undergoing a videofluoroscopic swallow study after ACSS between January 1, 2014, and January 1, 2018, were evaluated for evidence of ZTD. Patients with ZTD were age and gender matched to persons with ZD. Fluoroscopic parameters and patient-reported outcomes were compared between groups.Results: Eleven patients with ZTD were identified. The mean pharyngeal constriction ratio (PCR) was significantly higher for persons with ZTD (0.87 [AE0.07] vs. 0.17 [AE0.08]; P < 0.05). Mean hyolaryngeal elevation was significantly less (2.5 [AE0.9] cm vs. 3.5 [AE0.7] cm) and mean diverticulum size significantly smaller (1.3 [AE1.0] cm vs. 2.3 [AE2.0] cm) for persons with ZTD (P < 0.05). Five ZTD patients had exposed hardware necessitating open approach for removal.Conclusion: We report the largest cohort of ZTD after ACSS. ZTD are smaller than traditional Zenker's and associated with more pharyngeal weakness, poorer laryngeal elevation, and worse treatment outcomes. Although these diverticula can be managed endoscopically, the high percentage of exposed cervical hardware necessitates a thorough preoperative assessment and frequent need for open management and pharyngeal repair.

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study

“…7,24 Other hypopharyngeal diverticula include iatrogenic, also described as a "Zenker-like" diverticulum, or a traction type, most often associated with cervical spine surgery. 25 Only three patients were reported as an iatrogenic or traction type despite a 22% incidence of prior neck surgery. Prior neck surgery was included in the patient survey instrument as a possible confounder in the study population, with that being said, this is an unusual and surprising incidence of prior surgery compared to the current literature.…”

“…This cohort did not include any LD, which are only referenced in few case reports 7,24 . Other hypopharyngeal diverticula include iatrogenic, also described as a “Zenker‐like” diverticulum, or a traction type, most often associated with cervical spine surgery 25 . Only three patients were reported as an iatrogenic or traction type despite a 22% incidence of prior neck surgery.…”

Treatment of type II odontoid fracture in the elderly

“…We identified 30 cases of zenker’s diverticulum formation after anterior cervical surgery but not in case of ACSF for Odontoid fracture [ 9 , 10 ]. Whilst dysphagia was a recognized complication following ACSF.…”

Fluoroscopic Swallowing Abnormalities in Dysphagic Patients Following Anterior Cervical Spine Surgery

“…21 Traction diverticula were also noted and were defined as pharyngoesophageal diverticula located in the cervical region instrumented during ACSS, by definition these traction diverticula only occur in patients whose cervical esophagus have been instrumented, in contrast to the more common pulsion Zenker’s diverticula. 7 Posterior pharyngeal wall thickness was measured at the level of the UES, from the anterior longitudinal ligament (ALL) of the spine to the posterior pharyngeal wall. 11…”

“…4,5 Long-term complications of ACSS such as hardware erosion through mucosa and development of a Zenker’s-like hypopharyngeal traction diverticulum have also been reported. 6,7 The close proximity of cervical hardware to the pharynx, larynx, and pharyngoesophageal segment may also lead to edema, fibrosis, and stenosis.…”