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Dysphagia following Anterior Cervical Discectomy and Fusion
Danielle Clark B.S.
Case supervisor: Elizabeth Biggio MA CCC-SLP
Case Moderator: Dr. Lisa LaGorio
LEARNING OBJECTIVES
• Provide an overview of the Anterior Cervical Discectomy and Fusion procedure
• Review the effects ACDF has on swallowing
• Review current literature on dysphagia in ACDF patients
• Cervical Discectomy and Fusion (CDF): surgery to remove a herniated or degenerative disk of the cervical spine
• Surgery consists of two parts
• Discectomy: Cutting the disk
• Fusion: Insertion of a graft in the empty disc space between two vertebrae
Anterior Cervical Discectomy and Fusion
• Anterior Approach:
• Damaged disc accessed without disturbing the spinal cord
• Incision made in throat area
• Neck muscles, trachea, and esophagus moved to the side to access spine
• Risk of dysphagia and dysphonia
• Posterior approach
• Incision made in the back of the neck to access spine
• Risk of dysphonia, dysphagia, tetraplegia 4
Anterior vs Posterior approach
Discectomy
• Single or Multi-level
• One disk is removed, space between vertebrae must be filled
Anterior Cervical Discectomy and Fusion
• Bone graft inserted to fill open disk space
– Prevents collapse of vertebrae
• Graft connects two vertebrae to create spinal fusion
– Autograph: Bone removed from patient’s hip used for graft
• Bone graft fusion reinforced with metal plate screwed into vertebrae
Anterior Cervical Discectomy and Fusion
Fusion
Post Surgical Complications
• Hematoma
• Edema
• Recurrent laryngeal nerve palsy
• Esophageal perforation
• Worsening of preexisting myelopathy
• Dysphonia
• Dysphagia
Question for the audience
• What would you expect swallowing to look like in an ACDF patient?
Dysphagia following ACDF
• Dysphagia is the one of the most common complications following ACDF
• Swallowing Characteristics after ACDF
• Swelling of pharyngeal wall
• Reduced hyolaryngeal elevation
• Impaired epiglottic inversion
• Poor pharyngeal constriction
• Increased transit time
• Reduced UES opening
• Increased aspiration
• Clinical Signs
• Reflexive coughing
• Globus sensation
• Wet/gurgly voice after swallow
• Extra effort or time to chew or swallow
• Multiple swallows
• Recurring pneumonia
• Weight loss
• Dehydration
Dysphagia following ACDF
Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
• Purpose: Literature review on postoperative dysphagia after anterior cervical spine surgery (ACSS)
• Bazaz Dysphagia Score most commonly used assessment to assess dysphagia after ACSS
• Patients’ dysphagia symptoms graded based on telephone interviews
Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
• Damage of aerodigestivepathway
• Tissue damage with edema
• SLN injury leading to laryngeal sensory impairment
• Injuries to the pharyngeal plexus or vagus nerve, glossopharyngeal nerve, or hypoglossal nerve
• Prevertebreal soft tissue swelling
• Posterior pharyngeal wall edema
• Esophageal edema
• Esophageal denervation
• RLN injury
Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
Causes of dysphagia due to operative techniques
• Dysphagia is the most common postoperative patient complaint after ACSS
• Incidence of dysphagia 1 week post ACSS: 1 to 79%
• Incidence in intermediate to long term postoperative period (1-6 weeks): 28-57%
• Risk factors for dysphagia
• Greater number of levels operated
• Female
• Increased operative time
• Older age (>60 years)
Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior
cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
• Purpose: Assess incidence of dysphagia and present the changes of findings in VFSS after ACDF
• Participants: 47 ACDF patients diagnosed with radiculopathy or myelopathy
• Patients evaluated for preoperative and postoperative dysphagia, 1 week and 1 month post-surgery
• Dysphagia assessed using:
• BAZAZ Dysphagia Score (BDS)
• VFSS based penetration-aspiration scale
• Functional dysphagia scale (FDS)
Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial
videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine
Surgery, 29(4), E177-E181.
• Results:
• 1 Week follow-up
• 83% reported dysphagia (BDS)
• 4.3% had aspiration
• 1 month follow-up
• 59.6% reported dysphagia
• 4.3% had aspiration
• No significant changes in oral transit time, pharyngeal transit time, or pharyngeal delay time
• Conclusions:
• Dysphagia is common until 1 month after ACDF
• High incidence of aspiration and penetration but no reported PNA
• Dysphagia characterized by post-swallow residue in the valleculae and pyriform sinuses
Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial
videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine
Surgery, 29(4), E177-E181.
• Limitations
– No information on how transit times were measured
– Use of FDS
• Penetration:– Sensitivity 81%
– Specify: 70.7%
• Aspiration– Sensitivity: 78.1%
– Specificity: 77.9%
Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial
videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine
Surgery, 29(4), E177-E181.
Patient A
• Caucasian female in her 50s
• Admitted to inpatient rehab following C4-C7 ACDF surgery
• Presented with worsening diffuse weakness and gait dysfunction
• PMH:
• Cervical myelopathy
• Cervical radiculopathy
• Bilateral arm weakness
• Impaired gait
• Traumatic cervical fracture
• Possible MS
Clinical Swallow Evaluation Findings
• Oral phase:– Reduced bolus formation and control
– Reduced mastication
– Increased oral transit time
• Pharyngeal phase– Delayed response trigger 1-2 seconds
– Reduced hyolaryngeal elevation resulting in multiple swallows for purees
• Puree required 2 swallows
– Throat clearing present with thin liquids
– Functional swallow with Nectar thick liquids through straw sips
Clinical Swallow Evaluation Findings
• Moderate pharyngeal dysphagia
• Recommendations
• Dysphagia therapy 3x/week
• Diet: Puree with NTL
• VFSS
Videofluoroscopic Swallow Study
VFSS findings
• Oral phase• Reduced bolus formation and control
• Disorganized A-P transport
• Premature spillage
• mid-posterior tongue residue
• Pharyngeal phase• Delayed trigger 1-2 seconds
• Poor airway protection due to reduced hyolaryngeal excursion
• Reduced epiglottic retroflexion
• Decreased pharyngeal constriction
• Poor BOT and PPW approximation
• Residue: BOT, valleculae, and posterior pharyngeal wall
• Penetration/Aspiration with thin liquids
VFSS Findings
• Recommendations for Patient A:
– Dysphagia Diet with NTL
– No mixed textures
– Continue with dietary restrictions
– Smaller, more frequent meals due to decreased endurance
• ENT Consult
• Mild dysphonia characterized by :
• mildly hoarse, breathy vocal quality
• reduced endurance for conversational exchange due to poor breath support
Question for the audience
• What swallow findings were not consistent with what is typically seen post ACDF?
Patient A
• Medical history indicated possible diagnosis of multiple sclerosis
• Seen by neurologist prior to admission to inpatient rehab but diagnosis not confirmed
Multiple Sclerosis
• Inflammatory, demyelinating, neurodegenerative disorder of the central nervous system (CNS)
• Unknown etiology
• Peak onset: 20-40 years
• Women affected 2x as often as men
• Common symptoms
– Fatigue
– Weakness
– Sensory and/or motor dysfunction of the limbs
– Spasticity
– Gait dysfunction
– Vision loss
Characteristics of Dysphagia in MS
• Oral Stage:
• Difficulties with bolus control and formation
• Poor labial, lingual, and jaw strength
• Mastication difficulties
• Pharyngeal Stage
• Decreased hyolaryngeal elevation
• Decreased pharyngeal constriction
• Delayed swallow trigger
• Purpose: Conduct a systematic review to establish the prevalence of dysphagia in multiple sclerosis
• 15 studies reviewed
• All studies enrolled patients from neurology or MS center
• Studies split into subjective screening and objective measurement groups
• Objective: clinical or instrumental exam to detect dysphagia
• Subjective screening: questionnaire surveys
Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a
systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681.
http://dx.doi.org/10.1007/s10072-015-2067-7
• Subjective screening
– 12 studies
– Dysphagia in Multiple Sclerosis Questionnaire (DYMUS) most widely used
• Objective Screening
– 4 studies
– VFSS/FEES
Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a
systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681.
http://dx.doi.org/10.1007/s10072-015-2067-7
Dysphagia in Multiple Sclerosis Questionnaire (DYMUS)
• 10 items
• Items scored 1 or 0 indicating the presence or absence of an event
• Questions
– Difficulties swallowing food or liquid
– Globus sensation
– Coughing after liquid or solid ingestion
– Multiple swallows
– Weight loss
• Dysphagia prevalence rates:
– Objective group: 81%
– Subjective group: 36%
• Limitations:
• No unified diagnostic method to identify dysphagia in MS
• Lack of cohort or case-control studies
• Study population only included Europeans from developed countries
Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a
systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681.
http://dx.doi.org/10.1007/s10072-015-2067-7
Patient A Plan of Care
• Dysphagia therapy 5x week
• Goals
• Safe tolerance of recommended diet (dysphagia diet with NTL) with dysphagia precautions
• Dysphagia exercises x20 reps
• Effortful swallow
• Masako
• Falsetto
• Lingual press/resistance
Videofluoroscopic Swallow Study
Post-Therapy VFSS results
• Oral Phase
• Intermittent episodes of premature spillage
• Mild oral residue
• Mastication adequate for bolus breakdown
Post-Therapy VFSS Results
• Pharyngeal Phase
• Swallow response timely
• Reduced BOT and PPW approximation
• Hyolaryngeal elevation grossly adequate
• Reduced/absent epiglottic retroflexion
• Reduced pharyngeal constriction
• Residue: BOT, valleculae, PPW
• Flash penetration with thin liquids
• No aspiration
Pre vs. Post-Therapy VFSS
Before Therapy After Therapy
Delayed 1-2 seconds Swallow Response Timely
Reduced Hyolaryngeal excursion
Adequate
reduced Epiglottic retroflexion reduced
Reduced Pharyngeal Constriction
Reduced
Reduced BOT/PPW approximation
Reduced
Present Penetration Flash with thin liquids
Present Aspiration Absent
Post-Therapy VFSS results
• Improved, presenting with mild oropharyngeal dysphagia
• Diet recommendation
• Mechanical soft
• Thin liquids with swallowing strategies
• Safe swallowing strategies
• small bites/sips
• multiple swallows per bolus
• x2 with liquids and x3 with solids
• tilt head forward/down with solids
• cough/clear throat
Patient A Update
• Late summer 2016
– discharged from rehab
– Diagnosed with vocal fold paralysis and muscle tension dysphonia
– Received vocal fold injection to medializeparalyzed VF after discharge
• Fall 2016
– Upgraded to general diet with thin liquids
– Multiple Sclerosis diagnosis confirmed
– Re-admitted to inpatient rehab
Take Home Points
• Dysphagia is a common complication following ACDF
• Dysphagia is common in patients with multiple sclerosis
• It is important to consider that the majority of patients will not have a straightforward case
• Patients are complex, and often times the presenting diagnosis may not be the complete diagnosis
• Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
• Anterior Cervical Discectomy & Fusion (ACDF). (2016). Retrieved from http://www.mayfieldclinic.com/PE-ACDF.htm
• Bergamaschi, R., Crivelli, P., Rezzani, C., Patti, F., Solaro, C., Rossi, P., ... Cosi, V. (2008). The DYMUS questionnaire for the assessment ofdysphagia in multiple sclerosis. Journal of the Neurological Sciences, 269, 49-53. http://dx.doi.org/10.1016/j.jns.2007.12.021
• De Pauw, A., Dejaeger, E., D’hooghe, B., & Carton, H. (2002). Dysphagia in multiple sclerosis. Clinical Neurology and Neurosurgery, 104(4), 345-351.
• Fountas, K. N., Kapsalaki, E. Z., Nikolakakos, L. G., Smisson, H. F., Johnston, K. W., Girgorian, A. A., ... Robinson, J. S. (2007). Anterior cervical discectomy and fusion associated complications. Spine, 32(21), 2310-2317.
• Guan, X., Wang, H., Huang, H., & Meng, L. (2015). Prevalence of dysphagia in multiple sclerosis: a systematic review and meta-analysis. Neurological Sciences, 36(5), 671-681. http://dx.doi.org/10.1007/s10072-015-2067-7
• Min, Y., Kim, W., Kang, S. S., Choi, J. M., Yeom, J. S., & Paik, N. (2016). Incidence of dysphagia and serial videofluoroscopic swallow study findings after anterior cervical discectomy and fusion. Clinical Spine Surgery, 29(4), E177-E181.
• National Multiple Sclerosis Society. (n.d.). MS Symptoms. Retrieved from http://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms
• Northwestern Medicine. (2016). Anterior Cervical Discectomy and Fusion. Retrieved from https://www.nm.org/conditions-and-care-areas/treatments/anterior-cervical-disectomy-and-fusion
• Paik, N. J., Kim, I. S., Kim, J. H., Oh, B. M., & Han, T. R. (2005). Clinical validity of the functional dysphagia scale based on videofluoroscopic swallowing study. Journal of Korean Academy of Rehabilitation Medicine, 29(1), 43-49.
References