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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


• 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


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

• 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



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)



• 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



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%



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



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



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

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