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  1. 1. Dysphagia following Anterior Cervical Discectomy and Fusion Danielle Clark B.S. Case supervisor: Elizabeth Biggio MA CCC-SLP Case Moderator: Dr. Lisa LaGorio
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. Discectomy Single or Multi-level One disk is removed, space between vertebrae must be filled Anterior Cervical Discectomy and Fusion
  6. 6. Bone graft inserted to fill open disk space Prevents collapse of vertebrae Graft connects two vertebrae to create spinal fusion Autograph: Bone removed from patients hip used for graft Bone graft fusion reinforced with metal plate screwed into vertebrae Anterior Cervical Discectomy and Fusion Fusion
  7. 7. Post Surgical Complications Hematoma Edema Recurrent laryngeal nerve palsy Esophageal perforation Worsening of preexisting myelopathy Dysphonia Dysphagia
  8. 8. Question for the audience What would you expect swallowing to look like in an ACDF patient?
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal dysphagia after anterior cervical spine surgery: A review. Global Spine Journal, 3(4), 273-285.
  13. 13. Damage of aerodigestive pathway 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
  14. 14. 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.
  15. 15. 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.
  16. 16. 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.
  17. 17. 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.
  18. 18. 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
  19. 19. 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
  20. 20. Clinical Swallow Evaluation Findings Moderate pharyngeal dysphagia Recommendations Dysphagia therapy 3x/week Diet: Puree with NTL VFSS
  21. 21. Videofluoroscopic Swallow Study
  22. 22. 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
  23. 23. 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
  24. 24. Question for the audience What swallow findings were not consistent with what is typically seen post ACDF?
  25. 25. Patient A Medical history indicated possible diagnosis of multiple sclerosis Seen by neurologist prior to admission to inpatient rehab but diagnosis not confirmed
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. Dysphagia prevalence rates: Objective group: 81% Subjective group: 36% Limitations: No unified diagnostic method to identify dysphagia in MS Lack