Anterior Cervical Disc Fusion (ACDF) & Dysphagia
My first introduction to the effects of ACDF surgery on swallow function was during my graduate school placement at a large central Florida hospital.
My clearest recollection of that learning moment was “due to pharyngeal swelling (edema), thickened liquids are typically contra-indicated for this population.”
While there is research regarding prevalence and risk factors for developing dysphagia after ACDF surgery, there is a lack of research addressing treatment.
So instead of looking to the research to take our hand and guide treatment, we have to apply what the research tells us about how swallowing is impacted s/p ACDF surgery to deduce the best course of action.
“Postoperative dysphagia after ACDF is a relatively common occurrence in the early postoperative period. It is, however, a relatively transient finding with the vast majority of cases resolving within 3 months.”
Honestly, this sounds like the report from every VFSS, ever. However, the unifying feature resulting in each of these symptoms could be edema….
Let’s talk a little bit more about demographics: Who does this affect?
“Age greater than 60 years was significantly associated with aspiration risk…Surgical level, instrumentation, operative time, and presence of myelopathy or other comorbidities were not” (Smith-Hammond et al., 2004).
“Body mass index, gender, location of surgery, and the number of surgical levels were not related to the risk of developing dysphagia. We observed a correlation between operative time and the severity of postoperative dysphagia” (Rhin et al., 2011).
“Smoking, chronic obstructive pulmonary disease, and female sex are possible factors in the development of postoperative dysphagia” (Siska et al., 2011).
“We found no statistically significant risk factors leading to postoperative dysphagia” (Cameron et al., 2018).
“Postoperatively, 71% of patients having cervical spine surgery reported dysphagia at 2 weeks followup. This incidence decreased to 8% at 12 weeks followup.”
Devil’s advocate: Edema doesn’t equal dysphagia. “Instrumental assessments confirmed a lack of physiological swallowing impairments in some patients despite an increase in pharyngeal wall thickness“ (Lawton, 2020)
Whelp. The research appears to contradict itself. One study says gender is not related to the risk of developing dysphagia, another one says female sex is a possible factor…. Where does that leave us?
Cautious - as always. It means that there are no perfect answers (per the usual). Instead, we have guidelines to point us in a direction. For example, if we receive a dysphagia order for a female over 60 who smokes s/p ACDF surgery - there are some flags there. That’s not to say that a male in his 50s won’t experience dysphagia after ACDF. As with every case, we’re to play detective and suss out all the facts to ensure we’re managing the case appropriately.
We’re responsible for checking in with the latest research to guide our practice. Articles that informed this post are listed below in the resources section - check them out! Don’t rely on my interpretation of the research - let your review of the research inform your clinical practice in the context of where and how you practice.
“ There is a lack of studies addressing behavioral treatments to improve swallow function in this population. ”
Summary
Dysphagia after ACDF is likely (Rihn 2011 reported dysphagia in 71% of ACDF patients).
Dysphagia after ACDF is temporary (generally resolving within 3 months per Rihn 2011).
According to the review of seven studies utilizing instrumentation, pharyngeal wall edema or recurrent laryngeal nerve paralysis are the primary underlying impairments explaining dysphagia and dysphonia in this population (Lawton, 2020).
There are no (known at this time) articles discussing the efficaciousness of treatment modalities for this population.
There is a Patient Reported Outcome Measure (PROM) you can use with this population! Check out Hughes et al. 2018 citation for a link to the article.
Huge Shout Out to Sydney Schumacher for sharing this presentation she created to share with her hospital team!
Click the picture above to download your copy of Sydney’s presentation!
“Clinicians have a duty to understand the underlying physiological changes to the swallow mechanism that occur in each patient to determine the optimal course of treatment. ”
Resources to dig deeper:
Anterior Cervical Disc Fusion (ACDF) and Dysphagia: What we know so far. By: Jolene Lawton MS, CCC-SLP (Starts on page 29)
Anderson, K. K., & Arnold, P. M. (2013). Oropharyngeal Dysphagia after anterior cervical spine surgery: a review. Global spine journal, 3(4), 273–286. https://doi.org/10.1055/s-0033-1354253
APA Hughes, Alexander P. MD1; Salzmann, Stephan N. MD1; Aguwa, Okezie K. MD1; Miller, Courtney Ortiz BS1; Duculan, Roland MD1; Shue, Jennifer MS1; Cammisa, Frank P. MD1; Sama, Andrew A. MD1; Girardi, Federico P. MD1; Kacker, Ashutosh MD2; Mancuso, Carol A. MD1 HSS Dysphagia and Dysphonia Inventory (HSS-DDI) Following Anterior Cervical Fusion, The Journal of Bone and Joint Surgery: May 16, 2018 - Volume 100 - Issue 10 - p e66 doi: 10.2106/JBJS.17.01001
Rihn, J. A., Kane, J., Albert, T. J., Vaccaro, A. R., & Hilibrand, A. S. (2011). What is the incidence and severity of dysphagia after anterior cervical surgery?. Clinical orthopaedics and related research, 469(3), 658–665. https://doi.org/10.1007/s11999-010-1731-8. Open access for this article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032867/
Cameron, K., Lawless, M. H., Conway, R., Paik, G., Tong, D., Soo, T. M., & Lopez, P. P. (2018). Risk Factors for Dysphagia Following a Cervical Fusion in a Trauma Population. Cureus, 10(10), e3489. https://doi.org/10.7759/cureus.3489
Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976). 2004;29(13):1441-1446. doi:10.1097/01.brs.0000129100.59913.ea
Siska PA, Ponnappan RK, Hohl JB, Lee JY, Kang JD, Donaldson WF 3rd. Dysphagia after anterior cervical spine surgery: a prospective study using the swallowing-quality of life questionnaire and analysis of patient comorbidities. Spine (Phila Pa 1976). 2011;36(17):1387-1391. doi:10.1097/BRS.0b013e31822340f2
