Dysphagia following ACDF surgery

Upper Chesapeake Spine conference Friday December 4th, 2015

89 year old man Cc: L>R numbness thumb, IF, MF HPI: pins, needles, dropping objects PMH: appy, kidney stents, R knee scope, R TKA 2008, cardiac stents 2011.

MEDS: amlodipine, bystolic, clopidogrel, levothyrsine, omeprazole, sertraline, tolterodine, crestor, losartan, tamsulosin, ca, fish oil, glucosamine, MVI

SH: retired fed employee, RHD, widower twice, smokes 0.3 pk/day, one glass wine and one glass bourbon with dinner.

Exam: 5 feet 8inches, very articulate and intelligent. No CTS findings.

Oral Phase Voluntary muscles of the face and instrinsic musculature of the tongue move food. The tongue is innervated by the Hypoglossal nerve (XII). The soft palate, tongue peristalsis, salivary glands, and facial muscles are coordinated by the facial (VII), glossopharyngeal (IX) and hypoglossal nerves (XII).

Pharyngeal phase

Esophageal phase

Completely involuntary, coordinated peristalsis of esophageal musculature, neural coordination via the autonomous actions in myenteric plexus off Auerbach. The plexus lies between the longitudinal and circular muscle layers of the esophagus, triggered by the vagal nucleus.

50% have some degree of swallowing dysfunction

10% have some difficulty at 12 months

RISK FACTORS: females, age>60, pre-existing swallowing dysfunction, multiple levels

66% of patients with myelopathy hadPreoperative swallowing abnormalitiesSeen with barium swallow, suggesting a Centrally located mechanism by interferingWith preganglionic, sympathetic outflow orSpinal afferents that interrupt local reflexMechanismsFrempong: Swallowing and speech dysfunction in Patients undergoing ACDF. J Spinal Disord Tech 15(5): 362-8, 2002

Postoperative prevertebral or pharyngeal Swelling was observed in 61% of patientsAnd 86% of those had abnormal swallowing Tests Frempong: Swallowing and speech dysfunction in Patients undergoing ACDF. J Spinal Disord Tech 15(5): 362-8, 2002

Glossopharyngeal nerve #9 Hypoglossal nerve #12

C3C4 and above: SLN (pharynx), glossopharangeal, hypoglossal (oral)

C6: RLN Vagus nerve can be injured from retraction of the carotid sheath Pharyngeal swelling can impair epiglottic deflection

Dysphagia post ACDF

Tracey Citrano, MS CCC-SLPShannon Weinheimer, MS CCC-SLP

Dysphagia post ACDF Dysphagia is known to be a common complication of ACDF Causes are multifactorial Proposed causes include recurrent laryngeal nerve palsy and local soft tissue swelling

Studies have attempted to delineate the risk factors for dysphagia, however, results are inconsistent and no firm conclusions can be made

Factors most commonly reported as being an increased risk include increased age (60-65 +), revision surgery, and advanced co-morbidities

Some studies suggest additional risk factors include smoking, female gender, prolonged operative time, and number of levels fused

Dysphagia is usually transient and decreases over time; incidence of dysphagia within one week varies from 1%-79% in the literature

Bazaz et al (2002) Prospectively evaluated 249 patients at 1,2,6, and 12 months post ACDF using a dysphagia score from the Yoo- Bazaz scale with solid and liquid foods

Prevalence at 1 month was 50.2% Prevalence at 2 months was 32.2% Prevalence at 6 months was 17.8% Prevalence at 12 months was 12.5% Type of procedure, use of hardware, and number of levels fused did not increase the prevalence of dysphagia in the study time frame

Olsson et al (2014) Performed a cross sectional cohort of 100 patients who underwent ACDF between 2008 and 2012 at University of North Carolina School of Medicine in Chapel Hill, NC

Patients with pre-existing dysphagia were excluded Surgical technique was similar in all patients Dysphagia assessed with the Yoo-Bazaz questionnaire via telephone 1-5 years post surgery

Rate of dysphagia at an average of 2.75 years (33 months) was 26% Moderate dysphagia reported by 12% of patients; severe dysphagia was reported by 5% of patients

Smokers were more likely to report dysphagia symptoms and dysphagia scores were more severe than non smokers

Age, sex, diagnosis, severity of pain pre-operatively, and number of levels treated did not reach statistical significance

Rihn et al (2010) Prospectively determined the incidence and severity of dysphagia after ACDF with a lumbar control group at Thomas Jefferson University Hospital from April 2008 to July 2008

Patients undergoing 1 or 2 level ACDF (n=38) or posterior lumbar decompression (n=56) were prospectively followed. A dysphagia questionnaire (Bazaz) was administered preoperatively and during the 2 week, 6 week and 12 week postoperative visits.

All surgeries performed in a single institution All approaches were similar Post-operative dysphagia for ACDF: 2 week (71% vs 14%) 6-week (26% vs 7%). 12-week (8% vs 0%) -No significant difference at any follow-up time with comparing patients with two-level vs. one-level

Starmer et al (2014) Discharge data from the Nationwide Inpatient Sample was analyzed for 1,649,871 patients who underwent of ACDF of fewer of 4 vertebrate for benign acquired disease from 2001-2010

Dysphagia was reported in 32,922 cases (2%) Prevalence of dysphagia immediately following surgery ranged from .8 to 78%, Speech therapy dysphagia training was reported in less than .1% of all cases and in .2% cases with dysphagia

Dysphagia was significantly associated with age of 65 or greater, advanced co-morbidity, revision surgery, disc prosthesis placement, and vocal cord paralysis

Dysphagia was a significant predictor of aspiration pneumonia, tracheostomy, gastrostomy tube and speech therapy training

Dysphagia was significantly associated with increased morbidity, length of hospitalization, and hospital related costs

Approximately 1 /15 patients required use of a feeding tube

4% developed aspiration pneumonia during hospital stay, which was associated with increased mortality

Aspiration pneumonia resulted in the greatest increase of hospital stay and costs

Of the ACDF patients diagnosed with aspiration pneumonia, none were referred for speech pathology evaluations

Case Study 89 y/o male w/ hx of tobacco use and L>R numbness, pins and needles in thumb and index fingers and history of dropping objects.

MRI revealed cervical stenosis C3-C6 8/21/15 underwent C3-C6 ACDF Developed post-op dysphagia SLP consulted 8/22/15 Swallow did not improve, MBS completed 8/25/15 MBS revealed silent aspiration of thin and nectar-thick liquids, penetration of honey-thick liquids via cup, and severe residual with puree

Trial diet of puree with honey-thick liquid via spoon was recommended Patient unable to tolerate trial diet, had PEG placed on 9/2/15

Case Study Patient discharged to SAR and participated in ongoing swallowing therapy

Re-admitted with GI bleed on 9/24/15 Patient was PEG tube dependent at time of admission MBS completed 9/28/15 revealed significant improvement with only mild dysphagia. One instance of aspiration with thin liquids with immediate cough response to clear. Residue went from severe to mild and only with liquids. No residue with puree or solids. Recommended diet: regular with thin liquids via small sips via cup. Continue swallowing therapy.

Patient has tolerated diet since admission. Re-admitted on 10/10/15 for abdominal pain, chest CT revealed no infiltrates.

Benefits of SLP consult post ACDF

SLP treatment has been associated to reduce risk of medical and pulmonary complications as well as in hospital morality

Early identification of dysphagia and implementation of appropriate dysphagia can mitigate some of the negative outcomes

SLP treatment has found to reduce aspiration pneumonia, therefore reducing length of stay and hospital costs

Early identification of vocal cord dysfunction ( in collaboration with ENT), as patients with vocal cord paralysis had a 12 fold risk of dysphagia and 7 fold risk of aspiration pneumonia

Post-operative complications of dysphagia and vocal fold paralysis, appear under recognized, which may lead to negative repercussions for the patient’s health and quality of life

Current Role of SLP at UCMC Complete clinical bedside swallow evaluation Recommend an altered diet/liquid consistency if necessary Do not rush to an objective exam such as MBS Monitor the pt over 1-2 days. If pt is still showing signs of significant dysphagia, recommend MBS to determine safest PO diet prior to discharge

Conclusion Dysphagia is the most common complication post ACDF Incidence varies widely Dysphagia decreases over time Documentation of dysphagia may be under reported/under coded

Risk factors may be increased age, prolonged operative time, pre-existing dysphagia, co-morbidities, and/or revision surgery

Speech pathologists are nationally underutilized Early SLP evaluation can reduce risk of aspiration pneumonia, length of hospital stay, hospital costs, and morbidity

Thanks!