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3 Approach-Related Complications Following Anterior Cervical Spine Surgery: Dysphagia, Dysphonia, and Esophageal Perforations

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3 Approach-Related Complications Following Anterior Cervical Spine Surgery: Dysphagia, Dysphonia, and Esophageal Perforations 3 Approach-Related Complications Following Anterior Cervical Spine Surgery: Dysphagia, Dysphonia, and Esophageal Perforations Bharat R. Dave, D. Devanand, and Gautam Zaveri Introduction This chapter analyzes the problems of dysphagia, dysphonia, and esophageal tears during the Pathology involving the anterior subaxial anterior approach to the cervical spine and cervical spine is most commonly accessed suggests ways of prevention and management. through an anterior retropharyngeal approach (Fig. 3.1). While this approach uses tissue planes to access the anterior cervical spine, visceral Dysphagia structures such as the trachea and esophagus and nerves such as the recurrent laryngeal Dysphagia or difficulty in swallowing is a nerve (RLN), superior laryngeal nerve (SLN), and symptom indicative of impairment in the ability pharyngeal plexus are vulnerable to direct or to swallow because of neurologic or structural traction injury (Table 3.1). Complaints such as problems that alter the normal swallowing dysphagia and dysphonia are not rare following process. Postoperative dysphagia is labeled as anterior cervical spine surgery. The treating acute if the patient presents with difficulty in surgeon must be aware of these possible swallowing within 1 week following surgery, complications, must actively look for them in intermediate if the presentation is within 1 to the postoperative period, and deal with them 6 weeks, and chronic if the presentation is longer expeditiously to avoid secondary complications. than 6 weeks after surgery. Common carotid artery Platysma muscle Sternohyoid muscle Vagus nerve Recurrent laryngeal nerve Longus colli muscle Internal jugular artery Anterior scalene muscle Middle scalene muscle External jugular vein Posterior scalene muscle Fig. 3.1 Anterior retropharyngeal approach to the cervical spine. Table 3.1 Vulnerable nerves during ACDF Glossopharyngeal, hypoglossal nerves C3 level or above—oral and pharyngeal phases of swallowing. Superior laryngeal nerve C3–4 level—laryngeal sensory impairment—aspiration, dysphagia. Recurrent laryngeal nerve C6 level or below—milder dysphagia, mainly during swallowing of liquids. Nerves of the pharyngeal plexus Vagus nerve (normally protected by the carotid sheath)—retractional injury at any subaxial cervical levels—C2 to C5—pharyngeal dysphagia. Abbreviation: ACDF, anterior cervical decompression and fusion. 34 Complications in Spine Surgery CHAPTER 3 Approach-Related Complications Following Anterior Cervical Spine Surgery Anatomy and Physiology of Swallowing dysfunction can be divided into four categories: an inability or excessive delay Deglutition in initiating pharyngeal swallowing, aspiration Normal swallowing involves more than 30 of ingested food, nasopharyngeal regurgitation, muscles and is performed up to 600 times a day. and residue of ingested food within the 1 It involves the following three phases (Fig. 3.2): pharyngeal cavity even after swallowing. 1. Oral phase begins with the entry of food into the oral cavity. It involves preparing Incidence the food for digestion by sucking, chewing, The incidence of postoperative dysphagia after and rolling, followed by transport of food anterior cervical decompression and fusion into the throat. Oral phase is voluntary (ACDF) varies widely in literature, ranging from and is mediated by the facial, hypoglossal, 5 to 69%.2–8 Recent prospective studies have and glossopharyngeal nerves. reported a higher incidence when compared 2. Pharyngeal phase starts when the leading with previous retrospective studies.9,10 Bazaz edge of the bolus of food goes past the et al prospectively studied 249 patients who faucial arch. The larynx is elevated, and underwent anterior cervical spine surgery. They there is inversion of the epiglottis with reported difficulty in swallowing in 50.3%, 17.7%, closure of the true and false vocal cords, and 12.5% of their patients at 1, 6, and 12 months preventing aspiration of food or liquid. postsurgery, respectively.8 The wide variation The respiration temporarily ceases, in published incidence rates can be attributed while powerful contractions from the to differences in surgical technique, extent constrictor muscles clears the bolus of of surgery, and the size of the implant used. food from the pharynx. The pharyngeal Variations in the definition of dysphagia and its phase is involuntary and is mediated by measurement, as well as the time period when the SLN, RLN, and pharyngeal plexus. the patient is evaluated, also contributes to the 3. Esophageal phase begins with entry large variation in reported incidence. Although of food through the upper esophageal the incidence of postoperative dysphagia is high, sphincter and its exit through the lower most patients recover within 1 to 3 months esophageal sphincter into the stomach. It postsurgery. Yue et al reported that although 35% involves relaxation and tightening of the of 74 patients had varying degree of persistent esophageal sphincters and coordinated dysphagia when evaluated at 7.2 years following peristalsis of the esophageal musculature. anterior cervical surgery, only 1 patient reported The esophageal phase is mediated by the severe difficulty in swallowing.6 myenteric plexus of Auerbach, triggered by the vagus nerve. Valleculae Pharynx Vellum Hard palate Bolus Tongue Hyoid Vocal folds Epiglottis Trachea Esophagus a b c d Fig. 3.2 Phases of swallowing. (a) Oral preparatory phase. (b) Oral transport phase. (c) Pharyngeal phase. (d) Esophageal phase. Complications in Spine Surgery CHAPTER 3 Approach-Related Complications Following Anterior Cervical Spine Surgery 35 Causes that ipsilateral injury may be asymptomatic. Nerves of the pharyngeal plexus originate from Causes of dysphagia following anterior cervical the vagus nerve. A retraction injury at C2 to spine surgery can be divided into the following: C5 levels causes pharyngeal dysphagia with ••Intrinsic: Edema of the esophageal or difficulty in initiating swallowing, pooling of secretions in the throat, aspiration, choking pharyngeal wall due to excessive or sensation, and often severe dysphagia to both prolonged retraction at surgery or trauma solids and liquids. The glossopharyngeal and during intubation.11 Esophageal tears may hypoglossal nerves are vulnerable during also present with dysphagia. surgeries from C1 to C3. ••Extrinsic: Compression of the esophagus Patients undergoing revision surgery, multi­ or pharynx by a large retropharyngeal level procedures, prolonged surgery, female sex, hematoma (Fig. 3.3) and displaced bone and those in the older age group (> 60 years) are graft, cage, or plate (Fig. 3.4).12,13 at higher risk of dysphagia.11 Sixty­six percent ••Neurologic: Injury to the RLN, SLN, or of patients with cervical myelopathy have been nerves of pharyngeal plexus due to found to have subtle swallowing difficulties prolonged or forceful retraction, nerve on preoperative barium swallow. Spinal cord division, misplaced ligatures, or thermal compression can cause swallowing dysfunction injury due to aggressive use of monopolar by interfering with the preganglionic, sympa­ cautery. thetic outflow or spinal afferents that interrupt Extrinsic compression usually causes dysphagia local reflex mechanisms.16 These patients are to solids. Nerve injury usually results in dys­ more prone to developing worsening of dys­ phagia to both liquids and solids. Injury to phagia postoperatively. the RLN typically occurs at C6 or below. It can result in diminished closure of the glottis Investigations predisposing the patient to aspiration, coughing, and a gasping voice. Denervation of the inferior Radiography of the cervical spine gives the constrictor and cricopharyngeal muscles may initial clues in terms of increase in gas shadow, result in milder forms of dysphagia, especially prevertebral edema/hematoma, graft, and during swallowing of liquids.14,15 The SLN is implant position.17,18 Subjective assessment of vulnerable during anterior approach at C3–4. dys phagia can be done with a questionnaire Sensory innervation is usually bilateral, such and represented semiquantitatively using the a b Fig. 3.3 (a) Postoperative radiograph showing increased Fig. 3.4 Delayed esophageal perf- prevertebral space after surgery due to a large retropharyngeal oration due to backing out of plate hematoma. (b) Hematoma with plate impression removed and screws. during reexploration. 36 Complications in Spine Surgery CHAPTER 3 Approach-Related Complications Following Anterior Cervical Spine Surgery Bazaz-Yoo grading score (Table 3.2). Objective to be the main cause of postoperative assessment can be done with indirect and dysphagia, the trachea and esophagus direct laryngoscopy, video fluoroscopic swallow are manually mobilized by the patient evaluation (VSE), or fiberoptic endoscopic preoperatively. Using the thumb belly, evaluation of swallowing (FEES).8 Other tests the patient is asked to push the thyroid that may be useful include electromyography cartilage across the midline from right to (EMG) to record the electrical activity of the left multiple times a day. This exercise swallowing muscles, an ultrasound to observe started 3 to 4 days before surgery has movement of the swallowing muscles, and been shown to reduce the incidence of esophageal manometry. Indirect laryngoscopy swallowing difficulties after surgery.19 helps evaluate the position of the vocal cords in ••Atraumatic endotracheal intubation. patients with suspected RLN injury. The VSE is •• used to determine the presence, severity, and
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