Dysphagia is a common complication following anterior cervical discectomy and fusion (ACDF) surgery, with reported rates of dysphagia within the first week post-operatively ranging from 1-79% in studies. Risk factors for developing dysphagia may include increased age, pre-existing swallowing issues, multiple medical comorbidities, revision surgery, prolonged operative time, and smoking. While dysphagia usually improves over time, early speech language pathology (SLP) evaluation can help identify dysphagia and reduce risks of complications like aspiration pneumonia that result in longer hospital stays and higher costs.

1. Dysphagia following
ACDF surgery
Upper Chesapeake Spine conference Friday
December 4th, 2015

2. 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.

16. 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).

17. Pharyngeal phase

18. 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.

19. 50% havesomedegreeofswallowingdysfunction
10% havesomedifficultyat12months
RISK FACTORS: females, age>60, pre-existing
swallowing dysfunction, multiple levels

20. 66% of patients with
myelopathy had
Preoperative swallowing abnormalities
Seen with barium swallow, suggesting a
Centrally located mechanism by interfering
With preganglionic, sympathetic outflow or
Spinal afferents that interrupt local reflex
Mechanisms
Frempong: Swallowing and speech dysfunction in
Patients undergoing ACDF. J Spinal Disord Tech
15(5): 362-8, 2002

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

22. Glossopharyngealnerve#9
Hypoglossal nerve #12

23. 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

25. Dysphagia post
ACDF
Tracey Citrano, MS CCC-SLP
Shannon Weinheimer, MS CCC-SLP

26. 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

27. 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

28. 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 2.75years (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

29. 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

30. 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

31. 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

32. 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.

33. 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

34. 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

35. 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

36. Thanks!