anterior cervical nonunion repair

1. Anterior cervical
nonunion repair
Medstar Union Memorial Hospital spine conference
October 23, 2018

2. 48 year old woman neck pain R scapular burning pain shoulder pain, post arm elbow (presentat
August 2018), pain onset in 2017 2 years postop PMH: C4C7 ACDF 7/29/15, no dysphagia or
dysphonia postop, L5S1 disc 2010, L CTR, sinus surgery, chole, SH: RHD nurse VA married, 2 gro
children, nonsmoker PE: 5’7” 185 lb

4. 8/27/18

5. Causes of pain recurrence
following spinal fusion surgery
 Non-union
 Adjacent segment degeneration:
disc, facet, stenosis, instability
 Pain generator not included in fusion
 Pain generator not in spine

11. 3 patients in 65 articles
g time dx 2 years and Median time to dx 44 days
senting sx: dysphagia 63, fever 24, neck swelling 23, wound leakage 18
sphagia and odynophagia

12. Cause of esophageal perforation
stratified by time to diagnosis

14. ct 9/27/17
9mm
Graft
c6c7

15. 8/27/18
c6

16. c5c6
c6c7

19. Problem list:
1. C6C7 non-union with collapse
2. Symptoms of axial neck pain and R upper
extremity scapular, triceps and elbow
3. Anterior migrated cervical screws
4. Eroded C7 body
5. If long fusion mass C4C7 already
6. Options:
1. Anterior only c6c7 revision acdf, iliac
crest, corpectomy?
2. Posterior only c6c7 fusion:
instrumented?
3. Anterior/posterior
4. Foramenotomy?

20. ACDF implant
options
 Iliac crest
 Fibular allograft
 Corticocancellous composite
allograft
 Carbon fiber
 Polyetheretherketone (PEEK)
 Porous tantalum
 Threaded titanium

22. NON-UNION RISK FACTORS
 Metabolic
 Smoking (40%)
 Infection
 Excessive motion
 Non-instrumented
 Allograft
 L5S1 or C7T1
 Hip arthritis
 Multiple levels
 Acdf 1(92%)2(94%)3(82%)

23. DIAGNOSIS
 XRAY: implant failure, fusion mass,
flex/ext, halo sign
 CT: thin cut with recon
 MRI: coronal recon
 Ultrasound ?
 NUCLEAR MED: poor

24. Bone Graft
 Iliac crest
 Local
 Allograft: structural, morselized
 BMP
 DBM
 Ceramic: tricalcium phosphate and corraline
hydroxyapatitie

25. ILIAC CREST

26. CANCELLOUS ALLOGRAFT

28. Marshall Urist
made the key
discovery that
demineralized,
lyophilized segments
of bone induced new
bone formation when
implanted in muscle
pouches in rabbits
^ Urist, Marshall R. (1965). "Bone: formation by
autoinduction". Science 12:150 (698): 893–
899. doi:10.1126/science.150.3698.893. PMID 5
319761

29. INFUSE rhBMP-2
 FDA approval 7/2/02 for
the treatment of L4S1
ALIF for DDD after 6
month of nonop
treatment can include
grade 1
spondylolisthesis

30. INFUSE rh_BMP-2
 FDA approved
4/30/04 for acute
open tibial fractures
treated with IM
nailing within 14
days of injury
J Bone Joint Surg Am. 2002 Dec;84-A(12):2123-34.
Recombinant human bone morphogenetic protein-2 for
treatment of open tibial fractures: a prospective,
controlled, randomized study of four hundred and fifty
patients

31. Adverse swelling associated with use of rh-BMP-2
in anterior cervical discectomy and fusion: a case study
Brian Perri, DO*, Martin Cooper, MD, Carl Lauryssen, MD, Neel Anand, MD
The Spine Journal 2007

32. ORTHOPEDIC AND DENTAL INDUSTRY
NEWS COMPLETE ARCHIVE »
FDA Issues Warning Regarding Off-Label
Use of rhBMPBY LAUREN UZDIENSKI,
JULY 7, 2008
Last week the FDA released a public
health notification regarding the off-
label use of of rhBMP (InFuse, OP-1)
in the cervical spine. The agency says
that over the past four years there
have been at least 38 reports of
complications associated with using
BMP in unapproved cervical fusion
cases, ranging from difficulty
swallowing, breathing or speaking to
severe dysphagia.
Most reported complications occurred
between two and 14 days following
surgery. Treatments included
respiratory support with intubation,
anti-inflammatory medication,
tracheotomy and most commonly
second surgeries to drain the surgical
site. The seriousness of the
complications was correlated with the
anatomical proximity of the cervical
spine to airway structures. The FDA
adds, "The mechanism of action is
unknown, and characteristics of
patients at increased risk have not
been identified."

33. POSTOPERATIVE SEROMA
 Postoperative Cervical Myelopathy and
Cord Compression Associated with the
Use of rh-BMP-2 in Posterior Cervical
Decompression, Instrumentation, and
Arthrodesis: A report of two
cases; Anderson DW, Burton DC, Jackson
RS; Spine (Jan 2011)

34. 774 man with postoperative
seroma POD #8 I&D bedside
2011

39. Physical: Neuro exam
• Gait
• Motor
• Sensory
• Reflexes
• Fine motor
• CN exam

45. Cervical radiculopathy pathology
masquerade
Brachial plexopathy: mass/viral
C5: rotator cuff/impingement
C6/C7: CTS
C7: PIN
C8: AIN/cubital tunnel
“Double Crush” Upton & McComas Lancet 2:359 1973
Angina
CRPS (RSD)
Thoracic outlet syndrome

46. DDX Myelopathy Cervical
• amyotrophic lateral sclerosis
• myelitis
• multiple sclerosis
• demyelinating conditions
• intracranial pathology
• syringomyelia
• Chiari malformation
• Ossification of the Posterior Longitudinal Ligament
(OPLL)
• Ankylosing spondylitis

47. Shoulder impingement
• Neer: FE
• Hawkins:FE&ER
• Jobe:relocation
• Cross adduction

48. Rotator Cuff Tear

53. CERVICAL NONUNION WITH
IMMEDIATE POSTOP CT TO ASSESS
CSF LEAK INTRAOP

70. thanks

86. 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).

87. Pharyngeal phase

88. 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.

89. 50% havesomedegreeofswallowingdysfunction
10% havesomedifficultyat12months
RISK FACTORS: females, age>60, pre-existing
swallowing dysfunction, multiple levels

90. 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

91. 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

92. Glossopharyngealnerve#9
Hypoglossal nerve #12

93. 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

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

96. 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

97. 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

98. 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

99. 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

100. 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

101. 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

102. 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.

103. 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

104. 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

105. 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