Vol. 21 • Issue 10 • Page 8
Imagine being called on to evaluate and treat the status of patients post cervical surgery presenting with impaired swallow and phonation. This happens when patients undergo an anterior cervical discectomy with fusion (ACDF), which is commonly performed to treat cervical disc herniations and other cervical pathologies, including fractures and spinal instability.
Typically, these spinal injuries are the result of traumatic events, such as falls, sports-related injuries, or whiplash from motor vehicle accidents, or non-traumatic events, including congenital and structural misalignments, poor posture, or general wear-and-tear of the aging spine, as well as unknown or idiopathic.
Two common ACDF surgical complications are dysphagia and dysphonia. Although often temporary in nature, these conditions may be long-standing or even permanent. A significant number of patients improve, many with eventual total resolution following post-operative healing. However, some continue to have a residual dysphagia and/or dysphonia.
Therefore, speech-language pathologists treating this patient population should have good understanding of the surgical process in addition to the appropriate anatomical and physiological conditions before and after ACDF surgery. Armed with this knowledge, we can make sound clinical decisions as they relate to the evaluation, treatment, counseling and appropriate referrals of a client after anterior cervical surgery.
To understand cervical fractures, including disc herniation and spinal instability/fractures, review the anatomy of the region. Cervical spinal vertebral bodies are separated by intervertebral discs, which act as cushions or shock absorbers. In conjunction with the facet joints, muscles and ligaments, they also allow for smooth movement of the head and neck.
Cervical disc herniations occur when the fluid inside the disc ruptures through the tough connective tissue and into the spinal column, impinging against one or more of the nearby spinal nerves. This can cause pain, weakness or numbness in the neck, shoulder and arm. Typical pain patterns and motor involvement vary depending on which spinal segment is involved.
While sensory and motor dysfunction can be predicted based on the level of injury and clinical presentation, it is important to keep in mind that wiring can vary among individuals. In more severe cases cervical disc herniations can impinge and disturb the spinal cord itself. This condition, known as myelopathy, can present a more emergent surgical scenario.
Spinal instability refers to too much movement among the bones of the spine. As the disc degenerates, it loses tension, resulting in the extra movement. This can cause pain and potentially lead to osteophytes (bony overgrowths), spinal stenosis (narrowing of the spinal canal), and myelopathy. Osteophytes can cause dysphagia by impinging against the posterior pharyngeal wall.
The surgical procedure of ACDF involves making an incision to the anterior lateral area of the neck and moving the neck muscles aside. Retractors hold back the trachea, esophagus and arteries. The spinal muscles are lifted and pulled aside in order to gain access to the vertebrae and discs. Spreaders are inserted to pull apart each vertebra above and below the disc. Small grasping tools are used to remove the entire disc, and the disc space is replaced with bone graft to prevent collapse, restore nerve function, and/or prevent additional nerve damage. Cervical plates and screws may be placed for stability and to accelerate and support the fusion process. The hope is that the implanted bone will fuse with the levels above and below to become a motionless spinal segment.
The post-operative acute care hospitalization typically lasts one to two days. Some patients may return home with the recommendation to participate in an outpatient therapy program, while others may go to an acute rehabilitation hospital for additional inpatient medical care and intensive therapy. Each case is different and dependent on the needs of the patient, as well as the presence of complications or other diagnoses.
The incidence and prevalence of dysphagia and dysphonia post ACDF surgery vary, but all trend similarly. One study found that post-operative dysphagia occurred in 60 percent of patients, with 32 percent having symptoms for more than six months, and post-operative hoarseness occurred in 51 percent of patients, with 38 percent having symptoms for more than six months.1
Similarly, post-operative incidence of dysphagia following an anterior-approach cervical spine fusion was reported at 50.1 percent at one month, 32.2 percent at two months, 17.8 percent at six months, and 12.5 percent at 12 months, while vocal cord paresis was identified in 1.3 percent of patients at 12 months.2 Therefore, speech-language pathologists need to know how to treat both transient and long-standing dysphagia and/or dysphonia.
Prior to the consult of patient status post ACDF, review the medical records, including the specific diagnosis, type of surgery, circumstances of the surgery (urgent versus elective), the presence of peri- and post-surgical complications, date of surgery (to determine how much time has passed), and the cervical spinal segments involved.
Speech-language pathologists should have an understanding of the potential impact that cervical surgery can have on swallowing and phonation at specific cervical spinal segments. For example, the recurrent laryngeal branch of the vagus nerve passes through C5-6, which is responsible for many of the muscles used for swallowing; but it is important to keep in mind that it does not exclude dysphagia if other levels are involved.
Peri- and post-surgical causes for dysphagia and dysphonia include laryngeal and pharyngeal edema from intubation, endotracheal pressure, prolonged retraction of the esophagus, soft tissue dissection, infection, nerve injury, esophageal perforation (rare), and hardware complications. The conditions are likely to be temporary if, for example, the cause is related to edema and soft tissue dissection and requires several weeks for resolution due to post-operative healing. If nerve injury is suspected or known to have occurred during surgery, it may be appropriate to bypass this waiting period. Unless complications are well documented in the medical records or there are atypical clinical findings on initial evaluation, a "wait-and-see" approach may be necessary.
Commonalities exist relating to the "typical" post-operative course. Patients often report and demonstrate difficulty with solid consistencies sticking in their throat upon clinical evaluation or actual administration of post-operative trials. Patients may describe globus, a feeling of a lump-like sensation in their throat, and their vocal quality usually sounds hoarse. Research supports this. A study found that the majority of patients with post-operative dysphagia were more prominent regarding solid foods than liquids.3
Typical recommendations include a downgrade to a puree or fine-chopped texture, avoidance of thick and heavy food consistencies, and remaining on all liquids. Other strategies are small bites and sips, vigorous mastication and multiple swallows as needed. These patients often are cognitively intact and able to follow recommendations unless they have pre-existing cognitive deficits or a traumatic brain injury.
Speech-language pathologists should reassess patients who continue to report or demonstrate signs or symptoms of dysphagia and/or dysphonia several weeks post surgery. This may indicate nerve injury, rather than a typical post-operative healing course. Treatment may become more aggressive, with additional diagnostic testing; referrals to ENT, gastrointestinal and neurologists; and follow-up appointments with the surgeon who performed the procedure.
Diagnostic and objective testing may include a videofluoroscopic swallowing study (VFSS), videostroboscopy and electromyography (EMG). Speech-language pathologists may perform a VFSS to visualize the anatomy, physiology and function of the muscles. ENTs may scope to assess vocal cord function and rule out paresis; GIs may scope to evaluate the esophagus and rule out esophageal dysphagia; and neurologists may use EMG to determine nerve function and the presence of any damage.
Whether or not dysphagia and dysphonia post ACDF surgery is transient or long-standing, early intervention by a speech-language pathologist is important to ensure patients are tolerating and taking in adequate calories to maintain nutrition and hydration for healing and participation in therapy, to reduce or eliminate aspiration risk and potential for aspiration pneumonia, to continuously reassess and determine if further evaluation is warranted, and to educate and counsel patients through the process. Having the appropriate knowledge allows clinicians to efficiently and effectively assess and treat patients after anterior cervical surgery complications, as well as to make additional referrals as needed.
- Winslow, C.P., Winslow, T.J., Wax, M.K. (2001). Dysphonia and dysphagia following the anterior approach to the cervical spine. Archives of Otolaryngology-Head & Neck Surgery, 127 (1): 51-55.
- Bazaz, R., Lee, M. J., Yoo, J.U. (2002). Incidence of dysphagia after anterior cervical spine surgery: A prospective study. Spine, 27: 2453-58.
- Fountas, K.N., Kapsalaki, E.Z., Nikolakakos, L.G., et al. (2007). Anterior cervical discectomy and fusion associated complications. Spine, 32 (21): 2310-17.
Christina Piscopo is clinical manager of the Inpatient Speech-Language Pathology Department at Kessler Institute for Rehabilitation in West Orange, NJ. She can be contacted at firstname.lastname@example.org.