Category: Clinical Sciences/Health Conditions
Case Diagnosis: Dysphagia secondary to anterior cervical discectomy and fusion (ACDF)
The patient was a 78-year-old female with a traumatic C2 fracture who underwent C2-C3 ACDF. The post-op course was complicated by dysphagia and gastrostomy tube placement. Modified barium swallow study (MBSS) confirmed pharyngeal phase dysphagia. Laryngoscopy demonstrated posterior wall protrusion and impaired epiglottic inversion due to mechanical obstruction by the surgical hardware. The patient ultimately underwent removal of the surgical hardware when an adequate trial of speech therapy and conservative measures did not result in improvement. Following hardware removal, repeat MBSS showed continued aspiration with all liquid consistencies, and the patient continued to demonstrate aspiration with ice chips and oral care 2 weeks later. The patient continued to work with speech therapy on achieving swallowing goals.
Postoperative oropharyngeal dysphagia is a known complication associated with anterior cervical spine surgery (ACSS). Patients who develop dysphagia after ACSS show significant alterations in swallowing biomechanics, which include increased aspiration, thickening of the pharyngeal wall, prolonged transit time, poor pharyngeal constriction and peristalsis, and impaired epiglottic inversion. The primary treatment interventions are rehabilitation management including postural changes, swallowing maneuvers, and diet modifications. If the patient is still unable to swallow safely despite these rehabilitation strategies, then medical or surgical intervention may be indicated.
While there are numerous etiologies of dysphagia, it is important for rehabilitation clinicians to consider history of ACDF as one of the possible diagnoses. When rehabilitation strategies fail to improve symptoms, medical or surgical interventions may be reasonable options. Prior to surgical intervention, it is important to discuss the risks of undesired outcomes such as cervical spine instability and continued dysphagia despite hardware removal. Dysphagia following ACDF is a complication that can significantly impact a patient's quality of life that benefits from multidisciplinary support including medical, surgical, and rehabilitation intervention.