Prevention and management of dysphonia during anterior cervical spine surgery
ABSTRACT Dysphonia is a common postoperative complaint following anterior cervical spine surgery (ACSS). The purpose of this study was to analyze voice outcomes following ACSS, to identify risk factors predicting vocal cord impairment, and to develop an algorithm for postoperative management of dysphonic patients.
Retrospective cohort study.
This was a retrospective review of 815 consecutive patients undergoing ACSS from January 2000 to January 2009. All cases were performed using a team approach with a neurosurgeon and head and neck surgeon. Factors associated with voice change and vocal cord motion impairment were analyzed.
The mean age of the cohort was 53 years (range, 13-88 years), with a male-to-female ratio of 1.2. There were 32 of 815 available patients (3.9%) who developed dysphonia following ACSS. Fiberoptic laryngoscopy demonstrated that only nine (1.1%) of these patients had ipsilateral vocal fold motion impairment. Of these nine patients, only one (0.1%) was found to have permanent vocal fold paralysis at 1-year follow-up. Factors that correlated significantly with voice change included kyphosis, revision surgery, and level C6-C7 surgery. Kyphosis was the only independent factor correlating with voice change.
ACSS is a safe surgical procedure with a low incidence of postoperative dysphonia when exposure is provided by a head and neck surgeon. Team performance of ACSS appears to reduce laryngeal complications and optimize the management of temporary or permanent postoperative dysphonia.
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ABSTRACT: Anterior cervical disectomy and fusion (ACDF) is a highly effective and safe method for spinal cord and cervical root decompression. However, vocal cord paralysis (VCP) remains an important cause of postoperative morbidity. The true incidence and recovery course of postoperative VCP is still uncertain. This study is a report on VCP after ACDF to evaluate the incidence, recovery course, and possible risk factors. From 2004 to 2008, 1,895 consecutive patients underwent ACDF in our hospital and were followed up for at least 3 years. All surgeons were well trained and used a right-sided exposure. Prolonged VCP, where patients suffered from postoperative VCP lasting more than 3 months, was recorded and analyzed. In this retrospective study, 9 of the 1,895 patients (0.47 %) documented prolonged VCP lasting over 3 months. Six of the nine patients had total recovery within 9 months. Only three patients (0.16 %) still had symptoms even after 3 years postoperatively. All symptoms of VCP, except hoarseness, could be improved. After matching with 36 non-VCP patients, no differences with regard to longer operative or anesthesia time, shorter neck, obesity, and prevertebral edema. All cases of prolonged course of postoperative VCP occurred in patients who underwent exposure at the C67 level. In our study, only 0.47 % documented prolonged postoperative VCP, while most patients recovered within 9 months. However, if symptoms last longer, there could be almost permanent VCP (0.16 %). In our study, choking and dysphagia subsided mostly within 6 months, but hoarseness remained. The exposure of the C67 level obviously was a risk factor for postoperative VCP.European Spine Journal 11/2013; 23(3). DOI:10.1007/s00586-013-3084-y · 2.07 Impact Factor
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ABSTRACT: Study Design Review. Objective Postoperative oropharyngeal dysphagia is one of the most common complications following anterior cervical spine surgery (ACSS). We review and summarize recent literature in order to provide a general overview of clinical signs and symptoms, assessment, incidence and natural history, pathophysiology, risk factors, treatment, prevention, and topics for future research. Methods A search of English literature regarding dysphagia following anterior cervical spine surgery was conducted using PubMed and Google Scholar. The search was focused on articles published since the last review on this topic was published in 2005. Results Patients who develop dysphagia after ACSS show significant alterations in swallowing biomechanics. Patient history, physical examination, X-ray, direct or indirect laryngoscopy, and videoradiographic swallow evaluation are considered the primary modalities for evaluating oropharyngeal dysphagia. There is no universally accepted objective instrument for assessing dysphagia after ACSS, but the most widely used instrument is the Bazaz Dysphagia Score. Because dysphagia is a subjective sensation, patient-reported instruments appear to be more clinically relevant and more effective in identifying dysfunction. The causes of oropharyngeal dysphagia after ACSS are multifactorial, involving neuronal, muscular, and mucosal structures. The condition is usually transient, most often beginning in the immediate postoperative period but sometimes beginning more than 1 month after surgery. The incidence of dysphagia within one week after ACSS varies from 1 to 79% in the literature. This wide variance can be attributed to variations in surgical techniques, extent of surgery, and size of the implant used, as well as variations in definitions and measurements of dysphagia, time intervals of postoperative evaluations, and relatively small sample sizes used in published studies. The factors most commonly associated with an increased risk of oropharyngeal dysphagia after ACSS are: more levels operated, female gender, increased operative time, and older age (usually >60 years). Dysphagic patients can learn compensatory strategies for the safe and effective passage of bolus material. Certain intraoperative and postoperative techniques may decrease the incidence and/or severity of oropharyngeal dysphagia after ACSS. Conclusions Large, prospective, randomized studies are required to confirm the incidence, prevalence, etiology, mechanisms, long-term natural history, and risk factors for the development of dysphagia after ACSS, as well as to identify prevention measures. Also needed is a universal outcome measurement that is specific, reliable and valid, would include global, functional, psychosocial, and physical domains, and would facilitate comparisons among studies. Results of these studies can lead to improvements in surgical techniques and/or perioperative management, and may reduce the incidence of dysphagia after ACSS.Global Spine Journal 12/2013; 3(4):273-286. DOI:10.1055/s-0033-1354253
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ABSTRACT: Vocal cord palsy is a known complication of anterior cervical spine surgery. However, the true incidence and interventions to minimize this complication are not well studied. To conduct a systematic review to identify the incidence, risk and interventions for vocal cord palsy after anterior cervical spine surgery. Qualitative systematic literature review SAMPLE: Prospective and retrospective trials of patients undergoing anterior cervical spine surgery that reported on post-operative vocal cord palsy or recurrent laryngeal nerve palsy OUTCOME MEASURES: Primary: Incidence of vocal cord palsy after anterior cervical spine surgery; Secondary: risk factors and interventions for prevention of vocal cord palsy after anterior cervical spine surgery METHODS: Electronic searches were conducted on Ovid Medline, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Database of Systemic Reviews for clinical studies reporting vocal cord palsy in anterior cervical spine surgery, limited to studies published between 1995 and June 2013 in English and French language. After selection of studies independently by two review authors, data on incidence, risk and interventions were extracted. Qualitative analysis were performed on three domains: a) Quality of studies, b) Strength of evidence and c) Impact of interventions. This study is internally funded with no declared biases. Our search has identified 187 abstracts and 34 studies met our inclusion criteria. The incidence of vocal cord palsy ranges from 2.3% to 24.2%. Significant heterogeneity in study design and definition of vocal cord palsy were used in published studies. There is good evidence that reoperation increase the risk of vocal cord palsy. One study of moderate strength suggest that operating from the right side may increase the risk of vocal cord palsy. Among the interventions studied, endotracheal cuff pressure monitoring with deflation during retraction has shown to reduce the incidence from 6% to 2% but this result was not confirmed by randomized control trials. Limited evidence exists for other interventions of intraoperative electromyographic monitoring and methylprednisolone. Vocal Cord Palsy is a significant morbidity after anterior cervical surgery with incidence up to 24.2% in the immediate post-operative period, with a higher risk in reoperation of the anterior cervical spine. Moderate evidence exist for endotracheal cuff pressure adjustment in preventing this complication.The spine journal: official journal of the North American Spine Society 03/2014; 14(7). DOI:10.1016/j.spinee.2014.02.017 · 2.43 Impact Factor