Surgical treatment of dysphagia after anterior cervical interbody fusion

Dysphagia is a frequent complication after anterior cervical interbody fusion (ACIF). Although dysphagia usually improves over 6 months, it remains a significant and persistent problem for some patients. The etiology is poorly understood but has been reported to be associated with vocal cord paralysis, dislodgement of instrumentation and unidentified causes, such as hematoma, adhesion formation and denervation of the pharyngeal plexus. A surgical treatment of dysphagia after ACIF has not been reported.

We report the surgical treatment of persistent dysphagia occurring after ACIF with instrumentation.

A retrospective review of cervical discectomy and interbody fusion patients identified a subset of patients with symptomatic dysphagia who chose surgical treatment of the dysphagia. The hypothesis is that removal of the anterior cervical plate will release mechanical adhesions of the esophagus to the anterior spine around the plate. Outcome was graded by examination and a final telephonic interview with a dysphagia questionnaire.

Thirty-one patients who elected surgical treatment for persistent dysphagia were assessed at clinic visits after surgery at 3, 6 and 12 months for symptomatic dysphagia, and with a final telephonic questionnaire. The average time from initial surgery to time of surgical treatment for dysphagia was 18 months. Final follow-up was an average 11 months (range, 6 to 25 months) with a dysphagia questionnaire using the Bazaz-Yoo dysphagia score. Thirty-one patients responded to a phone questionnaire with the Bazaz-Yoo dysphagia score.

The primary operative finding was extensive adhesions attaching the esophagus to the prevertebral fascia and anterior cervical spine around the periphery of the cervical plate. Seventeen patients (55%) were significantly improved to no dysphagia of solids and liquids (p < or = .0001). Ten patients (32%) reported mild dysphagia occasionally with specific foods. Three patients had persistent moderate occasional dysphagia with solid food. Two patients had persistent severe dysphagia of solids and liquids. Previous cervical surgery, particularly with pre-existing dysphagia, and unexpectedly extreme amounts of adhesions at surgery were contributing factors to the cases with persistent severe dysphagia.

Surgical treatment of dysphagia after ACIF has not been reported. Removal of the cervical instrumentation in patients will improve the dysphagia. This improvement with surgical management, as compared with the dissatisfaction before surgical treatment, documents that this surgical treatment is a reasonable option.