Accepted Manuscript “Dysphagia after Anterior Cervical Spine Surgery: A Systematic Review of Potential Preventative Measures” Andrei F. Joaquim, MD, PhD Jozef Murar, MD Jason W. Savage, MD Alpesh A. Patel, MD, FACS PII:
S1529-9430(14)00304-0
DOI:
10.1016/j.spinee.2014.03.030
Reference:
SPINEE 55825
To appear in:
The Spine Journal
Received Date: 30 October 2013 Revised Date:
18 February 2014
Accepted Date: 16 March 2014
Please cite this article as: Joaquim AF, Murar J, Savage JW, Patel AA, “Dysphagia after Anterior Cervical Spine Surgery: A Systematic Review of Potential Preventative Measures”, The Spine Journal (2014), doi: 10.1016/j.spinee.2014.03.030. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT “Dysphagia after Anterior Cervical Spine Surgery: A Systematic Review of Potential Preventative Measures”
RI PT
Andrei F. Joaquim1MD, PhD; Jozef Murar2 MD, Jason W. Savage, MD2; Alpesh A. Patel2 MD, FACS.
Andrei F. Joaquim, MD, PhD – [email protected] Jozef Murar, MD - [email protected]
SC
Jason W. Savage, MD – [email protected]
Alpesh A. Patel, MD, FACS – [email protected] (corresponding author
1
M AN U
post-acceptation)
Department of Neurosurgery, State University of Campinas (UNICAMP), 13083-970, Campinas
SP, Brazil 2
Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N
TE D
St Clair St Suite 1350, Chicago IL, 60611, USA.
No funds were received in support of this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
EP
The authors have no financial interest in the subject of this article. The manuscript submitted
AC C
does not contain information about medical device(s).
1
ACCEPTED MANUSCRIPT Background context: Anterior cervical spine surgery is one of the most common spinal
2
procedures performed around the world, but dysphagia is a frequent postoperative
3
complication. Many factors have been associated with an increased risk of swallowing
4
difficulties, including multilevel surgery, revision surgery, and female gender.
5
Purpose: To review and define potential preventative measures that can decrease the
6
incidence of dysphagia after anterior cervical spine surgery.
7
Study Design: Systematic literature review
8
Methods: A systematic review in the Medline database was performed. Articles related
9
to dysphagia after anterior cervical spine surgery and potential preventative measures
M AN U
SC
RI PT
1
were included.
11
Results: Twenty articles met all inclusion and exclusion criteria. These articles reported
12
several potential preventative measures to avoid postoperative dysphagia. Preoperative
13
measures include performing tracheal exercises before the surgical procedure.
14
Intraoperative measures can be summarized as avoiding a prolonged operative time and
15
the use of rhBMP in routine anterior cervical spine surgery, using small and smoother
16
cervical plates, using anchored spacers instead of plate, application of steroid before
17
wound closure, performing arthroplasty instead of anterior cervical fusion for one level
18
disease, decreasing tracheal cuff pressure during medial retraction, using specific
19
retractors and changing the dissection plan.
20
Conclusions: The current literature supports several preventative measures that may
21
decrease the incidence of postoperative dysphagia. Although the evidence is limited and
22
weak, most of these measures did not appear to increase other complications and can be
AC C
EP
TE D
10
2
ACCEPTED MANUSCRIPT 1
easily incorporated into a surgical practice, especially in patients who are high risk for
2
postoperative dysphagia.
AC C
EP
TE D
M AN U
SC
RI PT
3
3
ACCEPTED MANUSCRIPT 1
INTRODUCTION Anterior cervical spine surgery (ACSS) is a common procedure performed to
3
treat many spine conditions, such as trauma and degenerative spinal disease. Many
4
studies have reported that one of the most common complications after ACSS is
5
dysphagia1,2,3. The reported incidence of dysphagia is widely variable, and is likely due
6
to the heterogeneity of the existing literature. However, an incidence of up to 71% has
7
been reported in well-designed prospective studies that assess dysphagia rate after
8
surgery4. Several risk factors have been associated with an increase in postoperative
9
dysphagia incidence including multilevel surgery, revision procedures, female gender,
10
older age, and involvement of C4-5 and C5-6 level5,6. The objective of this study is to
11
review potential measures that could be utilized to decrease the incidence and intensity
12
of postoperative dysphagia after ACSS.
TE D
13
14
18
19
20
21
AC C
17
EP
15
16
M AN U
SC
RI PT
2
4
ACCEPTED MANUSCRIPT 1
MATERIAL AND METHODS A systematic review of the literature using the MedLine Database (National
3
Library of Medicine), without time restriction, was performed. The following search
4
strategy was used: ("deglutition disorders"[MeSH Terms] OR ("deglutition"[All Fields]
5
AND
6
"dysphagia"[All Fields]) AND anterior[All Fields] AND ("neck"[MeSH Terms] OR
7
"neck"[All Fields] OR "cervical"[All Fields]) AND ("surgery"[Subheading] OR
8
"surgery"[All Fields] OR "surgical procedures, operative"[MeSH Terms] OR
9
("surgical"[All Fields] AND "procedures"[All Fields] AND "operative"[All Fields]) OR
10
"operative surgical procedures"[All Fields] OR "surgery"[All Fields] OR "general
11
surgery"[MeSH Terms] OR ("general"[All Fields] AND "surgery"[All Fields]) OR
12
"general surgery"[All Fields]).
Fields])
OR
"deglutition
disorders"[All
Fields]
OR
M AN U
SC
"disorders"[All
RI PT
2
The search produced a total of 451 published articles. Abstracts were reviewed
14
and included if dysphagia was a reported patient outcome measure and if the study
15
investigated perioperative measures to reduce dysphagia after anterior cervical spine
16
surgery. Only articles written in English language (or translated text) were included.
17
Exclusion criteria included case reports, literature reviews, and cadaveric or
18
experimental studies in animals. Twenty-one articles were eligible after abstract
19
screening and were fully reviewed. Of those, twenty were included based on the
20
purpose of our review and our inclusion criteria. The articles selected were then
21
classified according to an evidence-based medicine criteria proposed by Wright et al.7.
22
23
AC C
EP
TE D
13
5
ACCEPTED MANUSCRIPT 1
RESULTS The twenty articles that met all inclusion and exclusion criteria are summarized
3
in Table 1 and the preventative measures proposed are described in Table 2. The
4
following articles are described below:
RI PT
2
5
PREOPERATIVE MEASURES
7
Tracheal/ Esophageal traction exercise (TTE) Preoperative Treatment
SC
6
Chen et al. proposed a preoperative exercise to improve the compliance of the
9
trachea and the esophagus before anterior cervical spine surgery8. Chen el al. labeled the
10
exercise as tracheal/esophageal traction exercise (TTE), which consisted of maneuvers
11
that softly and gradually pushed off the thyroid cartilage at least 1 cm across the anterior
12
midline of the neck. The TTE was performed twice per day, 15 counts each time, for 3
13
days, starting 4 days before the surgery. A total of 52 patients underwent TTE and 50
14
patients were the control group. The dysphagia was assessed using the Bazaz dysphagia
15
score. One week postoperatively, the Bazaz dysphagia scores for patients with two to
16
four level fusions in the TTE group were significantly better than the control group
17
(P=0.000 for second- and third-level fusions and P=0.013 for fourth-level fusion). The
18
same was observed at 3 weeks postoperatively, the two to four level fusion patients in
19
the TTE group had better Bazaz scores than those in the control group (P = 0.000 for
20
second- and third-level fusions and P = 0.004 for fourth-level fusion). (Level II of
21
Evidence)
22
23
AC C
EP
TE D
M AN U
8
6
ACCEPTED MANUSCRIPT 1
INTRAOPERATIVE MEASURES
2
Avoiding a prolonged operative time Rihn et al. performed a prospective study to determine the incidence and severity
4
of postoperative dysphagia after ACDF4. Thirty-eight patients who underwent one or
5
two levels ACDF were followed and compared with a control group of 56 patients who
6
underwent posterior lumbar decompression. They observed a correlation between
7
operative time and the severity of dysphagia after 12 weeks (p = 0.04). (Level II of
8
Evidence)
9
Bone Morphogenetic Proteins (BMP)
M AN U
SC
RI PT
3
Bone morphogenetic proteins have previously been shown to increase
11
complications after anterior cervical spine surgery. Bone morphogenetic proteins are
12
characterized by osteoinductive properties which make them a useful adjuvant in
13
arthrodesis procedures to enhance bone fusion. They are commercially available in two
14
forms: recombinant human BMP-2 and BMP79. In our study, four papers relating the
15
use of BMP and dysphagia after cervical spine procedures were found.
EP
TE D
10
Tumialán et al. reported the results of a retrospective review of 200 patients who
17
underwent single or multilevel anterior cervical discectomy and fusion (ACDF) with
18
titanium plate fixation and polyetheretherketone (PEEK) spacers filled with
19
recombinant rhBMP-2 impregnated in a type I collagen sponge to achieve fusion10.
20
After a mean of 16.7 months of follow-up (ranging from 8 to 36 months), good to
21
excellent results were reported in 85% of the cases based on ODOM criteria, with
22
fusion obtained in 100% of patients. However, fourteen patients (7%) had significant
23
clinical dysphagia and four (2%) required reoperation for hematoma or seroma after
24
surgery. (Level IV of Evidence)
AC C
16
7
ACCEPTED MANUSCRIPT Butterman et al. performed a prospective nonrandomized study of 66 patients
2
that underwent a one to three level ACDF with iliac-crest bone autograft (36 patients)
3
compared with a group of patients using BMP and allograft (30 patients)11. Although
4
clinical and radiological outcomes were similar between the groups, 15 (50%) patients
5
receiving BMP experienced neck swelling and dysphagia compared with 5 (14%) in the
6
iliac-crest group. Among patients that underwent a two level fusion (25 patients total),
7
the BMP group had 10 (63%) of 16 patients with dysphagia compared to 3 (16%) of 9
8
patients. These results suggested a potential role of BMP in the development of
9
dysphagia. (Level II of Evidence)
M AN U
SC
RI PT
1
Lu et al. reported their experience in a retrospective study of 150 patients that
11
underwent multilevel anterior cervical discectomy and fusion, divided in two groups: 1)
12
Group 1 – patients who had a PEEK interbody spacer filled with rhBMP-2 and 2) Group
13
2 – patients with allograft interbody spacer without rhBMP-212. The demographic
14
characteristics between groups were similar. The complication rate in the BMP group
15
was 13% compared with 8% in the allograft group (p < 0.005). The incidence of
16
dysphagia was not statistically significant between groups (40 in the BMP versus 44 in
17
the allograft) (p>0.05) but the severity of dysphagia using the SWAL-QOL dysphagia
18
scoring system was more pronounced in the BMP group than in the allograft group,
19
0.757 and 0.596 respectively (p < 0,005). When subgroup analysis was performed, Lu et
20
al reported that the use of rhBMP-2 increased the severity of dysphagia in patients who
21
underwent 2 level ACDF (p < 0.005), but showed no difference between groups when 3
22
or 4 level ACDF cases were compared. There were no cases of pseudarthrosis in Group
23
1 (BMP) compared with a 16% pseudarthrosis rate in Group 2 (allograft) (p < 0.05).
24
The authors concluded that rhBMP-2 increased the severity of dysphagia in two levels
AC C
EP
TE D
10
8
ACCEPTED MANUSCRIPT 1
ACDF but concurrently demonstrated that rhBMP-2 decreases the risk of
2
pseudarthrosis. (Level III of Evidence) Fineberg et al. performed a retrospective analysis of a nationwide inpatient
4
database, from 2002 to 2009, seeking to identify the incidence of complications and
5
mortality associated with “off-label” BMP use in cervical spine surgery9. In a total of
6
213,421 anterior cervical spine procedures, the incidence of BMP use was 0.3% in
7
2002, 10.8% in 2007 and 8.5% in 2009. The complication rates when BMP was used for
8
ACDF were 59.6 per 1,000 versus 39.8 per 1,000 when no BMP was used (p< 0.0005).
9
The complication rates were elevated due to the increased incidence of dysphagia (37.2
10
with BMP versus 22.5 per 1,000) (p
S1529-9430(14)00304-0
DOI:
10.1016/j.spinee.2014.03.030
Reference:
SPINEE 55825
To appear in:
The Spine Journal
Received Date: 30 October 2013 Revised Date:
18 February 2014
Accepted Date: 16 March 2014
Please cite this article as: Joaquim AF, Murar J, Savage JW, Patel AA, “Dysphagia after Anterior Cervical Spine Surgery: A Systematic Review of Potential Preventative Measures”, The Spine Journal (2014), doi: 10.1016/j.spinee.2014.03.030. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT “Dysphagia after Anterior Cervical Spine Surgery: A Systematic Review of Potential Preventative Measures”
RI PT
Andrei F. Joaquim1MD, PhD; Jozef Murar2 MD, Jason W. Savage, MD2; Alpesh A. Patel2 MD, FACS.
Andrei F. Joaquim, MD, PhD – [email protected] Jozef Murar, MD - [email protected]
SC
Jason W. Savage, MD – [email protected]
Alpesh A. Patel, MD, FACS – [email protected] (corresponding author
1
M AN U
post-acceptation)
Department of Neurosurgery, State University of Campinas (UNICAMP), 13083-970, Campinas
SP, Brazil 2
Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N
TE D
St Clair St Suite 1350, Chicago IL, 60611, USA.
No funds were received in support of this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
EP
The authors have no financial interest in the subject of this article. The manuscript submitted
AC C
does not contain information about medical device(s).
1
ACCEPTED MANUSCRIPT Background context: Anterior cervical spine surgery is one of the most common spinal
2
procedures performed around the world, but dysphagia is a frequent postoperative
3
complication. Many factors have been associated with an increased risk of swallowing
4
difficulties, including multilevel surgery, revision surgery, and female gender.
5
Purpose: To review and define potential preventative measures that can decrease the
6
incidence of dysphagia after anterior cervical spine surgery.
7
Study Design: Systematic literature review
8
Methods: A systematic review in the Medline database was performed. Articles related
9
to dysphagia after anterior cervical spine surgery and potential preventative measures
M AN U
SC
RI PT
1
were included.
11
Results: Twenty articles met all inclusion and exclusion criteria. These articles reported
12
several potential preventative measures to avoid postoperative dysphagia. Preoperative
13
measures include performing tracheal exercises before the surgical procedure.
14
Intraoperative measures can be summarized as avoiding a prolonged operative time and
15
the use of rhBMP in routine anterior cervical spine surgery, using small and smoother
16
cervical plates, using anchored spacers instead of plate, application of steroid before
17
wound closure, performing arthroplasty instead of anterior cervical fusion for one level
18
disease, decreasing tracheal cuff pressure during medial retraction, using specific
19
retractors and changing the dissection plan.
20
Conclusions: The current literature supports several preventative measures that may
21
decrease the incidence of postoperative dysphagia. Although the evidence is limited and
22
weak, most of these measures did not appear to increase other complications and can be
AC C
EP
TE D
10
2
ACCEPTED MANUSCRIPT 1
easily incorporated into a surgical practice, especially in patients who are high risk for
2
postoperative dysphagia.
AC C
EP
TE D
M AN U
SC
RI PT
3
3
ACCEPTED MANUSCRIPT 1
INTRODUCTION Anterior cervical spine surgery (ACSS) is a common procedure performed to
3
treat many spine conditions, such as trauma and degenerative spinal disease. Many
4
studies have reported that one of the most common complications after ACSS is
5
dysphagia1,2,3. The reported incidence of dysphagia is widely variable, and is likely due
6
to the heterogeneity of the existing literature. However, an incidence of up to 71% has
7
been reported in well-designed prospective studies that assess dysphagia rate after
8
surgery4. Several risk factors have been associated with an increase in postoperative
9
dysphagia incidence including multilevel surgery, revision procedures, female gender,
10
older age, and involvement of C4-5 and C5-6 level5,6. The objective of this study is to
11
review potential measures that could be utilized to decrease the incidence and intensity
12
of postoperative dysphagia after ACSS.
TE D
13
14
18
19
20
21
AC C
17
EP
15
16
M AN U
SC
RI PT
2
4
ACCEPTED MANUSCRIPT 1
MATERIAL AND METHODS A systematic review of the literature using the MedLine Database (National
3
Library of Medicine), without time restriction, was performed. The following search
4
strategy was used: ("deglutition disorders"[MeSH Terms] OR ("deglutition"[All Fields]
5
AND
6
"dysphagia"[All Fields]) AND anterior[All Fields] AND ("neck"[MeSH Terms] OR
7
"neck"[All Fields] OR "cervical"[All Fields]) AND ("surgery"[Subheading] OR
8
"surgery"[All Fields] OR "surgical procedures, operative"[MeSH Terms] OR
9
("surgical"[All Fields] AND "procedures"[All Fields] AND "operative"[All Fields]) OR
10
"operative surgical procedures"[All Fields] OR "surgery"[All Fields] OR "general
11
surgery"[MeSH Terms] OR ("general"[All Fields] AND "surgery"[All Fields]) OR
12
"general surgery"[All Fields]).
Fields])
OR
"deglutition
disorders"[All
Fields]
OR
M AN U
SC
"disorders"[All
RI PT
2
The search produced a total of 451 published articles. Abstracts were reviewed
14
and included if dysphagia was a reported patient outcome measure and if the study
15
investigated perioperative measures to reduce dysphagia after anterior cervical spine
16
surgery. Only articles written in English language (or translated text) were included.
17
Exclusion criteria included case reports, literature reviews, and cadaveric or
18
experimental studies in animals. Twenty-one articles were eligible after abstract
19
screening and were fully reviewed. Of those, twenty were included based on the
20
purpose of our review and our inclusion criteria. The articles selected were then
21
classified according to an evidence-based medicine criteria proposed by Wright et al.7.
22
23
AC C
EP
TE D
13
5
ACCEPTED MANUSCRIPT 1
RESULTS The twenty articles that met all inclusion and exclusion criteria are summarized
3
in Table 1 and the preventative measures proposed are described in Table 2. The
4
following articles are described below:
RI PT
2
5
PREOPERATIVE MEASURES
7
Tracheal/ Esophageal traction exercise (TTE) Preoperative Treatment
SC
6
Chen et al. proposed a preoperative exercise to improve the compliance of the
9
trachea and the esophagus before anterior cervical spine surgery8. Chen el al. labeled the
10
exercise as tracheal/esophageal traction exercise (TTE), which consisted of maneuvers
11
that softly and gradually pushed off the thyroid cartilage at least 1 cm across the anterior
12
midline of the neck. The TTE was performed twice per day, 15 counts each time, for 3
13
days, starting 4 days before the surgery. A total of 52 patients underwent TTE and 50
14
patients were the control group. The dysphagia was assessed using the Bazaz dysphagia
15
score. One week postoperatively, the Bazaz dysphagia scores for patients with two to
16
four level fusions in the TTE group were significantly better than the control group
17
(P=0.000 for second- and third-level fusions and P=0.013 for fourth-level fusion). The
18
same was observed at 3 weeks postoperatively, the two to four level fusion patients in
19
the TTE group had better Bazaz scores than those in the control group (P = 0.000 for
20
second- and third-level fusions and P = 0.004 for fourth-level fusion). (Level II of
21
Evidence)
22
23
AC C
EP
TE D
M AN U
8
6
ACCEPTED MANUSCRIPT 1
INTRAOPERATIVE MEASURES
2
Avoiding a prolonged operative time Rihn et al. performed a prospective study to determine the incidence and severity
4
of postoperative dysphagia after ACDF4. Thirty-eight patients who underwent one or
5
two levels ACDF were followed and compared with a control group of 56 patients who
6
underwent posterior lumbar decompression. They observed a correlation between
7
operative time and the severity of dysphagia after 12 weeks (p = 0.04). (Level II of
8
Evidence)
9
Bone Morphogenetic Proteins (BMP)
M AN U
SC
RI PT
3
Bone morphogenetic proteins have previously been shown to increase
11
complications after anterior cervical spine surgery. Bone morphogenetic proteins are
12
characterized by osteoinductive properties which make them a useful adjuvant in
13
arthrodesis procedures to enhance bone fusion. They are commercially available in two
14
forms: recombinant human BMP-2 and BMP79. In our study, four papers relating the
15
use of BMP and dysphagia after cervical spine procedures were found.
EP
TE D
10
Tumialán et al. reported the results of a retrospective review of 200 patients who
17
underwent single or multilevel anterior cervical discectomy and fusion (ACDF) with
18
titanium plate fixation and polyetheretherketone (PEEK) spacers filled with
19
recombinant rhBMP-2 impregnated in a type I collagen sponge to achieve fusion10.
20
After a mean of 16.7 months of follow-up (ranging from 8 to 36 months), good to
21
excellent results were reported in 85% of the cases based on ODOM criteria, with
22
fusion obtained in 100% of patients. However, fourteen patients (7%) had significant
23
clinical dysphagia and four (2%) required reoperation for hematoma or seroma after
24
surgery. (Level IV of Evidence)
AC C
16
7
ACCEPTED MANUSCRIPT Butterman et al. performed a prospective nonrandomized study of 66 patients
2
that underwent a one to three level ACDF with iliac-crest bone autograft (36 patients)
3
compared with a group of patients using BMP and allograft (30 patients)11. Although
4
clinical and radiological outcomes were similar between the groups, 15 (50%) patients
5
receiving BMP experienced neck swelling and dysphagia compared with 5 (14%) in the
6
iliac-crest group. Among patients that underwent a two level fusion (25 patients total),
7
the BMP group had 10 (63%) of 16 patients with dysphagia compared to 3 (16%) of 9
8
patients. These results suggested a potential role of BMP in the development of
9
dysphagia. (Level II of Evidence)
M AN U
SC
RI PT
1
Lu et al. reported their experience in a retrospective study of 150 patients that
11
underwent multilevel anterior cervical discectomy and fusion, divided in two groups: 1)
12
Group 1 – patients who had a PEEK interbody spacer filled with rhBMP-2 and 2) Group
13
2 – patients with allograft interbody spacer without rhBMP-212. The demographic
14
characteristics between groups were similar. The complication rate in the BMP group
15
was 13% compared with 8% in the allograft group (p < 0.005). The incidence of
16
dysphagia was not statistically significant between groups (40 in the BMP versus 44 in
17
the allograft) (p>0.05) but the severity of dysphagia using the SWAL-QOL dysphagia
18
scoring system was more pronounced in the BMP group than in the allograft group,
19
0.757 and 0.596 respectively (p < 0,005). When subgroup analysis was performed, Lu et
20
al reported that the use of rhBMP-2 increased the severity of dysphagia in patients who
21
underwent 2 level ACDF (p < 0.005), but showed no difference between groups when 3
22
or 4 level ACDF cases were compared. There were no cases of pseudarthrosis in Group
23
1 (BMP) compared with a 16% pseudarthrosis rate in Group 2 (allograft) (p < 0.05).
24
The authors concluded that rhBMP-2 increased the severity of dysphagia in two levels
AC C
EP
TE D
10
8
ACCEPTED MANUSCRIPT 1
ACDF but concurrently demonstrated that rhBMP-2 decreases the risk of
2
pseudarthrosis. (Level III of Evidence) Fineberg et al. performed a retrospective analysis of a nationwide inpatient
4
database, from 2002 to 2009, seeking to identify the incidence of complications and
5
mortality associated with “off-label” BMP use in cervical spine surgery9. In a total of
6
213,421 anterior cervical spine procedures, the incidence of BMP use was 0.3% in
7
2002, 10.8% in 2007 and 8.5% in 2009. The complication rates when BMP was used for
8
ACDF were 59.6 per 1,000 versus 39.8 per 1,000 when no BMP was used (p< 0.0005).
9
The complication rates were elevated due to the increased incidence of dysphagia (37.2
10
with BMP versus 22.5 per 1,000) (p
