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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
studies attempting to find associations
between osteophyte features and dysphagia. Anecdotally, there are many
clinical scenarios where removal of
obstructive cervical osteophytes may
improve swallowing function. However, much of the literature supporting
the use of osteophytectomy to improve
dysphagia is based on small case series
or case reports, so a well-constructed
prospective study would be a welcome
addition to the literature.
Spinal Surgery
The role of cervical spinal surgery in the
development and treatment of dysphagia is a complicated and challenging
field. Wide variation in the rate of dysphagia postoperatively from 1% to 79%
is found in the existing literature, with
results often dependent on instruments
used to evaluate dysphagia (Anderson
& Arnold, 2013). However, the ability to select appropriate spine disease
patients for surgical treatment of dysphagia is hampered by inconsistent surgical indications without rigorous validation in large patient series, despite
the prevalence of spinal surgery.
Postoperative changes that contribute to dysphagia include structural
alterations such as hematoma, edema,
plate size, and nerve injury (cranial
nerves IX, X, and XII; ansa cervicalis;
cervical plexus; and vagal plexus can
all be affected). The vagus nerve is a
key element in swallowing function,
so nerve injury can affect pharyngeal
function through a number of mechanisms: disruption of the pharyngeal
branch of the vagus or vagal plexus,
superior laryngeal nerve injury impacting laryngeal sensation, or vocal fold
immobility following recurrent laryngeal nerve damage. Cricopharyngeus
muscle control, pharynx sensation,
and tongue mobility and strength can
also be affected through related nerves.
In addition, intraoperative factors that
contribute to prolonged pressure or
traction on the esophageal or recurrent
laryngeal nerve are thought to alter
oropharyngeal and esophageal motility and function, potentially through
impaired microcirculation and muscular injury (Tortolani et al., 2006). In the
case of cervical fusion and instrumentation, plate thickness and level have
also been associated with increased
dysphagia, with more severe impact
among patients needing C3–C4 instrumentation or multilevel plating (Lee
etal., 2007; Papadopoulou et al., 2013).
Immediate postoperative swallowing symptoms are common and not
surprising given the necessary surgical approach and postoperative tissue
edema and healing; generally, these
effects decrease with time (Min et al.,
2016; Ziegler et al., 2021). Late postoperative concerns include pharyngeal or
esophageal perforation, delayed ischemic nerve injury, or traction diverticulum. Traction diverticuli are related
to pharyngeal mucosal and submucosal adherence to hardware or fibrosis,
with pharyngeal stripping wave forces
leading to progressive diverticulum
formation in the pharyngeal mucosa
and submucosa, which is distinct from
the Zenker’s diverticulum due to a
hypertonic cricopharyngeus muscle
(Figure 19–5). For patients with high
cervical traumatic injuries that require
stabilization, injuries to the spinal cord
and cervical nerves can cause complete
sensory deficiency as well as motor
impairment.
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445
Various instruments and methods
have been used to evaluate patients for
dysphagia who undergo spinal surgery.
Most large series investigating oropharyngeal dysphagia following anterior
spinal surgery are found in the spine
surgery literature and use the Bazaz
dysphagia grading system (Table 19–1),
which is simple and accomplished via
telephone interviews (Bazaz et al., 2002).
One of the largest and earliest prospective cohort series including multiple
types of anterior spine surgery found
early postoperative dysphagia in 54%
of patients, which declined to 13.6% at
24 months (Lee et al., 2007). Approximately half of these patients had some
form of permanent instrumentation
Figure 19–5. Traction diverticulum. Videofluoroscopic swallow study (A) of a patient
who required initial spinal surgery for traumatic cervical spine injury that was complicated by late infection and osteomyelitis, which caused the appearance of a diverticulum. CT scan (B) suggested hardware had extruded through the posterior pharyngeal
wall, which was confirmed on suspension laryngoscopy and found to be the opening
of a fistula tract.
Table 19–1. Bazaz Dysphagia Scoring System
Degree of Dysphagia Liquid Solid
None None None
Mild None Rare
Moderate None or rare Occasional (only
with specific food)
Severe Present Frequent (majority of
solids)
Source: Bazaz, R., Lee, M. J., and Yoo, J. U. (2002). Incidence of dysphagia
after anterior cervical spine surgery: A prospective study. Spine, 27, pp. 2453–
2458. Reprinted by permission of Wolters Kluwer Health, Inc.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
placed. Limitations of this study were
that it was based on telephone interviews and the Bazaz grading system
has not undergone rigorous validation
(Bazaz et al., 2002). A recent review
of dysphagia assessment in anterior
cervical discectomy and fusion highlighted the potential biases and shortcomings of the literature, with the
majority of studies relying on retrospective study designs. Furthermore,
46% of studies relied on “unvalidated
patient-reported outcome measures”
(Molfenter et al., 2023).
Review of patients presenting at a
tertiary dysphagia center with symptoms of dysphagia after spine surgery
found aspiration and objective fluoroscopy abnormalities to be very common
in both the early and later postoperative periods. When evaluated within
2 months postoperatively, significant
worsening in epiglottic inversion (absent or incomplete), elevated pharyngeal constriction ratio, increased
posterior pharyngeal wall thickness,
decreased pharyngoesophageal segment opening, and prolonged pharyngeal transit time were identified. Most
parameters improved over time, but
mean hyoid elevation and pharyngeal
transit time appeared worse (Leonard
& Belafsky, 2011). One unknown factor
is the prevalence of dysphagia owing
to cervical spine surgery itself. This is a
difficult parameter to evaluate secondary to the indications for spine surgery
and lack of recognition of dysphagia
preoperatively due to more pressing
concerns. In one small series evaluating the prevalence of dysphagia 3 days
preoperatively and 2 days postoperatively, 47% of patients who underwent
anterior spinal surgery developed dysphagia (Smith-Hammond et al., 2004).
None of these patients had dysphagia
preoperatively according to videofluoroscopic swallowing study (VFSS). Posterior cervical approach was still associated with dysphagia in 21% of patients,
while no patients who underwent
lumbar surgery developed dysphagia.
Interestingly, a more current randomized, prospective study found a similar rate of dysphagia among patients
with cervical spondylotic myelopathy
who underwent anterior cervical surgery with instrumented fusion (41%)
but no incidence of dysphagia among
those with a posterior decompressive
approach (Ghogawala et al., 2021).
MANAGEMENT
Medical
Prior to attributing dysphagia squarely
to cervical spine abnormalities or
sequelae of treatment, all additional
causes of dysphagia must be considered. Due to the increasing prevalence
of spinal deformity with advancing
age, numerous comorbidities may coexist with spinal abnormalities. In particular, neurodegenerative disease and
dementia, cerebrovascular accident,
cricopharyngeus muscle dysfunction,
pill and infectious esophagitis, presbyesophagus, and achalasia increase
with age and their contribution to dysphagia cannot be disregarded. Gastroesophageal reflux disease (GERD)
affects between 2.5% and 20% of the
population and varies depending on
geographic location (Dent et al., 2005;
Wong & Kinoshita, 2006). Rihn et al.
(2011) showed, by utilizing the GERD
Impact Scale (GIS) to compare patients
undergoing anterior cervical spine sur-
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447
gery with those undergoing lumbar
spine surgery, the immediate postoperative (<2 week) absolute rate increase in
reflux symptoms was 36% (relative rate
increase = 83%), with a positive correlation between severity of dysphagia
and GIS. The clinical outcome of this
increased reflux symptomatology was
that cervical surgery patients required
more antacid medications. While there
were increased reflux symptoms postoperatively among the cervical surgery
group at 6 and 12 weeks, this difference
was not statistically significant.
Lower spine kyphosis, scoliosis, lordosis, osteoporosis, and wedge compression fractures are associated with
increased rate of GERD (Hosogane et
al., 2017; Imagama et al., 2012; Kusano
et al., 2008; Miyakoshi et al., 2009;
Sugimoto et al., 2016; Yamaguchi etal.,
2005; Yoshimura et al., 2008), secondary to anatomic changes with subsequent hiatus hernia. Cervical spine
anomalies commonly cooccur with
lower spinal abnormalities, so GERD is
an important cofactor to consider. In a
Japanese population with thoracolumbar kyphosis, 70.8% of patients had
endoscopic mucosal changes consistent
with GERD, varying from Los Angeles
(LA) grade A to D in severity (Sugimoto
etal., 2016). Thoracolumbar kyphosis is
often associated with excessive cervical
lordosis as an adaptation in order to
maintain an appropriate visual plane,
and for thoracolumbar lordosis, cervical kyphosis may be present as a similar
adaptation.
Swallowing Strategies
Sensory stimulation and maneuvers are
important components in managing
dysphagia among patients with cervical spine abnormalities. Details of these
topics are covered elsewhere and so are
not dealt with in this chapter, but their
value rests in improving the sensory
response and strengthening oral and
pharyngeal muscle function. Reducing bolus size in the scenario of diminished PES opening can be considered,
while larger bolus sizes may be more
manageable for patients with poor epiglottic deflection. Bolus consistency is
another controllable variable, where
thicker consistency may be easier to
control but requires more effort to swallow. Multiple swallows is a consistently
effective strategy in the spinal surgery
population. For patients with obstructive pathology and solid food dysphagia, lubrication of foods may allow
easier passage. There are no therapeutic studies evaluating the use of different swallowing exercises or maneuvers
in spinal abnormalities, so all techniques are extrapolated from other
conditions. (See videos on the companion website associated with Chapter19,
including Video 19–1, CSpineBolusConsistManipulation, Video 19–2, CSpineBolusVolManipulation, and Video 19–3,
CSpine BolusRedirect).
Surgical
The primary target for spinal surgical
therapy to improve dysphagia are anterior cervical osteophytes. It is essential
that patients proposed to have dysphagia in the context of osteophytes be
evaluated to ensure that other common
causes of dysphagia are excluded, as
described above. Dysphagia clinicians
must question whether the impairment
is severe enough to limit diet, typically
www
www
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
with solids, or is potentially life-threatening due to risk of aspiration, which
is more common with liquids (Seidler
et al., 2009). In these instances, surgical osteophytectomy is a valuable procedure to greatly improve a patient’s
quality of life and safety in eating. However, as mentioned earlier, only lowquality evidence exists to support its
use (Carlson et al., 2011; Krause & Castro, 1994; Lambert et al., 1981; Urrutia &
Bono, 2009; von der Hoeh et al., 2015).
Unfortunately, it has also been shown
that osteophytes can recur, reportedly
at 1 mm/year, and require repeat resection for recurrent dysphagia in some
patients, with higher risk present in
those with DISH (Miyamoto et al., 2009),
though this has not been replicated in
other series with similar follow-up duration (Urrutia & Bono, 2009). Operative
risks of anterior cervical spine surgery
include hardware failure, neural injury,
cerebrospinal fluid leak, infection, hematoma, or worsened dysphagia, among
others. For these reasons, enteral feeding through nasogastric or gastrostomy
tubes is an important consideration
among patients with severe dysphagia
and comorbidities that preclude surgical intervention. Preoperative realimentation is a valuable consideration in
select patients due to malnutrition and
higher risk of complications secondary
to poor wound healing.
An alternative approach to patients
with obstructing cervical osteophytes
or with cervical hardware limiting epiglottic inversion is partial epiglottectomy. In a small case series of patients
with complaints of dysphagia and
fluoroscopic findings of limited epiglottic deflection with anterior cervical
protrusion, partial epiglottectomy was
associated with decreased pharyngeal
transit time and reduced vallecula residue (Jamal et al., 2015). Though promising for its simplicity and familiarity to
many surgeons, further investigation
is necessary to determine appropriate
selection criteria.
STUDY QUESTIONS
1. What are three possible causes of
dysphagia related to the spine?
2. What is the difference between
kyphosis and lordosis? Would you
expect them to affect swallowing
differently? If so, how?
3. What structural variables postoperatively might affect swallowing in
patients undergoing cervical spine
surgery?
4. How might PES opening be affected
by spine surgery?
5. What strategy (or strategies) might
be worthwhile to consider in patients experiencing difficulty with
epiglottic inversion related to spine
surgery?
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33/acs-210034
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Bonus Online-Only Chapter
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Telehealth
Georgia A. Malandraki
www
The use of telehealth for the management of dysphagia has significantly
increased worldwide since the start of
the COVID-19 pandemic. This increase
has presented many opportunities but
also challenges for clinicians managing adult and pediatric patients with
dysphagia. In this chapter, the author
will summarize the research evidence
on dysphagia telemanagement and
will share regulatory guidance, train-
ing components, and patient candidacy considerations. Then, telehealth
and hybrid models of dysphagia
management will be discussed as
well as where we are now and what
the future holds. The role of newer
technologies (wearables, AI) as catalysts for the future of dysphagia care
will also be introduced. This Bonus
Online-Only Chapter can be accessed
on the PluralPlus companion website.
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