What are typical problems and therapy related to anterior cervical fusion and dysphagia?
Let me preface my comments with the fact that there are no longitudinal studies that assess and report functional swallowing mechanics in patients who have had ACFs. There are some small cohort studies (Martin, et al., 1997) and others that describe patient symptoms (e.g., complaints) (Winslow, et al., 1997), but that is about it. I do have quite a bit of personal professional experience with this population, and my comments are thus based on my observations during those experiences. Please note that my observations are biased by the fact that I only see patients who complain of problems to their surgeon.
1. Sensation: Many patients express a change in the way their swallowing ''feels'' following the fusion surgery. Some describe the problem as devastating and even complain of pain in their neck that radiates to their face and ear. When one considers the nature of the required pharyngeal incision and the retraction of structures necessary to access the C-spine, I guess this should not be surprising. Other patients show a delay in the initiation of the pharyngeal swallow that does not trigger until the level of the pyriform, and some report a sensation of ''choking'' on their saliva. This may also be related to impairment of sensory innervation in the hypopharynx.
2. Motor Function: This appears variable. This variability may be due to the presence/absence of cervical hardware, the level and extent of fusion, etc. But again, none of these issues have been systematically examined regarding their outcome on swallowing. Some patients have a reduction in pharyngeal contraction. Is this because of the incision, dennervation related to a plate or perhaps to spinal deformity? We don't know.
In my experience, most patients return to functional swallowing, but many are unsatisfied with the way their swallowing feels. They feel as though they have to be extremely careful when they swallow and often avoid hard solids such as meats. I am sure many patients do just fine, but again, we don't see those patients. In summary, it is very important to document any presurgical swallowing abnormalities to ensure that the surgery didn't ''cause'' the problem. Further, surgeons need to ask the right questions before and after surgery and work up patient with complaints that go beyond the length of hospitalization. Often doing an MBS with visualization of the nature of the impairment assists the patient with peace of mind and control over the problem. You are often limited with compensatory posturing because of the neck restrictions. Sensitization techniques and biofeedback may be helpful.
In conclusion, we need a longitudinal study that examines this population preoperatively and for a sufficient post-operative period to really understand the scope of swallowing impairment..
Martin, R.E., M.A. Neary, and N.E. Diamant. 1997. Dysphagia following Anterior Cervical Spine Surgery. Dysphagia 12: 2-8
Winslow, CP, Winslow, TY, Wax MK. 1997. Dysphonia and Dysphagia Following Anterior Approach to the Cervical Spine. Archives of Otolaryngology and Head and Neck Surgery., 105: 85-91
Bonnie Martin-Harris, Ph.D.
Bonnie Martin-Harris, Ph.D., is Associate Professor in the Departments of Otolaryngology Head and Neck Surgery and College of Health Professions at the Medical University of South Carolina. She is Director of the MUSC Evelyn Trammell Institute for Voice and Swallowing, and founder and consultant to the Evelyn Trammell Voice and Swallowing Center at Saint Joseph's Hospital of Atlanta. Dr. Martin-Harris chairs the Inaugural Board for Board Recognition in Swallowing and Swallowing Disorders and serves on the Membership Committee of the Dysphagia Research Society. Dr. Martin-Harris's clinical and research interests are focused in the areas of laryngeal and pharyngeal dynamics during swallowing, respiration and vocalization. She is a reviewer for the Dysphagia Journal, American Journal of Speech Language Pathology, Journal of Speech Language Hearing Research, a national and international lecturer, and has published chapters and articles in the areas of upper aerodigestive tract function and disorders. Her work is funded in part by a grant from the National Institutes on Deafness and Other Communication Disorders (R03: DC04864-01) and the Mark and Evelyn Trammell Foundation.