The Journal of Bone and Joint Surgery (American). 2008;90:256-263.
doi:10.2106/JBJS.G.00258
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Dysphagia Following Anterior Cervical Arthrodesis Is Associated with Continuous, Strong Retraction of the Esophagus

Sergio Mendoza-Lattes, MD1, Kirk Clifford, MD1, Robert Bartelt, MD1, Janet Stewart, RN1, Charles R. Clark, MD1 and André P. Boezaart, MD, PhD1

1 Departments of Orthopaedic Surgery and Rehabilitation (S.M.-L., K.C., R.B., J.S., C.R.C., A.P.B.) and Anesthesia (A.P.B.), The University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242. E-mail address for S. Mendoza-Lattes: sergio-mendoza{at}uiowa.edu

Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, The University of Iowa, Iowa City, Iowa

A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Cervical Spine Research Society (Grant Research Award 2004). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Medtronic) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

Background: The prevalence of dysphagia after anterior cervical decompression and arthrodesis is estimated to be 50% within one month and 21% at twelve months. However, its exact etiology is not well understood. The objective of the present study was to explore the relationship between intraoperative intra-esophageal pressure due to surgical retraction, esophageal mucosal blood flow at the level of surgery, and postoperative dysphagia. Our hypothesis was that sustained elevated pressure on the esophagus during anterior cervical arthrodesis is associated with postoperative dysphagia.

Methods: Seventeen selected patients scheduled for anterior cervical arthrodesis were studied. Throughout the procedure, intraluminal pressure in the upper esophageal sphincter was measured (mm Hg) with a custom-made manometer probe and mucosal perfusion was measured at the level of surgery with a laser Doppler flowmeter. The type of retraction chosen by the surgeon was noted. Postoperatively, the patients were specifically evaluated for dysphagia on the first postoperative day and at six weeks, three months, and six months postoperatively with use of the M.D. Anderson Dysphagia Inventory.

Results: Four of the eleven patients who had dynamic retraction and five of the six patients who had static retraction during surgery had postoperative dysphagia. In the group of patients with dysphagia, the average M.D. Anderson Dysphagia Inventory score decreased from 93.8 ± 12.1 preoperatively to 67.7 ± 11.4 on the first postoperative day (p < 0.001). The patients with dysphagia had a significantly higher average intraluminal pressure (60.8 ± 54.3 compared with 54.4 ± 51.8 mm Hg; p < 0.0001) as well as significantly lower average mucosal perfusion (26.1 ± 18.1 compared with 40.8 ± 26.2 tissue perfusion units; p < 0.0001) in comparison with the asymptomatic patients.

Conclusions: Patients with dysphagia following anterior cervical arthrodesis were exposed to higher intraoperative esophageal pressure and decreased esophageal mucosal blood flow during surgical retraction as compared with patients without dysphagia. In this small series, dynamic retraction seemed to be associated with a lower prevalence of postoperative dysphagia.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.


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