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Severe dysphagia was reduced with local steroid application after ACDF
Future research should identify ways of limiting severe dysphagia after ACDF.
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Patients undergoing anterior cervical discectomy and fusion who received an application of local steroid at the conclusion of the cervical plating had better patient-report outcomes for dysphagia than patients who received IV steroids or a control group, based on results presented at a meeting.
“Mild dysphagia is extraordinarily common after [anterior cervical discectomy and fusion] ACDF and can be considered a side effect of the surgery. However, at a certain point dysphagia is no longer a side effect and must be seen as a complication of surgery. The good news is that it seems to be a modifiable complication that we can help patients with,” Tyler J. Jenkins, MD, said. “We showed the use of local steroid application at the conclusion of ACDF yielded better patient-reported outcomes for severe dysphagia.”
Severe dysphagia, Jenkins said, is associated with increased morbidity and increased health care expenditures.
Jenkins and his colleagues randomly assigned 75 patients with degenerative cervical spine disease undergoing ACDF for myelopathy or radiculopathy to one of three groups: local steroid; IV steroid; or control group. The patients received, respectively, 40 mg triamcinolone in the retropharyngeal space after cervical plating, a one-time dose of 10-mg IV dexamethasone intraoperatively or no steroids.
All patients were blinded to the treatment they received.
Researchers collected patient outcomes preoperatively and postoperatively on day 1 and at 2 weeks, 6 weeks and 3 months. They measured dysphagia with the Bazaz classification and the eating assessment tool (EAT-10) survey and they measured dysphonia with the voice handicap index-10. The researchers used the neck disability index and VAS score for neck pain as secondary outcome measures.
“When looking at all mild dysphagia using the Bazaz classification, there was no difference in any time points between the groups,” Jenkins said.
There were significantly better outcomes in the local steroid group when the investigators looked specifically at moderate and severe dysphagia. A similar trend was noted with the EAT-10 score for dysphagia, he said.
“When we looked at all comers of dysphagia [for the EAT-10], there was no difference at the different time points,” Jenkins said. “However, when we looked specifically at severe dysphagia, the local steroid cohort performed significantly better.”
Jenkins told Orthopedics Today research should seek to define the etiology of severe dysphagia and identify the right dose of steroids, as well as identify other approaches that may limit dysphagia. It will be important to develop patient outcomes specifically for severe dysphagia, he noted.
“I think the other thing is just to look at how [dysphagia] impacts cost in the future,” Jenkins said. “If we can truly reduce hospital stays and cost without any risks or side effects, this would be a game changer,” he said. – by Casey Tingle
- Reference:
- Bhatt SA, et al. Paper #498. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 14-18, 2017; San Diego.
- For more information:
- Tyler J. Jenkins, MD, can be reached at Northwestern Feinberg School of Medicine, Department of Orthopedic Surgery, 676 N. Saint Clair, Suite 1350, Chicago, IL 60611; email: tyler.jenkins@fsm.northwestern.edu.
Disclosure: Jenkins reports no relevant financial disclosures.
Perspective
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Sanford E. Emery, MD, MBA
Jenkins and colleagues have conducted a study regarding postoperative swallowing and voice issues after ACDF procedures for radiculopathy and myelopathy. The study design is strong, with a patient-blinded, randomized protocol. Topical steroids were statistically better than the other two groups for lessening severe moderate/dysphagia at 2 weeks as measured by the Bazaz scale and the EAT-10 survey, and at 6 weeks as measured by the Bazaz scale. Topical steroids also decreased dysphonia on postoperative day 1 vs. the other two groups. However, IV steroids did not seem to have as much benefit, with statistically significant improvement for severe dysphagia seen only at 6 weeks for the EAT-10 survey. Our randomized study presented at the American Academy of Orthopaedic Surgeons Annual Meeting in 2016 found three perioperative doses of IV steroids diminished dysphagia symptoms at several time periods up to 1 year postoperatively vs. saline, which is a different protocol than the one dose used in this study. One caveat of which I am sure the authors are aware is a report by Lee and colleagues of two patients who developed delayed esophageal perforations (at 2 months and 1 year postoperatively) that may or may not be linked to the use of topical steroids in this patient population.
I commend the authors on a well-designed and well-executed study that addresses a common problem with simple interventions that can benefit patient care. Longer term follow-up of the topical group and larger numbers to look at hospital length of stay might be of interest for future work.
References:
Emery SE, et al. Paper #60. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 1-5, 2016; Orlando, Fla.
Lee SH, et al. Spine J. 2015;doi:10.1016/j.spinee.2015.06.058.
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