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Guilty by Association – Cervical Spine

May 06, 2009 Posted by: DiagnosTEX Educational Handouts,  Patient/Family Education

The cervical spine begins at the base of the skull. Seven vertebrae make up the cervical spine with eight pairs of cervical nerves. The individual cervical vertebrae are abbreviated C1, C2, C3, C4, C5, C6 and C7. The cervical nerves are also abbreviated; C1 through C8.

Dysphagia following cervical spine intervention has been under-diagnosed and overlooked.  Understanding the occurrence of post surgical dysphagia is essential in diagnosing and treating the condition.  With increased awareness of the risks and proper identification treatment can be initiated promptly to avoid unnecessary complications during the hospital stay. Dysphagia research, as limited as it is, indicates anywhere from a 45-85% rate of dysphagia after surgery, with percentages of 10-15% suffering from persistent dysphagia over a 6 months period.
 

Three types of cervical fusion:

  1. Corpectomy – removal of entire vertebral body and 2 adjacent discs
  2. Discectomy – removal of disc of soft tissue between the vertebrae
  3. Laminectomy – removal of posterior lamina and spiny processes.

 

Left side anterior cervical fusion is preferred due to less risk of dysphagia as the recurrent laryngeal nerve runs laterally. But each surgeon has a preferred approach of his or her own.  The recurrent laryngeal nerve is vulnerable anywhere between C1-T1.

Fact: Dysphonia can result from cervical fusion and can be attributed to vagus nerve damage

 

The oropharyngeal structures correlate with the cervical spine (see attachment).  Cervical Spine 1-5 as well as C6 and C7 correspond with many anatomic landmarks important to swallowing. 
            C-1 – Hard Palate, Soft Palate, Velum
            C-2 – Base of tongue, valleculae
            C-3 – Base of Tongue, Retropharyngeal space, valleculae, epiglottis
            C-4 – Hyoid Bone, Pyriform Sinuses
            C-5 – Vocal cords
            C-6 – Vocal Cords, Pyriform Sinuses, Cricopharyngeal muscle
            C-7 – Cricopharyngeal muscle
 

Cervical osteophytes and other hypertrophic changes of the cervical spine are found in approximately 20-30% of the elderly However, large osteophytes that protrude from the anterior edge of the cervical vertebrae can impinge on the pharynx or upper esophagus. Large osteophytes have been found to cause dysphagia, odynophagia, and globus symptoms. Resnick et al. coined the term “diffuse skeletal hyperostosis” to describe these large multisegmental bridging osteophytes of the cervical and lumbar spine. They found that dysphagia was fairly common in patients with diffuse skeletal hyperostosis. Retention and aspiration were more often seen with increased osteophyte size. However, even small osteophytes may cause clinically relevant pharyngeal residue and aspiration if they occur concomitantly with other clinical conditions. The presence of a cervical osteophyte in an elderly patient does not necessarily explain individual symptoms. Swallowing dysfunction is common in this age group and can be caused by a variety of diseases, including stroke, Parkinson’s disease, dementia, and esophageal carcinoma. Videofluoroscopy has been found to be the most sensitive method to detect swallowing abnormalities in patients suffering from dysphagia.

 

Treatment of cervical osteophyte—induced dysphagia should depend on the nature and severity of disease. Sedation, antiinflammatory drugs, and muscle relaxants with an appropriate soft diet have been used successfully . Surgical excision of a large anterior cervical osteophyte via an anterior extrapharyngeal approach was first described by Iglauer in 1938. In a review of the literature, Sobol and Rigual found 70-80 patients with osteophyte-induced dysphagia. Of these, 19 patients underwent surgery that successfully relieved the dysphagia in all but three patients. Vocal cord paralysis has been reported in 2-11% of patients as the most common complication, followed by fistula, hematoma, infection, and transient aspiration.  One patients suffered from a hypoglossal nerve paralysis postoperatively, which, to our knowledge, has not been reported as a complication of osteophyte surgery. However, some studies have suggested that surgery should be reserved for patients with severe symptoms or for those patients for whom conservative treatment failed.
 

References 
Resnick D, Shaul SR, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier’s disease with extraspinal manifestations. Radiology 1975;115:513-524[Abstract]
Jones B, Donner M. Examination of the patients with dysphagia. Radiology 1988;167:319-326[Abstract/Free Full Text]
Deutsch EC, Schild JA, Mafee MF. Dysphagia and Forestier’s disease. Arch Otolaryngol 1985;111:400-402[Abstract/Free Full Text]
Umerah BC, Mukherjee BK, Ibekwe O. Cervical spondylosis and dysphagia. J Laryngol Otol 1981;95:1179-1183[Medline]
Iglauer S. A case of dysphagia due to an osteochondroma of the cervical spine-osteotomy-recovery. Ann Otol Rhinol Laryngol 1938;47:799-803
Heeneman H. Vocal cord paralysis following approaches to the anterior cervical spine. Laryngoscope 1973;83:17-21[Medline]
Komisar A, Tabaddor K. Extrapharyngeal (anterolateral) approach to the cervical spine. Head Neck Surg 1983;6:600-604[Medline]