Long-term result of vocal cord paralysis after anterior cervical disectomy

Characterizing Long-Term Swallowing and Voice Outcomes Following Anterior Transcervical Approach

OBJECTIVES

(1) Assess the frequency and severity of long-term swallowing and voice complaints, follow-up care, risk factors for the development of long-term swallowing and voice complications in patients who underwent anterior transcervical approach (ACA). (2) Determine incidence of long-term swallowing and voice complications requiring follow-up otolaryngologic care and assess the frequency of otolaryngologic follow-up for postoperative swallowing and voice complaints.

METHODS

Retrospective cohort study of patients between January 2017 and March 2020 who underwent ACA. Demographic information, data from preoperative evaluation, operative records, and data from postoperative visits were collected. Patients were contacted to complete the Eating Assessment Tool and the "Impairment" subset of the Voice Symptoms Scale.

RESULTS

A total of 48 patients (10.6%) followed up with a head and neck surgeon for swallowing complaints and 31 patients (6.8%) for voice complaints. Otolaryngology follow-up for swallowing complaints among patients with at least 3 and 12 months of follow-up was 16.4% and 17.8%, respectively. Otolaryngology follow-up for voice complaints among patients with at least 3 and 12 months of follow-up was 11.7% and 11.9%, respectively. Swallowing function was abnormal in 40.7% at least 3 months after surgery and in 41.8% 12 months after. Voice function was abnormal in 55.7% of respondents at least 3 months after surgery and in 54.5% of respondents 12 months after.

CONCLUSIONS

ACA is associated with otolaryngologic complications that include dysphagia and dysphonia. This study demonstrates that long-term swallowing and voice dysfunction appear to persist longer than what is noted by patient utilization of follow-up otolaryngologic care.

LEVEL OF EVIDENCE

IV Laryngoscope, 2024.

Study on the Influencing Factors of Short-Term Recovery of Neurological Symptoms after Carotid Body Tumor Resection

OBJECTIVE

To compare the differences in the short-term recovery from neurological symptoms (SRN) (≤ 6 months) and clinical characteristics of patients with different Shamblin classifications carotid body tumor (CBT) resection and to analyze the risk factors affecting SRN after surgery.

METHODS

Patients who underwent CBT resection between June 2018 and September 2022 were recruited. Perioperative factors and indicators of the nature of the tumor were recorded. The risk factors affecting SRN after CBT resection were analyzed using logistic regression analysis.

RESULTS

Eighty-five patients (43.86 ± 12.7 years, 46 females) were included, 40 (47.06%) of whom exhibited SRN. Univariate logistic regression showed that preoperative symptoms, surgical side, bilateral posterior communicating artery (PcoA) opening, some indicators of tumor size, operative/anesthesia time, and Shamblin III classification were correlated with postoperative neurological prognosis (all p < 0.05). After adjusting for confounders, preoperative symptoms (OR, 5.072; 95% CI 1.027-25.052; p = 0.046), surgical side (OR, 0.025; 95% CI 0.003-0234; p = 0.001), bilateral PcoA opening (OR, 22.671; 95% CI 2.549-201.666; p = 0.005), distance from the tip of the C2 dens to the superior aspect (dens-CBT) (OR, 0.918; 95% CI 0.858-0.982; p = 0.013) and Shamblin III classification (OR, 28.488; 95% CI 1.986-408.580; p = 0.014) were correlated with postoperative neurological symptom recovery.

CONCLUSION

Preoperative symptoms, surgical side (right), bilateral PcoA opening, a short dens-CBT and Shamblin III classification are risk factors affecting SRN after CBT resection. Early resection is recommended for small-volume CBTs without neurovascular compression or invasion to obtain SRN.

A Systematic Review of Definitions for Dysphagia and Dysphonia in Patients Treated Surgically for Degenerative Cervical Myelopathy

STUDY DESIGN

Systematic review. Surgical decompression for degenerative cervical myelopathy (DCM) is associated with perioperative complications, including difficulty or discomfort with swallowing (dysphagia) as well as changes in sound production (dysphonia). This systematic review aims to (1) outline how dysphagia and dysphonia are defined in the literature and (2) assess the quality of definitions using a novel 4-point rating system.

METHODS

An electronic database search was conducted for studies that reported on dysphagia, dysphonia or other related complications of DCM surgery. Data extracted included study design, surgical details, as well as definitions and rates of surgical complications. A 4-point rating scale was developed to assess the quality of definitions for each complication.

RESULTS

Our search yielded 2,673 unique citations, 11 of which met eligibility criteria and were summarized in this review. Defined complications included odynophagia (n = 1), dysphagia (n = 11), dysphonia (n = 2), perioperative swelling complications (n = 2), and soft tissue swelling (n = 3). Rates of dysphagia varied substantially (0.0%-50.0%) depending on whether this complication was patient-reported (4.4%); patient-reported using a modified Swallowing Quality of Life questionnaire (43.1%) or the Bazaz criteria (8.8%-50.0%); or diagnosed using an extensive protocol consisting of clinical assessment, a bedside swallowing test, evaluation by a speech and language pathologist and a modified barium swallowing test/fiberoptic endoscopy (42.9%). The reported incidences of dysphonia also ranged significantly from 0.6% to 38.0%.

CONCLUSION

There is substantial variability in reported rates of dysphagia and dysphonia due to differences in data collection methods, diagnostic strategies, and definitions. Consolidation of nomenclature will improve evaluation of the overall safety of surgery.

A Tapered Cuff Tracheal Tube Decreases the Need for Cuff Pressure Adjustment After Surgical Retraction During Anterior Cervical Spine Surgery: A Randomized Controlled, Double-Blind Trial

Background

Surgical retraction to expose the vertebrae during anterior cervical spine surgery increases tracheal tube cuff pressure and may worsen postoperative sore throat and dysphonia. This randomized double-blind study investigated the effect of cuff shape on intraoperative cuff pressure and postoperative sore throat and dysphonia.

Methods

Eighty patients were randomized to tracheal intubation with a tapered cuff or a conventional cylindrical high-volume low-pressure cuff (control) during anesthesia. Intraoperative cuff pressures were compared. The primary outcome was the incidence of pressure adjustment needed when the cuff pressure increased to &gt; 25 mm Hg after surgical retraction. The secondary outcome was the incidence of postoperative sore throat and dysphonia.

Results

The incidence of pressure adjustment after surgical retraction was significantly lower in the tapered group than in the control group (13% vs. 48%; P = 0.001; relative risk reduction, 74%). The median [interquartile range (IQR)] cuff pressure (mm Hg) was significantly lower for the tapered cuff than for the control cuff before surgical retraction [9 (7–12) vs. 12 (10–15); P &lt; 0.001] and after retraction [18 (15–23) vs. 25 (18–31); P = 0.007]. The median (IQR) postoperative dysphonia score assessed by a single speech-language pathologist was lower in the tapered group than in the control group [4 (3–6) vs. 5.5 (5–7); P = 0.008].

Conclusion

A tapered cuff tracheal tube decreased the need for the adjustment of cuff pressure after surgical retraction during anterior cervical spine surgery, thereby avoiding intraoperative pressure increase. It also has a better outcome in terms of dysphonia.

Clinical Trial Registration

[www.clinicaltrials.gov], identifier [NCT04591769].

Free Tissue Transfer for Repair of Chronic Esophageal Perforations

Objective

Anterior cervical discectomy and fusion have become a common intervention for cervical spine stabilization. However, complications can cause life-threatening morbidity. Among them, esophageal perforation is associated with severe morbidity, including dysphagia, malnutrition, and infection with the potential development of mediastinitis. Presentation is variable but often results in chronic morbidity. Herein we examine our experiences in the management of esophageal perforation with microvascular free tissue transfer.

Study Design

Retrospective review from January 2013 to September 2020.

Setting

Single academic tertiary care center.

Methods

This study comprised all patients (age, 41-73 years) undergoing free tissue transfer for the repair of chronic esophageal perforation secondary to anterior cervical discectomy and fusion at an academic tertiary care center. Four patients underwent repair via vastus lateralis myofascial onlay grafting for defects ≤2 cm in greatest dimension, while 1 patient underwent a fasciocutaneous radial forearm free flap repair of an 11 × 5-cm defect.

Results

Defect location ranged from hypopharynx to cervical esophagus. Mean operative time was 6.2 hours; the average length of stay for all patients was 6.6 days. Of 5 patients, 1 required additional hardware placement for spine stabilization. All patients underwent gastrostomy tube placement to bypass the surgical site during healing, and all eventually resumed an oral diet postoperatively. Recurrent fistula occurred in 1 of 5 patients. No flap failures were encountered in the study population.

Conclusion

Vastus lateralis myofascial onlay grafting and fasciocutaneous radial forearm free flap are robust, relatively low-morbidity interventions with a high success rate for definitive repair of chronic esophageal perforation. Repair should be undertaken in concert with a spine surgeon for management of the cervical spine.

Neurophysiological monitoring during anterior cervical discectomy and fusion for ossification of the posterior longitudinal ligament

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Postoperative neurological complications are not rare in ACDF for OPLL pathology.

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Multimodal IONM may reduce neurological damage in ACDF surgery for OPLL.

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IONM and preoperative myelopathy were associated with neurological complications.

Objective

This study aimed to investigate the value of intraoperative neurophysiological monitoring (IONM) in anterior cervical spine discectomy with fusion (ACDF) for ossification of the posterior longitudinal ligament (OPLL).

Methods

Patients who underwent multimodal IONM (transcranial electrical motor-evoked potentials [tcMEP], somatosensory-evoked potentials, and continuous electromyography) for ACDF from 2009 to 2019 were compared to historical controls from 2003 to 2009. The rates of postoperative neurological deficits, neurophysiological warnings, and their characteristics were analyzed.

Results

Among 196 patients, postoperative neurological deficit rates were 3.79% and 14.06% in the IONM and historical control (non-IONM) groups, respectively (p < 0.05). The use of IONM (OR: 0.139, p = 0.003) and presence of myelopathy (OR: 8.240, p = 0.013) were associated with postoperative neurological complications on multivariate regression. In total, 23 warnings were observed during IONM (17 tcMEP and/or electromyography; six electromyography). Sensitivity and specificity of IONM warnings for detecting neurological complications were 84.2% and 93.7%, respectively.

Conclusions

IONM, especially multimodal IONM, may be a useful tool to detect neurological damage in ACDF for high-risk conditions such as OPLL with pre-existing myelopathy.

Significance

The utility of IONM in ACDF for OPLL has not been evaluated due to its rarity. This study supports the use of IONM in cervical OPLL with myelopathy.

Covering of Plate after Anterior Cervical Fusion in Patients with Complete Spinal Cord Injury to Prevent Esophageal Injury: Technical Note

BACKGROUND

 Esophageal injury after anterior corpectomy and fusion is a rare but life-threatening complication. It may cause mediastinitis due to anatomical continuity between the retropharyngeal space and the mediastinum, with reported high mortality rates. The acute and subacute injuries are most commonly of iatrogenic origin, while late perforation has been described several weeks to years later as a result of continuous friction or pressure of the instruments against the posterior wall of the esophagus, leading to ischemia and necrosis. This phenomenon is more common among quadriplegic patients who have undergone corpectomy and insertion of expandable or mesh cages and plate probably due to chronic erosion by hardware at the supine position.

METHODS

 Since 2015, we have applied the technique of using a patch of autologous fascia lata to cover the anterior cervical plate by suturing to the longus colli muscles in 58 quadriplegic patients; the mean follow-up was 35.2 (28-41) months.

RESULTS

 Since we started using this procedure, based on our follow-up at our center, there have been no cases of late esophageal perforation among quadriplegic patients.

CONCLUSION

 As a technical note, it seems like this method would be able to reduce the prevalence of esophagus injury among quadriplegic patients. However, to substantiate the efficacy of this technique, long-term follow-up and larger sample size are needed because esophageal injury occurs rarely.

Anatomical Variations of the Recurrent Laryngeal Nerve and Implications for Injury Prevention during Surgical Procedures of the Neck

Accurate knowledge of anatomical variations of the recurrent laryngeal nerve (RLN) provides information to prevent inadvertent intraoperative injury and ultimately guide best clinical and surgical practices. The present study aims to assess the potential anatomical variability of RLN pertaining to its course, branching pattern, and relationship to the inferior thyroid artery, which makes it vulnerable during surgical procedures of the neck. Fifty-five formalin-fixed cadavers were carefully dissected and examined, with the course of the RLN carefully evaluated and documented bilaterally. Our findings indicate that extra-laryngeal branches coming off the RLN on both the right and left side innervate the esophagus, trachea, and mainly intrinsic laryngeal muscles. On the right side, 89.1% of the cadavers demonstrated 2–5 extra-laryngeal branches. On the left, 74.6% of the cadavers demonstrated 2–3 extra-laryngeal branches. In relation to the inferior thyroid artery (ITA), 67.9% of right RLNs were located anteriorly, while 32.1% were located posteriorly. On the other hand, 32.1% of left RLNs were anterior to the ITA, while 67.9% were related posteriorly. On both sides, 3–5% of RLN crossed in between the branches of the ITA. Anatomical consideration of the variations in the course, branching pattern, and relationship of the RLNs is essential to minimize complications associated with surgical procedures of the neck, especially thyroidectomy and anterior cervical discectomy and fusion (ACDF) surgery. The information gained in this study emphasizes the need to preferentially utilize left-sided approaches for ACDF surgery whenever possible.

Ultrasound prediction for vocal cord dysfunction in patients scheduled for anterior cervical spine surgeries: a prospective cohort study

Prediction of vocal cord dysfunction is essential after anterior cervical spine surgeries. This study aimed to detect the validity of transcutaneous laryngeal ultrasonography by both anterior and novel lateral approaches for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries. A prospective cohort study conducted on 90 patients scheduled for anterior cervical spine surgeries underwent consecutive pre and postoperative vocal cord examination for edema and paralysis by both anterior and lateral approaches laryngeal ultrasonography. Rigid laryngoscopy was the standard confirmatory tool. For postoperative vocal cord edema, the anterior ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 78.9% with PPV = 78.9% and NPV = 88.2% and the novel lateral ultrasonography approach diagnostic sensitivity = 88.2%, specificity = 94.7% with PPV = 93.75% and NPP = 90%. While for paralysis, the anterior ultrasonography approach diagnostic sensitivity = 86.7%, specificity = 85.7% with PPV = 81.25% and NPV = 90% and the novel lateral ultrasonography approach diagnostic (sensitivity, specificity with PPV and NPP) = 100%. The diagnostic accuracy of the novel lateral approach was more correlated to rigid laryngoscopy (91.7% and 100%) compared to anterior approach for vocal cord edema and paralysis (83.3% and 80.6%). Overall incidence of vocal cord paralysis was 16.6%. Risk of vocal cord paralysis was statistically significant more in female, multiple disc herniation, lower and mixed disc levels, Langenbeck retractor, cage and plate and duration of surgery ≥ 1.5 h. Transcutaneous Laryngeal ultrasound is a valid comfortable tool for prediction of vocal cord edema and paralysis after anterior cervical spine surgeries with superiority of the novel lateral over anterior approach.

Clinical outcomes of epidural and intradural decompression for treatment of degenerative cervical myelopathy

Objective

This study was performed to examine the clinical outcomes of epidural and intradural decompression for degenerative cervical myelopathy.

Methods

The data for 13 patients who underwent epidural and intradural decompression for treatment of degenerative cervical myelopathy (study group) and 20 patients who underwent only cervical laminoplasty, fusion, and epidural decompression (historical control group) were retrospectively reviewed. The preoperative and postoperative neurological status was evaluated using the Japanese Orthopaedic Association (JOA) score.

Results

All patients’ neurological symptoms were significantly improved at the final follow-up. In the study group, the patients’ mean preoperative JOA score was 8.07 ± 1.80, and the final score improved by 70.88% ± 21.18%. The blood loss and operation time were significantly greater in the study group than control group. The recovery time was shorter in the study group than control group. The improvement rate was not significantly different between the two groups.

Conclusions

A pia mater incision with separation of the arachnoid adhesion can significantly improve the cerebrospinal fluid flow and spinal blood flow in degenerative cervical myelopathy. Arachnoid adhesion can lead to intradural spinal scar compression. The surgical intervention described herein can achieve satisfactory neurological outcomes and shorten the recovery time.

Case of Vagal Nerve Stimulator-Induced Stridor After Anterior Cervical Diskectomy and Fusion-Induced Vocal Cord Paralysis

BACKGROUND

Vagal nerve stimulation is a generally safe adjunctive treatment for medically refractory epilepsy. Nevertheless, reports of vocal cord dysfunction during stimulation can be found in the literature. When vagal nerve stimulation-induced vocal cord dysfunction is compounded with contralateral dysfunction, such as that which can occur after anterior cervical diskectomy and fusion, serious pulmonary complications can occur.

CASE DESCRIPTION

A 56-year-old female presented to the emergency department 3 weeks postoperatively from a cervical 7-thoracic 2 anterior cervical diskectomy and fusion through a right-sided approach with new-onset, intermittent stridor. Otorhinolaryngology conducted a fiberoptic laryngoscopy and determined that the patient had a right vocal cord paralysis and intermittent left vocal cord paresis that coincided with activation of the patient's vagal nerve stimulator. The stimulator was shut off, and the patient's stridor disappeared.

CONCLUSIONS

Vagal nerve stimulation-induced vocal cord paralysis is a rare but known complication. Given this potential for vocal cord dysfunction, neurosurgeons should plan further anterior cervical diskectomy and fusions accordingly to ensure that patients do not develop dysfunction of bilateral vocal cords. Should this develop, however, cessation of vagal nerve stimulation can improve or treat the pulmonologic complication that develops.

Vocal cord dysfunction following esophageal atresia and tracheoesophageal fistula (EA/TEF) repair

BACKGROUND

The purpose of this study was to determine risk factors and long-term outcomes in patients with esophageal atresia +/-tracheoesophageal fistula (EA/TEF) with vocal cord dysfunction (VCD) owing to recurrent laryngeal nerve (RLN) injury.

METHOD

A retrospective chart review was performed for EA/TEF patients repaired at our institution from 1999 to 2014 (REB #1000032265).

RESULTS

Of 197 patients, 22 (11.2%) were diagnosed with VCD by indirect laryngoscopy following EA/TEF repair. Aspiration was documented on video swallow study for 21 patients, and as a result, 13 required thickened feeds and 8 required gastrostomy tube feeds. Of the 16 H-type TEF patients, 8 (50%) had VCD. Following discharge, 20 (90.9%) patients with VCD eventually tolerated full feeds orally without aspiration but only 8 (36.4%) had documented recovery of vocal cord movement at long-term follow up (mean 452 days). Overall, patients with VCD were more likely to have feeding modifications, increased exposure to radiological studies, and increased frequency of Otolaryngology follow-up compared to EA/TEF patients without VCD.

CONCLUSION

EA/TEF patients are at risk for VCD. Clinical improvement did not always correlate with recovery of VC motion. Strategies to minimize RLN damage will improve outcomes and quality of life for EA/TEF patients.

LEVEL OF EVIDENCE

Level III.

The assistance of coblation in arytenoidectomy for vocal cord paralysis

BACKGROUND

There are many causes for vocal cord paralysis, which can cause difficulty in breathing in serious cases. The common surgical methods for solving vocal cord paralysis include laryngeal splitting or laser surgery, but there are limitations. Plasma radiofrequency ablation is a new treatment with good achievements in clinical applications.

OBJECTIVE

To investigate the effect of coblation-assisted arytenoidectomy (CSA) in the treatment of bilateral vocal cord paralysis (BVCP).

METHODS

All patients had undergone preoperative electrolaryngoscopic examination of the glottidis rima; electronic laryngoscopy can assess the width of the glottis. The purpose of preoperative electronic laryngoscopic evaluation is to assess the width of the glottis, and arytenoid cartilage movement. Unilateral arytenoid cartilage and a section of the vocal cords were removed in all cases.

RESULTS

Of the 14 patients, 13 were successfully extubated after CSA; 1 patient could not be extubated and underwent a second CSA of the contralateral arytenoid cartilage, after which extubation was achieved. All patients were continuously followed up (6 months to 2 years), and all achieved satisfactory results.

CONCLUSIONS AND SIGNIFICANCE

CSA can effectively relieve post-CSA dyspnea in patients with BVCP. More patients underwent tracheal cannula extubation after tracheotomy compared with other surgeries.

Automated Quantification of Vocal Fold Motion in a Recurrent Laryngeal Nerve Injury Mouse Model

OBJECTIVES/HYPOTHESIS

The goal of this study was to objectively examine vocal fold (VF) motion dynamics after iatrogenic recurrent laryngeal nerve (RLN) injury in a mouse surgical model. Furthermore, we sought to identify a method of inducing injury with a consistent recovery pattern from which we can begin to evaluate spontaneous recovery and test therapeutic interventions.

STUDY DESIGN

Animal model.

METHODS

The right RLN in C57BL/6J mice was crushed for 30 seconds using an aneurysm clip with 1.3-N closing force. Transoral laryngoscopy enabled visualization of VF movement prior to surgery, immediately post-crush, and at two endpoints: 3 days (n = 5) and 2 weeks (n = 5). VF motion was quantified with our custom motion-analysis software. At each endpoint, RLN samples were collected for transmission electron microscopy for correlation with VF motion dynamics.

RESULTS

Our VF tracking software permitted automated quantification of several measures of VF dynamics, such as range and frequency of motion. By 2 weeks post-injury, the frequency of VF movement on the right (injured) side equaled the left, yet range of motion only partially recovered. These objective outcome measures enabled detection of VF dysfunction that persisted at 2 weeks post-crush. Transmission electron microscopy images revealed RLN degeneration 3 days post-crush and partial regeneration at 2 weeks, consistent with functional results obtained with automated VF tracking.

CONCLUSIONS

Our motion-analysis software provides novel objective, quantitative, and repeatable metrics to detect and describe subtle VF dysfunction in mice that corresponds with underlying RLN degeneration and recovery. Adaptation of our tracking software for use with human patients is underway.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E247-E254, 2019.

Recurrent Laryngeal Nerve Palsy Is More Frequent After Secondary than After Primary Anterior Cervical Discectomy and Fusion: Insights from a Registry of 525 Patients

BACKGROUND

Recurrent laryngeal nerve (RLN) palsy is a common complication after anterior cervical discectomy and fusion (ACDF) and usually manifests with dysphagia, hoarseness, and respiratory difficulties. Next to proven risk factors, such as age and multilevel procedures, RLN palsy has been speculated to occur more frequently after secondary ACDF procedures.

METHODS

We analyzed a prospective registry of all consecutive patients undergoing zero-profile ACDF for disc herniation, myelopathy, or stenosis. RLN palsy was defined as persistent patient self-reported dysphagia, hoarseness, or respiratory problems without other identifiable causes. RLN palsy was assessed at scheduled 6-week telephone interviews.

RESULTS

Among 525 included patients, 511 primary and 40 secondary ACDF procedures were performed. Hoarseness was present in 12 (2.2%) cases, whereas dysphagia and respiratory difficulties both occurred in 3 (0.5%) cases. Overall incidence of RLN palsy was 2% after primary procedures and 8% after secondary procedures (P = 0.017). These rates are in line with the peer-reviewed literature, and the difference remained significant after controlling for confounders in a multivariate model (P = 0.033). Other reported risk factors, such as age, sex, surgical time, and multilevel procedures, had no relevant effect (P > 0.05).

CONCLUSIONS

Based on our data and other published series in the literature, RLN palsy may occur more frequently after secondary ACDF procedures with a clinically relevant effect size. There is a striking lack of uniformity in methods and reporting in research on RLN injury.

Management of Symptomatic Cervical Disk Herniation: A Survey Among Dutch Neurosurgeons

STUDY DESIGN

A questionnaire survey.

OBJECTIVE

To assess the preferred surgical technique, the optimal timing of surgery, and the expectations of different surgical techniques of neurosurgeons in the Netherlands, regarding patients with cervical disc herniation (CDH).

SUMMARY OF BACKGROUND DATA

To treat CDH, multiple surgical techniques are performed. Due to the lack of consensus, the daily routine management may vary.

METHODS

All 134 neurosurgeons of the Dutch Association of Neurosurgery were sent a survey, evaluating the operative management as well as the attitude towards different surgical treatments for CDH.

RESULTS

Ninety-six (74.4%) of the neurosurgeons treating CDH completed the survey. Anterior cervical discectomy with fusion (ACDF) was the standard procedure for the majority of neurosurgeons (76.3%). ACDF was expected to have the highest effectiveness on arm pain, yet also a higher risk for complications as compared with anterior cervical discectomy (ACD). Approximately, 47.9% of the surgeons regarded a minimal duration of 8 to 12 weeks of radicular arm pain before deciding to perform surgery. Regarding the risk of recurrent CDH, DCF was expected to give the highest risk, whereas ACDF the lowest.

CONCLUSION

Despite the lack of solid evidence in favor for ACDF this survey showed that ACDF is the preferred technique to treat cervical radiculopathy. A minimum duration of 8 to 12 weeks of radicular arm pain was considered the optimal timing to perform surgery for CDH by the majority of the neurosurgeons. Whether to fuse or not remains a controversial subject in degenerative spinal surgery. This study emphasizes the need of high-quality evidence on the optimal surgical management of CDH.

LEVEL OF EVIDENCE

N/A.

High-resolution Imaging of Neural Anatomy and Pathology of the Neck

The neck has intricately connected neural structures, including cervical and brachial plexi, the sympathetic system, lower cranial nerves, and their branches. Except for brachial plexus, there has been little research regarding the normal imaging appearance or corresponding pathologies of neural structures in the neck. The development in imaging techniques with better spatial resolution and signal-to-noise ratio has made it possible to see many tiny nerves to predict complications related to image-guided procedures and to better assess treatment response, especially in the management of oncology patients. The purposes of this review is to present imaging-based anatomy of major nerves in the neck and explain their relevant clinical significance according to representative pathologies of regarded nerves in the neck.

Cervical Spondylotic Myelopathy

Cervical spondylotic myelopathy (CSM) is a degenerative disease that represents the most common spinal cord disorder in adults. The natural history of the disease can be insidious, and patients often develop debilitating spasticity and weakness. Diagnosis includes a combination of physical examination and various imaging modalities. There are various surgical options for CSM, consisting of anterior and posterior procedures. This article summarizes the literature regarding the pathophysiology, natural history, and diagnosis of CSM, as well as the various treatment options and their associated risks and indications.

An Outcome Study of Anterior Cervical Discectomy and Fusion among Iranian Population

Background and Aim. First-line treatment strategy for managing cervical disc herniation is conservative measures. In some cases, surgery is indicated either due to signs/symptoms of severe/progressive neurological deficits, or because of persistence of radicular pain despite 12 weeks of conservative treatment. Success for treatment of cervical disc herniation using ACDF has been successfully reported in the literature. We aim to determine the outcome of ACDF in treatment of cervical disc herniation among Iranians. Methods and Materials/Patients. In a retrospective cohort study, we evaluated 68 patients who had undergone ACDF for cervical disc herniation from March 2006 to March 2011. Outcome tools were as follows: (1) study-designed questionnaire that addressed residual and/or new complaints and subjective satisfaction with the operation; (2) recent (one week prior to the interview) postoperative VAS for neck and upper extremity radicular pain; (3) Japanese Orthopaedic Association Myelopathy Evaluation Questionnaire (JOACMEQ) (standard Persian version); and (4) follow-up cervical Magnetic Resonance Imaging (MRI) and lateral X-ray. Results. With mean follow-up time of 52.93 (months) ± 31.89 SD (range: 13-131 months), we had success rates with regard to ΔVAS for neck and radicular pain of 88.2% and 89.7%, respectively. Except QOL functional score of JOAMEQ, 100% success rate for the other 4 functional scores of JOAMEQ was achieved. Conclusion. ACDF is a successful surgical technique for the management of cervical disc herniation among Iranian population.

Esophageal perforation after anterior cervical spine surgery: a systematic review of the literature

OBJECTIVE Esophageal perforation is a rare but well-known complication of anterior cervical spine surgery. The authors performed a systematic review of the literature to evaluate symptomatology, direct causes, repair methods, and associated complications of esophageal injury. METHODS A PubMed search that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included relevant clinical studies and case reports (articles written in the English language that included humans as subjects) that reported patients who underwent anterior spinal surgery and sustained some form of esophageal perforation. Available data on clinical presentation, the surgical procedure performed, outcome measures, and other individual variables were abstracted from 1980 through 2015. RESULTS The PubMed search yielded 65 articles with 153 patients (mean age 44.7 years; range 14-85 years) who underwent anterior spinal surgery and sustained esophageal perforation, either during surgery or in a delayed fashion. The most common indications for initial anterior cervical spine surgery in these cases were vertebral fracture/dislocation (n = 77), spondylotic myelopathy (n = 15), and nucleus pulposus herniation (n = 10). The most commonly involved spinal levels were C5-6 (n = 51) and C6-7 (n = 39). The most common presenting symptoms included dysphagia (n =63), fever (n = 24), neck swelling (n = 23), and wound leakage (n = 18). The etiology of esophageal perforation included hardware failure (n = 31), hardware erosion (n = 23), and intraoperative injury (n = 14). The imaging modalities used to identify the esophageal perforations included modified contrast dye swallow studies, CT, endoscopy, plain radiography, and MRI. Esophageal repair was most commonly achieved using a modified muscle flap, as well as with primary closure. Outcomes measured in the literature were often defined by the time to oral intake following esophageal repair. Complications included pneumonia (n = 6), mediastinitis (n = 4), osteomyelitis (n = 3), sepsis (n = 3), acute respiratory distress syndrome (n = 2), and recurrent laryngeal nerve damage (n = 1). The mortality rate of esophageal perforation in the analysis was 3.92% (6 of 153 reported patients). CONCLUSIONS Esophageal perforation after anterior cervical spine surgery is a rare complication. This systematic review demonstrates that these perforations can be stratified into 3 categories based on the timing of symptomatic onset: intraoperative, early postoperative (within 30 days of anterior spinal surgery), and delayed. The most common source of esophageal injury is hardware erosion or migration, each of which may vary in their time to symptomatic manifestation.