Farber S Harrison, Mauler David J, Sagar Soumya, Pacult Mark A, Walker Corey T, Bohl Michael A, Snyder Laura A, Chapple Kristina M, Sonntag Volker K H, Uribe Juan S, Turner Jay D, Chang Steve W, Kakarla U Kumar
J Neurosurg Spine. 2021 Apr 2;34(6):849-856. doi: 10.3171/2020.10.SPINE201307. Print 2021 Jun 1.
Anterior cervical discectomy and fusion (ACDF) is a common and robust procedure performed on the cervical spine. Literature on ACDF for 4 or more segments is sparse. Increasing the number of operative levels increases surgical complexity, tissue retraction, and risks of complications, particularly dysphagia. The overall risks of these complications and rates of dysphagia are not well studied for surgery on 4 or more segments. In this study, the authors evaluated their institution's perioperative experience with 4- and 5-level ACDFs.
The authors retrospectively reviewed patients who underwent 4- or 5-level ACDF at their institution over a 6-year period (May 2013-May 2019). Patient demographics, perioperative complications, readmission rates, and swallowing outcomes were recorded. Outcomes were analyzed with a multivariate linear regression.
A total of 174 patients were included (167 had 4-level and 7 had 5-level ACDFs). The average age was 60.6 years, and 54.0% of patients (n = 94) were men. A corpectomy was performed in 12.6% of patients (n = 22). After surgery, 56.9% of patients (n = 99) experienced dysphagia. The percentage of patients with dysphagia decreased to 22.8% (37/162) at 30 days, 12.9% (17/132) at 90 days, and 6.3% (5/79) and 2.8% (1/36) at 1 and 2 years, respectively. Dysphagia was more likely at 90 days postoperatively in patients with gastroesophageal reflux (OR 4.4 [95% CI 1.5-12.8], p = 0.008), and the mean (± SD) lordosis change was greater in patients with dysphagia than those without at 90 days (19.8° ± 13.3° vs 9.1° ± 10.2°, p = 0.003). Dysphagia occurrence did not differ with operative implants, including graft and interbody type. The mean length of time to solid food intake was 2.4 ± 2.1 days. Patients treated with dexamethasone were more likely to achieve solid food intake prior to discharge (OR 4.0 [95% CI 1.5-10.6], p = 0.004). Postsurgery, 5.2% of patients (n = 9) required a feeding tube due to severe approach-related dysphagia. Other perioperative complication rates were uniformly low. Overall, 8.6% of patients (n = 15) returned to the emergency department within 30 days and 2.9% (n = 5) required readmission, whereas 1.1% (n = 2) required unplanned return to surgery within 30 days.
This is the largest series of patients undergoing 4- and 5-level ACDFs reported to date. This procedure was performed safely with minimal intraoperative complications. More than half of the patients experienced in-hospital dysphagia, which increased their overall length of stay, but dysphagia decreased over time.
颈椎前路椎间盘切除融合术（ACDF）是颈椎常见且成熟的手术。关于4节段及以上ACDF的文献较少。手术节段数量增加会使手术复杂性、组织牵拉以及并发症风险增加，尤其是吞咽困难。对于4节段及以上手术，这些并发症的总体风险和吞咽困难发生率尚未得到充分研究。在本研究中，作者评估了其所在机构4节段和5节段ACDF的围手术期经验。
作者回顾性分析了在6年期间（2013年5月至2019年5月）在其机构接受4节段或5节段ACDF的患者。记录患者人口统计学资料、围手术期并发症、再入院率和吞咽结果。采用多变量线性回归分析结果。
共纳入174例患者（167例行4节段ACDF，7例行5节段ACDF）。平均年龄为60.6岁，54.0%（n = 94）的患者为男性。12.6%（n = 22）的患者行椎体次全切除术。术后，56.9%（n = 99）的患者出现吞咽困难。吞咽困难患者的比例在30天时降至22.8%（37/162），90天时降至12.9%（17/132），1年和2年时分别降至6.3%（5/79）和2.8%（1/36）。胃食管反流患者术后90天时更易出现吞咽困难（OR 4.4 [95% CI 1.5 - 12.8]，p = 0.008），90天时吞咽困难患者的平均（±标准差）颈椎前凸变化大于无吞咽困难患者（19.8°±13.3°对9.1°±10.2°，p = 0.003）。吞咽困难的发生与手术植入物（包括移植物和椎间融合器类型）无关。固体食物摄入的平均时间为2.4±2.1天。接受地塞米松治疗的患者在出院前更易实现固体食物摄入（OR 4.0 [95% CI 1.5 - 10.6]，p = 0.004）。术后，5.2%（n = 9）的患者因严重的手术入路相关吞咽困难需要鼻饲管。其他围手术期并发症发生率均较低。总体而言，8.6%（n = 15）的患者在30天内返回急诊科，2.9%（n = 5）的患者需要再次入院，而1.1%（n = 2）的患者在30天内需要非计划再次手术。
这是迄今为止报道的接受4节段和5节段ACDF患者数量最多的系列研究。该手术安全进行，术中并发症极少。超过一半的患者在住院期间出现吞咽困难，这增加了他们的总体住院时间，但吞咽困难随时间推移而减轻。
