Bohara Sandeep, Thapa Bikas, Regmi Prakash, Shilpakar Sushil K
Department of Neurosurgery, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
Ann Med Surg (Lond). 2024 Nov 8;86(12):7444-7448. doi: 10.1097/MS9.0000000000002728. eCollection 2024 Dec.
Postoperative dysphagia following anterior cervical discectomy fusion (ACDF) for cervical disc herniation is still poorly understood. Dysphagia after anterior spinal cervical approach is mild and transient. Here, the authors present a rare case suffering with severe progressive dysphagia for over 1 year after 20 years of ACDF due to expulsed bone cement abutting the esophagus which was successfully removed after reoperation.
A 59-year-old homemaker female presented to us with a foreign body sensation in the throat and progressive difficulty in swallowing for 1 year. She was previously operated for C5-C6 cervical intervertebral disc prolapse via ACDF using bone cement at another center. On examination, power in the left upper limb was MRC grade 3, and the left-hand grip was 25% only. MRI of the cervical spine showed increased prevertebral soft tissue space and a notable rectangular-shaped black prevertebral shadow at the C5-C6 level, causing esophageal compression. The patient underwent an exploration of previous ACDF surgery. Intraoperative findings revealed an extruded piece of bone cement of size ~2×1.5×1 cm at C-C disc space level, compressing the esophagus. The yellowish extruded piece was removed and C-C was reinforced with an anterior cervical plate with screws. The postoperative course was uneventful.
The exact pathophysiology of dysphagia after ACF surgery remains unknown. In our case, there was an expulsion of the graft. The graft used was polymethyl methacrylate, commonly known as bone cement, which was placed 20 years back. Since polymethyl methacrylate is bioinert material, the graft may have expulsed from its site of placement and thus compressed the esophagus. Taking into consideration of the cost-effectiveness and maintenance of spinal mobility, few neurosurgeons believe that the application of bone cement in ACF surgery as a spacer is a safe and very cost-effective modality compared to modern expensive artificial disc.
Dysphagia after ACDF surgery is usually underrecognized. Although the serious complications after ACDF surgery are rare, dysphagia can cause prolonged morbidity to patients. Using bone cement alone for ACDF surgery may carry the risk of its anterior expulsion even after a long period of surgery.
颈椎间盘突出症行前路颈椎间盘切除融合术（ACDF）后发生的术后吞咽困难仍未得到充分认识。颈椎前路手术后的吞咽困难通常较轻且为一过性。在此，作者报告一例罕见病例，该患者在ACDF术后20年出现严重进行性吞咽困难超过1年，原因是骨水泥移位至食管附近，再次手术后成功取出。
一名59岁的家庭主妇因咽喉部异物感及进行性吞咽困难1年前来就诊。她曾在另一中心因C5 - C6颈椎间盘突出症接受ACDF手术，术中使用了骨水泥。检查发现，左上肢肌力为MRC 3级，左手握力仅为25%。颈椎MRI显示椎体前方软组织间隙增宽，C5 - C6水平可见明显的矩形黑色椎体前阴影，压迫食管。患者接受了对既往ACDF手术的探查。术中发现C5 - C6椎间盘间隙水平有一块约2×1.5×1 cm大小的骨水泥移位，压迫食管。取出淡黄色的移位骨水泥块，并用带螺钉的颈椎前路钢板对C5 - C6进行加固。术后恢复顺利。
ACF手术后吞咽困难的确切病理生理机制尚不清楚。在我们的病例中，出现了移植物移位。所使用的移植物是聚甲基丙烯酸甲酯，俗称骨水泥，于20年前植入。由于聚甲基丙烯酸甲酯是生物惰性材料，移植物可能从植入部位移位，从而压迫食管。考虑到成本效益和脊柱活动度的维持，与现代昂贵的人工椎间盘相比，很少有神经外科医生认为在ACF手术中使用骨水泥作为间隔物是一种安全且非常经济有效的方式。
ACDF手术后的吞咽困难通常未得到充分认识。虽然ACDF手术后的严重并发症很少见，但吞咽困难会给患者带来长期的发病率。仅在ACDF手术中使用骨水泥可能存在即使在手术后很长时间仍有骨水泥向前移位的风险。
