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Dysphagia is a less reported but serious adverse outcome post occipitocervical fusion. Any patient suffering from dysphagia and or nasal regurgitation post fusion in flexion should be offered early revision. The right position for occipitocervical fusion is neutral alignment.
Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement.
Here we present a patient suffering from rheumatoid arthritis, multilevel cervical instability, stenosis and cervical myelopathy, who developed dysphagia post occipitocervical fusion.
2. Case
A 58 year old male, presented to us in the outpatient department with complaints of tingling sensations over the back, jerks in lower limbs and imbalance while walking. The patient was a known case of rheumatoid arthritis, diabetes, hypertension and a chronic smoker.
The clinical examination of all 4 limbs revealed increased tone with intact antigravity power, asymmetrically diminished light touch and proprioception, hyperreflexia and extensor plantars. Hoffman sign and finger escape sign were positive.
Cervical spine MRI and dynamic x-rays revealed C1–C2/C2–C3 instability with C3–C4 cervical canal stenosis and cord oedema (Fig. 1).
Fig. 1Cervical spine T2W MRI sagittal view and dynamic lateral x-rays showing increased C1–C2 instability, cervical canal stenosis and cord oedema at C3–C4 level and C2–C3 instability (arrowheads).
The surgical plan of Occiput to C5 fixation with C3–C4 laminectomy was formulated and discussed with the patient.
The patient head was placed in slight flexion in prone position.
The patient had left dominant vertebral artery so we placed occipital plate, C2 translaminar screw and C4–C5 lateral mass screws on left, C2 pedicle and C3–C5 lateral mass screws on the right side. We did not place left C3 lateral mass screw fore sighting the difficulty connecting translaminar screw to C3 screw. We also had to contour the rod disproportionately on the left side to connect the translaminar screw to the occipital plate and C4–C5 lateral mass screws (Fig. 2).
Fig. 2Post op x-ray first surgery showing differently bent connecting rod on the left compared to right side (arrows).
The patient was extubated and shifted to room uneventfully. The patent was given cervical collar and was started on liquid diet the same evening.
On post-operative day 1, the patient complained of throat discomfort and difficulty swallowing. Assuming it to be sequelae of endotracheal tube intubation and pharyngeal oedema we offered the patient steam inhalation and throat lozenges. On post-operative day 2 the patient complained of liquids regurgitating through his nose while sipping. We checked the post-operative x-rays and the patient's clinical head neck position. It showed flexion (Fig. 3).
Fig. 3Post-operative day 1. Picture of patient head and neck alignment.
We discussed about it with other spine surgeons and decided to wait and observe the symptoms. An ENT evaluation was also done. The otolaryngologist did a thorough clinical evaluation alongwith video laryngoscopy and barium swallow. The tests revealed no gross abnormality. The ENT specialist deemed the symptoms to be post chronic smoking habit of the patient. The doctor counselled the patient and modified his diet regime. The patient was then discharged to home. The patient came back one week later in the outpatient department with no relief. Patient attributed the position of his head to be the cause of his problems. We reviewed the literature and decided to revise the occipito-cervical junction position. After the revision surgery patient's dysphagia and nasal regurgitation disappeared and 4 months post-surgery he is satisfied and is continuing his activities of daily living successfully (Fig. 4) .
Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement.
But our patient showed no improvement in first 2 weeks. He was from a Middle Eastern country, and it would be difficult to keep him in regular follow up. Henceforth, we decided to revise the surgery. Occipitocervical angle (OCA) and pharyngeal inlet angles (PIA) have been proposed in literature as good predictors of post-operative dysphagia.
Influence of postoperative O-C2 angle on the development of dysphagia after occipitocervical fusion surgery: results from a retrospective analysis and prospective validation.
However, considering the complexity of measuring these parameters intraoperatively in our OR, we used the literature by Tan et al. to come up with the revision plan.
During revision we removed left C5 lateral mass screw and placed it into left C3 lateral mass and connected the occipital plate to the lateral mass screws. We connected the translaminar screw to the connecting rod using a lateral connector (Fig. 5) .
Fig. 5Post-op X-ray after revision spine surgery showing domino connecting translaminar screw to the rod on left side (arrows) and the similar contours of both right and left connecting rods (arrowheads).
We applied the pre op measurements to intra op positioning. Out of Tan's three parameters we found occipitocervical distance (OCD) was easiest to measure and execute. We believe that patient's endotracheal tube affected the mandible cervical distance (MCD) while OCA was difficult to calculate intra-op on fluoroscopy. We used lateral connector which provided us freedom of movement to achieve desired position. We were able to restore near all preop parameters after revision surgery using OCD as intraop reference (Table 1).
Table 1Pre-op, post primary & revision surgery occipitocervical parameters.
Deviation from patient's physiological neutral position to flexion or extension can lead to dysphagia and multiple factors have been implicated for the discomfort.
Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement.
It is difficult to replicate the neutral head neck alignment of a standing patient to a prone and intubated patient. In our case we found OCD helped us achieve the correct head neck alignment.
4. Message
All the patients should undergo preoperative occiptiocervical parameter measurement. OCD is a reliable and convenient parameter for most OR setups. The aim of the surgeon should be to achieve the preop alignment intraoperatively. Having lateral connectors is helpful in anatomically variant cases.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
Bagley C.A.
Witham T.F.
Pindrik J.A.
et al.
Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement.
Influence of postoperative O-C2 angle on the development of dysphagia after occipitocervical fusion surgery: results from a retrospective analysis and prospective validation.
Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement.
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