Alentado, Vincent J.

OBJECTIVE Dysphagia has been shown to have an adverse effect on patient quality of life following cervical spine surgery, but its impact on patients’ ability to return to work (RTW) and return to physical activities (RTA) has never been investigated. This study aimed to evaluate the impact of postoperative dysphagia on patients’ ability to RTW and RTA after surgery. METHODS A prospectively maintained multi-institutional spine registry of patients who underwent cervical spine surgery between 2016 and 2023 was retrospectively reviewed. An Eating Assessment Tool-10 (EAT-10) score ≥ 3 was used to quantify preoperative and 12-month postoperative dysphagia. Prolonged dysphagia was defined as new dysphagia present at 12 months among patients without baseline dysphagia. RTW and RTA were assessed at baseline and 12 months postoperatively. Mixed-effects logistic regressions were used to evaluate the effect of dysphagia on RTW and RTA. RESULTS Of the 1208 patients meeting inclusion criteria, 240 (20%) experienced prolonged dysphagia, of whom 208 (87%) underwent anterior surgery. Preoperatively, 709 (59%) patients were fully employed or on short-term leave, 307 (25%) were retired, and 191 (16%) were otherwise unemployed. At the 12-month follow-up, RTW and RTA status were collected for 629 (95%) of the 664 employed patients who planned to RTW after surgery and 1127 (93%) of the total cohort, respectively. Significantly lower rates of RTW (86% vs 96%, p < 0.001) and RTA (62% vs 79%, p < 0.001) were observed in patients with prolonged dysphagia. Multivariable analysis identified dysphagia as being independently associated with lower odds of RTW (OR 0.35, 95% CI 0.14–0.86; p = 0.022) and RTA (OR 0.44, 95% CI 0.31–0.63; p < 0.001). CONCLUSIONS Prolonged postoperative dysphagia—defined as a new EAT-10 score ≥ 3 at 12 months—was associated with substantially lower odds of returning to work and physical activities after cervical spine surgery, underscoring the importance of dysphagia prevention and management in postoperative care.

OBJECTIVE This study examines the recovery rates of patients who experience postoperative dysphagia within 1 month following cervical spine surgery. METHODS Data from a prospectively maintained multi-institutional quality registry were retrospectively analyzed. Eating Assessment Tool-10 (EAT-10) questionnaire scores were collected at baseline and 1, 3, and 12 months postoperatively, with total scores ≥ 3 indicating dysphagia. Patients were grouped by whether they reported baseline dysphagia to assess the impact of baseline dysphagia on recovery. Recovery was defined as resolution of postoperative dysphagia and not reporting the condition at any follow-up time point. Patients were excluded from the recovery model if they did not report dysphagia within 1 month of surgery. Recovery to baseline was defined as reporting a postoperative EAT-10 score equal to or less than the baseline score at subsequent time points. Patients were excluded from the recovery-to-baseline model if they did not report EAT-10 scores within 1 month of surgery that were worse than their baseline score. Survival curves were generated for both models. RESULTS Of the 2003 patients in the registry, 627 met inclusion criteria for the recovery curve and 714 for the recovery-to-baseline curve. Of the patients without baseline dysphagia, 498 developed new postoperative dysphagia within 1 month, with cumulative recovery probabilities of 39.5% by 3 months and 59.1% by 12 months after cervical spine surgery. Furthermore, of the patients without baseline dysphagia, 73.5% (175/238) who reported no dysphagia at 3 months and 32.5% (68/209) who reported no dysphagia at 12 months experienced long-term recovery. Eighty patients with baseline dysphagia reported worse EAT-10 scores within 1 month, with cumulative probabilities of improvement to baseline or below of 37.7% by 3 months and 54.1% by 12 months. Patients with baseline dysphagia were significantly less likely to recover than patients without baseline dysphagia (hazard ratio [HR] 0.37, 95% CI 0.26–0.53; p < 0.001) but significantly more likely to recover to baseline (HR 1.45, 95% CI 1.05–2.00; p = 0.025). CONCLUSIONS Patients who develop postoperative dysphagia within 1 month of cervical spine surgery generally see symptomatic improvement over time. This analysis may aid in clinical decision-making when informing patients about the risk of developing postoperative dysphagia and the recovery rate of this surgical complication.

BACKGROUND AND OBJECTIVES: This study proposes and assesses the validity of postoperative dysphagia severity categories based on patients' Eating Assessment Tool-10 (EAT-10) scores and quality-of-life patient-reported outcome measures (PROMs) collected before and after cervical spine surgery. METHODS: A prospectively collected multi-institutional quality registry including 2003 patients was retrospectively reviewed. Patients were categorized based on EAT-10 score severities, with thresholds determined by existing literature and significant differences in PROMs: none (0-2), mild (3-4), moderate (5-15), and severe (16-40). Correlations between EAT-10 severity and established PROMs were assessed at baseline, 3-, and 12-month follow-ups. The Dunn test using Bonferroni adjustment was used to identify differences in PROMs between EAT-10 severities. Multivariate linear regression assessed how EAT-10 severity affects PROMs at baseline, 3-, and 12-month follow-ups. RESULTS: Among 1659 patients with 3-month EAT-10 data, there were 1183 no, 149 mild, 245 moderate, and 82 severe dysphagia patients. Neck Disability Index and EuroQol 5-Dimension scores were significantly different between none vs mild ( P < .001; P = .001), mild vs moderate ( P < .001; P < .001), and moderate vs severe ( P = .035; P = .024) at 3 months. Among 1405 patients with 12-month EAT-10 data, there were 1044 no, 100 mild, 194 moderate, and 67 severe dysphagia patients. Neck Disability Index scores were significantly different between none vs mild ( P < .001) and moderate vs severe ( P = .004) but not for mild vs moderate ( P > .9) at 12 months. EuroQol 5-Dimension scores were significantly different between none vs mild ( P = .004) and mild vs moderate ( P = .005) but not for moderate vs severe ( P = .08). In multivariate regression, EAT-10 severity categories independently predicted worse PROMs at all time points. CONCLUSION: We propose none (0-2), mild (3-4), moderate (5-15), and severe (16-40) dysphagia categories based on EAT-10 scores. Evidence from univariate and multivariate analyses strengthens the validity of our proposed EAT-10 severity categories, providing statistical justification for their incorporation into clinical practice.

OBJECTIVE This study investigated the relationship between diabetes and the incidence of postoperative dysphagia following cervical spine surgery (CSS). METHODS A prospectively collected multi-institutional quality registry was retrospectively reviewed. Patients who underwent CSS were categorized on the basis of diabetes status, and correlations with preoperative and postoperative Eating Assessment Tool-10 (EAT-10) dysphagia questionnaire scores were assessed. Mixed-effects logistic regressions were performed to examine the impact of preoperative diabetes on postoperative dysphagia. RESULTS Of the 2001 patients who met the inclusion criteria, 400 (20%) had diabetes. Baseline dysphagia rates were not significantly different between groups (18% vs 14%, p = 0.08). Patients with diabetes had a significantly higher incidence of dysphagia at 1 month (66% vs 54%, p = 0.002), 3 months (39% vs 26%, p < 0.001), and 12 months (33% vs 24%, p = 0.004) after surgery compared to patients without diabetes. Including baseline dysphagia as a fixed effect, multivariable analysis indicated that diabetes was a significant predictor of postoperative dysphagia at 1 month (OR 1.46, p = 0.041) and 3 months (OR 1.63, p = 0.001) but not at 12 months (OR 1.21, p = 0.3). In patients with no baseline dysphagia, those with diabetes (329 of 400 [82.3%]) had a significantly higher incidence of new dysphagia than nondiabetics at 1 month (62% vs 50%, p = 0.003), 3 months (34% vs 21%, p < 0.001), and 12 months (27% vs 18%, p = 0.001). The mean change in EAT-10 scores between baseline and 12 months was significantly worse in patients with preoperative diabetes (2.440 ± 5.013 vs 1.688 ± 4.139, p = 0.025). Multivariable analysis indicated that diabetes was a significant predictor of new postoperative dysphagia at 1 month (OR 1.49, p = 0.040) and 3 months (OR 1.81, p < 0.001) but not at 12 months (OR 1.31, p = 0.2). CONCLUSIONS Diabetes is a significant risk factor for experiencing postoperative dysphagia following CSS. Diabetes correlated with higher incidence of dysphagia at all postoperative time points and was a strong independent predictor of postoperative dysphagia at 1 and 3 months.

OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is commonly performed in both inpatient and outpatient settings. In this study, the authors evaluate the influence of surgical setting on patient-reported outcome measures (PROMs), satisfaction, dysphagia, and complications following ACDF. METHODS A prospectively collected, multi-institutional quality improvement registry was retrospectively reviewed. Patients eligible for study inclusion were those who underwent ACDF without corpectomy or arthroplasty between 2016 and 2023. The patients were stratified by surgery setting, with same-day discharge indicating outpatients and an overnight stay indicating inpatients. PROMs were collected preoperatively and at 3 and 12 months postoperatively. Patient satisfaction was measured using the North American Spine Society (NASS) outcome assessment questionnaire, and dysphagia was measured using the 10-item Eating Assessment Tool (EAT-10). Propensity score overlap weighting (average treatment effect in the overlap population) was used to balance baseline covariates. RESULTS Of the 1514 patients who underwent ACDF, 462 were inpatients and 1052 were outpatients. The outpatient cohort was younger (55.1 ± 10.7 vs 60.5 ± 11.0 years, p < 0.001), had higher rates of private insurance (73% vs 52%, p < 0.001), had a lower mean American Society of Anesthesiologists (ASA) physical status (2.3 ± 0.6 vs 2.6 ± 0.6, p < 0.001), and underwent more single-level surgeries (53% vs 33%, p < 0.001). Propensity weighting resulted in comparable mean ages (58.9, p > 0.9) and ASA classes (2.5, p = 0.8) as well as private insurance rates (56%, p > 0.9) between the cohorts. After weighting, the inpatient cohort had a higher share of single-level fusions (46% vs 37%, p = 0.007). An outpatient status was associated with significantly better 12-month numeric rating scale (NRS) scores for neck pain (2.4 ± 2.7 vs 3.1 ± 3.0, p = 0.006), NRS scores for arm pain (1.7 ± 2.6 vs 2.2 ± 3.0, p = 0.047), and Neck Disability Index (NDI; 7.7 ± 7.8 vs 9.8 ± 9.4, p = 0.004) and greater improvement from baseline to 12 months on the NDI (−12.5 ± 9.7 vs −10.8 ± 10.5, p = 0.017), EQ-5D (0.242 ± 0.220 vs 0.209 ± 0.226, p = 0.047), and EQ visual analog scale (10.6 ± 21.6 vs 7.1 ± 20.8, p = 0.012). Fewer outpatients reported dysphagia at 3 months postoperatively (31% vs 40%, p = 0.010). No differences were observed in readmissions or revision procedures, although fewer outpatients experienced new neurological deficits (1.0% vs 2.6%, p = 0.032) and pneumonia (< 0.1% vs 0.9%, p < 0.001). In terms of the 12-month NASS outcome assessment, a smaller proportion of the outpatient cohort reported the lowest satisfaction score (3.9% vs 8.0%, p = 0.019). CONCLUSIONS Outpatient setting was associated with better PROMs at the 12-month follow-up when patients were weighted by baseline health status. These findings support the efficacy of outpatient ACDF in appropriately selected patients.

OBJECTIVE Patient-reported outcome measures (PROMs) are standardized questionnaires used to evaluate patients’ quality of life and health status before and after medical procedures. While worse preoperative health is often associated with worse postoperative outcomes, the role of baseline PROMs in predicting postoperative dysphagia following cervical surgery has been unexplored with Eating Assessment Tool–10 (EAT-10) scores. This study aimed to investigate the relationship between baseline PROMs and the incidence of postoperative dysphagia. METHODS A prospectively collected multi-institutional quality registry of patients undergoing anterior cervical spine surgery was retrospectively reviewed. Eight baseline PROMs were assessed: Neck Disability Index (NDI), modified Japanese Orthopaedic Association scale, EQ-5D questionnaire, EuroQol visual analog scale, visual analog scales for neck pain (NP-VAS) and arm pain, and 10-item Patient-Reported Outcomes Measurement Information System Global Physical Health and Global Mental Health. Including baseline dysphagia as a fixed effect, multivariable logistic regressions were performed to examine the impact of patient-reported baseline PROMs on the incidence of dysphagia. RESULTS Baseline PROMs were collected from 1706 patients. When assessing baseline PROMs independently in multivariable analyses, worse baseline NDI score (OR 1.04, p = 0.001) was a significant predictor of dysphagia at 12 months after surgery, while other PROMs were not. When assessing baseline PROMs together in multivariable analysis, worse baseline NDI score (OR 1.07, p < 0.001) and better NP-VAS score (OR 0.88, p = 0.006) were significant predictors of dysphagia at 12 months, while other PROMs were not. Patients in the severe or complete disability NDI categories (NDI score ≥ 25; 465/1466 patients without baseline dysphagia) experienced significantly more new dysphagia at 1 month (65% vs 50%, p < 0.001), 3 months (30% vs 21%, p < 0.001), and 12 months (32% vs 14%, p < 0.001) after anterior cervical spine surgery. These patients also had no significant difference in baseline EAT-10 scores (0.103 ± 0.386 vs 0.115 ± 0.405, p = 0.6), yet experienced significantly worse EAT-10 score changes between baseline and 12 months (3.369 ± 5.954 vs 1.208 ± 3.332, p < 0.001). CONCLUSIONS Baseline NDI score appears to be the strongest independent predictor of the 8 PROMs in determining whether patients have dysphagia at 12 months after anterior cervical surgery.

OBJECTIVE This study examined the extent to which preoperative depression predicts dysphagia after cervical spine surgery. METHODS A prospectively collected multi-institutional quality registry was retrospectively reviewed. Patients undergoing cervical surgery were categorized based on preoperative depression, and correlations with pre- and postoperative Eating Assessment Tool-10 (EAT-10) dysphagia questionnaire scores were assessed. Mixed-effects logistic regressions were performed to assess the impact of preoperative depression on the incidence of dysphagia. RESULTS Of 2002 patients meeting inclusion criteria, 524 (26%) reported having preoperative depression. Depression was associated with a higher incidence of dysphagia at baseline (25% vs 12%, p < 0.001) and at 1 (62% vs 54%, p = 0.038), 3 (36% vs 26%, p < 0.001), and 12 months (36% vs 22%, p < 0.001) postoperatively. Including baseline dysphagia as a fixed effect, multivariable analysis revealed that depression is not a significant independent predictor of postoperative dysphagia at 1 (OR 1.14, p = 0.5), 3 (OR 1.09, p = 0.6), or 12 months (OR 1.27, p = 0.2). Patients with depression and no baseline dysphagia (395 of 524) were significantly more likely to report new dysphagia at 12 months (26% vs 18%, p = 0.006), but not at 1 (53% vs 52%, p = 0.7) or 3 months (28% vs 22%, p = 0.06). The average change in EAT-10 scores between baseline and 12 months was significantly worse in patients with preoperative depression and no baseline dysphagia (2.552 [SD 5.041] vs 1.634 [SD 4.095], p < 0.001). Post hoc multivariable analyses excluding those with baseline dysphagia did not significantly affect the results. CONCLUSIONS Although patients with preoperative depression report dysphagia more often at baseline and at 1, 3, and 12 months after cervical surgery, preoperative depression is not an independent predictor of postoperative dysphagia. Preoperative depression may be valuable to consider as a risk factor for developing dysphagia after cervical surgery, but the heightened dysphagia risk in patients with depression may be attributed to secondary factors associated with depression such as comorbid conditions.