Spontaneous cervical epidural hematoma

Spontaneous cervical epidural hematoma

This spontaneous spinal epidural hematoma in the cervical region is an uncommon cause of acute spinal cord compression.

Currently, the incidence of SSEH is expected to increase. Pain physicians must include SSEH in their differential diagnosis for patients with axial pain or radicular symptoms alone, particularly when risk factors are present 1).

The cause of bleeding in the current literature is both venous and arterial in origin. Venous bleeding owing is the commonly accepted hypothesis for the source of the hematoma because spinal epidural venous plexus have no sphincters, and thus have no protection against pressure changing 2). This theory seems to be invalid in the cervical region because the venous pressure is low. It is said that the cervical epidural hematoma has an arterial source from free anastomotic arteries in connection with radicular arteries that exist in the epidural space 3).

Acute cervical epidural hematoma is definitely a condition of neurologic emergency. Although it is a rare condition, it must be considered in nontraumatic patients with sudden onset of neurologic deficits. Patients with spontaneous spinal epidural hematoma typically present with acute onset of severe back pain, and they rapidly develop signs of compression of the spinal cord or cauda equina 4)

High index of suspicion followed by T2-weighted gradient echo sequences are particularly useful in early diagnosis. 5)

Cervical spontaneous spinal epidural hematoma is a serious neurosurgical pathology that often requires prompt surgical intervention.

Prompt surgical evacuation of the hematoma leads to a favorable neurological outcome, whereas delay in treatment can be disastrous. The role of conservative management needs to be proven and should be tailored on an individual basis 6)

This is a rare idiopathic condition that leads to acute onset of neurologic deficits, which if not recognized early can have catastrophic consequences.

Hines et al. from the Thomas Jefferson University Hospital presented the first case in the literature of cervical disc extrusion provoking epidural hematoma and acute neurological deterioration.

A 65 year old male presented with six months of worsening signs and symptoms of cervical myelopathy. He had progressive deterioration over the course of two weeks leading to ambulatory dysfunction requiring a cane for assistance. While undergoing his medical workup in the emergency department, the patient became acutely plegic in the right lower extremity prompting emergent surgical decompression and stabilization.

Based on imaging, pathology, and intraoperative findings, it was concluded that the patient had an extruded disc segment that may have precipitated venous bleeding in the epidural space and findings of acute cervical spinal cord compression. Cervical disc extrusion may lead to venous damage, epidural hematoma, and spinal cord compression. If this unique presentation is recognized and addressed in a timely manner, patient outcomes may still be largely positive as this case demonstrates 7).

A 41-year-old male, diagnosed with SCEH, with a presenting chief complaint of cervical pain followed by progressive quadriparesis and urgency of micturition who was managed surgically.

SCEH is a rare pathologic entity. Due to the high risk of poor neurological outcome without treatment, SCEH should be a diagnostic possibility when the presentation is even slightly suggestive. Prompt surgical evacuation of the hematoma and hemostasis leads to a favorable neurological outcome, whereas delay in treatment can be disastrous 8).

A 31-year-old man who presented with acute onset of neck pain with radicular component with progressive neurologic deficit. Emergent magnetic resonance imaging revealed cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery was achieved within 48 hours. The level of preoperative neurologic deficit and its severity, as well as operative interval, are important factors significantly affecting the postoperative outcome 9)

A 28-year-old healthy man developed a sudden onset of severe neck and right shoulder pain with mild arm weakness. The MRI revealed an SSEH that was compressing his spinal cord in the right posterolateral epidural space from C2-C6. On the second hospital day, his symptoms suddenly improved, and most of the hematoma had spontaneously resolved Currently, the incidence of SSEH is expected to increase. Pain physicians must include SSEH in their differential diagnosis for patients with axial pain or radicular symptoms alone, particularly when risk factors are present 10).

A 70-year-old man presented with acute onset neck pain with a radicular component and rapidly progressive quadriparesis. Magnetic resonance imaging revealed a posteriorly located cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery to near normal function occurred within 24 hours of surgery.

SSEH in its true idiopathic form is a rare pathologic entity. Because of the high risk of poor outcome without treatment, SSEH should be a diagnostic possibility when presentation is even slightly suggestive. Prompt surgical evacuation of the hematoma leads to a favorable neurological outcome, whereas delay in treatment can be disastrous. The role of conservative management needs to be proven and should be tailored on an individual basis 11)

A 25-year-old male presented with a history of sudden onset of complete quadriplegia with sensory loss below the neck along with loss of bowel and bladder control. He had no history of any constitutional symptoms. He reported 10 days later. He was managed conservatively and after two weeks of intensive rehabilitation he had complete neural recovery. The spontaneous recovery of neurological impairment is attributed to the spreading of the hematoma throughout the epidural space, thus decreasing the pressure with partial neural recovery. Conservative treatment is a fair option in young patients who present late and show neurological improvement. The neurological status on presentation will guide the further approach to management 12).

1) , 10)

Huh J, Kwak HY, Chung YN, Park SK, Choi YS. Acute Cervical Spontaneous Spinal Epidural Hematoma Presenting with Minimal Neurological Deficits: A Case Report. Anesth Pain Med. 2016 Aug 27;6(5):e40067. eCollection 2016 Oct. PubMed PMID: 27853682; PubMed Central PMCID: PMC5106555.
2) , 5) , 6) , 11)

Gopalkrishnan CV, Dhakoji A, Nair S. Spontaneous cervical epidural hematoma of idiopathic etiology: case report and review of literature. J Spinal Cord Med. 2012 Mar;35(2):113-7. doi: 10.1179/2045772312Y.0000000001. Epub 2012 Feb 4. PMID: 22333537; PMCID: PMC3304555.

Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg. 1984 Jul;61(1):143-8. doi: 10.3171/jns.1984.61.1.0143. PMID: 6726389.
4) , 9)

Salehpour F, Mirzaei F, Kazemzadeh M, Alavi SAN. Spontaneous Epidural Hematoma of Cervical Spine. Int J Spine Surg. 2018 Mar 30;12(1):26-29. doi: 10.14444/5005. PMID: 30280079; PMCID: PMC6162037.

Hines K, Hafazalla K, Bailey JW, Jallo J. Extruded disc causes acute cervical epidural hematoma and cord compression: a case report. Spinal Cord Ser Cases. 2021 May 21;7(1):39. doi: 10.1038/s41394-021-00403-8. PMID: 34021115.

Taha MM, Elsharkawy AM, Al Menshawy HA, AlBakry A. Spontaneous cervical epidural hematoma: A case report and review of literature. Surg Neurol Int. 2019 Dec 13;10:247. doi: 10.25259/SNI_543_2019. PMID: 31893148; PMCID: PMC6935966.

Halim TA, Nigam V, Tandon V, Chhabra HS. Spontaneous cervical epidural hematoma: report of a case managed conservatively. Indian J Orthop. 2008 Jul;42(3):357-9. doi: 10.4103/0019-5413.41863. PMID: 19753167; PMCID: PMC2739458.

Neck pain after cervical laminoplasty

Neck pain after cervical laminoplasty

Axial neck pain remains the most important problem of cervical laminoplasty. Hosono et al. 1)), reviewed a series of 72 laminoplasties conducted to treat cervical spondylotic myelopathy, and found a 60% incidence of axial pain. Kawaguchi et al. 2)), reported significant axial neck pain in 44% of their patiensts. Other authors have reported incidence of axial neck pain after laminoplasty of about 30% 3)4) 5). The possible causes of axial neck pain after cervical laminoplasty are ischemia of the shoulder muscles, atrophy of nuchal muscles, and delayed union in the facet joints 6)).

Axial pain after cervical laminoplasty has been reported to be due to neck muscle disruption, especially because of detachments of muscle insertions to the C2 or C7 spinous processes, or deep extensor muscles 7) 8) 9)

A study demonstrated that C7 spinous process preserving laminoplasty decreases the incidence of aggravated axial neck pain after cervical laminoplasty 10).

The presence of anterolisthesis was associated not only with the highest odds ratio of persistent neck pain but also with significantly poorer functional outcomes. Indications for cervical laminoplasty should be carefully determined in patients with cervical anterolisthesis 11).

The use of a rigid collar after laminoplasty leads to less axial neck pain in the first 2 wk after surgery. However, there is no additional benefit with regards to range of motion, quality of life, and complication risk 12).

The preoperative CSA of the Semispinalis cervicis muscle (SC) has been reported to correlate with loss of lordosis (LL) after laminoplasty, with a CSA <154.5 mm2 associated with a 10 degrees LL.

Laminoplasty patients at the University of California San Francisco between 2009 and 2018 by 2 spine surgeons were retrospectively studied. Patients with previous cervical spine surgery or nondegenerative diagnoses were excluded. Measurements included the C2-C7 angleT1 slope, and cervical sagittal vertical axis. Preoperative DEM CSA was measured on magnetic resonance imaging. Variables associated with lordosis were analyzed with univariate analysis and multivariate logistic regression, and association between postoperative cervical alignment and the musculature was evaluated.

Seventy-six patients with a mean age of 64 years were included. The average follow-up was 22.53 months. The overall average CSA of the DEM was 2274.55 mm2 and that of the SC was 275.64 mm2. Means of both CSAs were higher in men (P<0.001). Linear regression showed no correlation between LL with CSA of the DEM or the SC (r=0.005, P=0.119; r=0.001, P=0.095). Univariate and multivariate regression showed no differences in the CSA of the DEM and SC between groups with and without LL (P=0.092, 0.117 and 0.163, 0.292). There was no correlation in LL with sex or body mass index (P>0.05).

Preoperative CSA of the deep neck extensors may not predict lordosis after cervical laminoplasty. The correlation between the preoperative SC CSA and postoperative cervical alignment may not be as strong as previously reported 13).

Axial neck pain after C3-6 laminoplasty has been reported to be significantly lesser than that after C3-7 laminoplasty because of the preservation of the C-7 spinous process and the attachment of nuchal muscles such as the trapezius and rhomboideus minor, which are connected to the scapula. The C-6 spinous process is the second longest spinous process after that of C-7, and it serves as an attachment point for these muscles. The effect of preserving the C-6 spinous process and its muscular attachment, in addition to preservation of the C-7 spinous process, on the prevention of axial neck pain is not well understood. The purpose of the current study was to clarify whether preservation of the paraspinal muscles of the C-6 spinous process reduces postoperative axial neck pain compared to that after using nonpreservation techniques.

Montano et al. studied 60 patients who underwent C3-6 double-door laminoplasty for the treatment of cervical spondylotic myelopathy or cervical ossification of the posterior longitudinal ligament; the minimum follow-up period was 1 year. Twenty-five patients underwent a C-6 paraspinal muscle preservation technique, and 35 underwent a C-6 nonpreservation technique. A visual analog scale (VAS) and VAS grading (Grades I-IV) were used to assess axial neck pain 1-3 months after surgery and at the final follow-up examination. Axial neck pain was classified as being 1 of 5 types, and its location was divided into 5 areas. The potential correlation between the C-6/C-7 spinous process length ratio and axial neck pain was examined.

The mean VAS scores (± SD) for axial neck pain were comparable between the C6-preservation group and the C6-nonpreservation group in both the early and late postoperative stages (4.1 ± 3.1 vs 4.0 ± 3.2 and 3.8 ± 2.9 vs 3.6 ± 3.0, respectively). The distribution of VAS grades was comparable in the 2 groups in both postoperative stages. Stiffness was the most prevalent complaint in both groups (64.0% and 54.5%, respectively), and the suprascapular region was the most common site in both groups (60.0% and 57.1%, respectively). The types and locations of axial neck pain were also similar between the groups. The C-6/C-7 spinous process length ratios were similar in the groups, and they did not correlate with axial neck pain. The reductions of range of motion and changes in sagittal alignment after surgery were also similar.

The C-6 paraspinal muscle preservation technique was not superior to the C6-nonpreservation technique for preventing postoperative axial neck pain 14).

1) , 6)

Hosono N, Yonenobu K, Ono K. Neck and shoulder pain after laminoplasty. A noticeable complication. Spine (Phila Pa 1976). 1996 Sep 1;21(17):1969-73. doi: 10.1097/00007632-199609010-00005. PMID: 8883196.

Kawaguchi Y, Kanamori M, Ishiara H, Nobukiyo M, Seki S, Kimura T. Preventive measures for axial symptoms following cervical laminoplasty. J Spinal Disord Tech. 2003 Dec;16(6):497-501. doi: 10.1097/00024720-200312000-00002. PMID: 14657744.

Hidai Y, Ebara S, Kamimura M, Tateiwa Y, Itoh H, Kinoshita T, Takaoka K, Ohtsuka K. Treatment of cervical compressive myelopathy with a new dorsolateral decompressive procedure. J Neurosurg. 1999 Apr;90(2 Suppl):178-85. doi: 10.3171/spi.1999.90.2.0178. PMID: 10199246.

Satomi K, Nishu Y, Kohno T, Hirabayashi K. Long-term follow-up studies of open-door expansive laminoplasty for cervical stenotic myelopathy. Spine (Phila Pa 1976). 1994 Mar 1;19(5):507-10. doi: 10.1097/00007632-199403000-00003. PMID: 8184342.

Wada E, Suzuki S, Kanazawa A, Matsuoka T, Miyamoto S, Yonenobu K. Subtotal corpectomy versus laminoplasty for multilevel cervical spondylotic myelopathy: a long-term follow-up study over 10 years. Spine (Phila Pa 1976). 2001 Jul 1;26(13):1443-7; discussion 1448. doi: 10.1097/00007632-200107010-00011. PMID: 11458148.

Iizuka H, Shimizu T, Tateno K, Toda N, Edakuni H, Shimada H, Takagishi K. Extensor musculature of the cervical spine after laminoplasty: morphologic evaluation by coronal view of the magnetic resonance image. Spine (Phila Pa 1976). 2001 Oct 15;26(20):2220-6. doi: 10.1097/00007632-200110150-00013. PMID: 11598512.

Shiraishi T, Fukuda K, Yato Y, Nakamura M, Ikegami T. Results of skip laminectomy-minimum 2-year follow-up study compared with open-door laminoplasty. Spine (Phila Pa 1976). 2003 Dec 15;28(24):2667-72. doi: 10.1097/01.BRS.0000103340.78418.B2. PMID: 14673367.

Takeshita K, Seichi A, Akune T, Kawamura N, Kawaguchi H, Nakamura K. Can laminoplasty maintain the cervical alignment even when the C2 lamina is contained? Spine (Phila Pa 1976). 2005 Jun 1;30(11):1294-8. doi: 10.1097/01.brs.0000163881.32008.13. PMID: 15928555.

Cho CB, Chough CK, Oh JY, Park HK, Lee KJ, Rha HK. Axial neck pain after cervical laminoplasty. J Korean Neurosurg Soc. 2010 Feb;47(2):107-11. doi: 10.3340/jkns.2010.47.2.107. Epub 2010 Feb 28. PMID: 20224708; PMCID: PMC2836444.

Kimura A, Shiraishi Y, Inoue H, Endo T, Takeshita K. Predictors of Persistent Axial Neck Pain After Cervical Laminoplasty. Spine (Phila Pa 1976). 2018 Jan 1;43(1):10-15. doi: 10.1097/BRS.0000000000002267. PMID: 28591073.

Cheung JPY, Cheung PWH, Law K, Borse V, Lau YM, Mak LF, Cheng A, Samartzis D, Cheung KMC. Postoperative Rigid Cervical Collar Leads to Less Axial Neck Pain in the Early Stage After Open-Door Laminoplasty-A Single-Blinded Randomized Controlled Trial. Neurosurgery. 2019 Sep 1;85(3):325-334. doi: 10.1093/neuros/nyy359. PMID: 30113664.

Liu J, Xie R, Ruan H, Rivera J, Li B, Mahmood B, Lee J, Guizar R 3rd, Mahmoudieh Y, Mummaneni PV, Chou D. The Preoperative Cross-sectional Area of the Deep Cervical Extensor Muscles Does Not Predict Loss of Lordosis After Cervical Laminoplasty. Clin Spine Surg. 2021 May 24. doi: 10.1097/BSD.0000000000001199. Epub ahead of print. PMID: 34029263.

Mori E, Ueta T, Maeda T, Yugué I, Kawano O, Shiba K. Effect of preservation of the C-6 spinous process and its paraspinal muscular attachment on the prevention of postoperative axial neck pain in C3-6 laminoplasty. J Neurosurg Spine. 2015 Mar;22(3):221-9. doi: 10.3171/2014.11.SPINE131153. Epub 2014 Dec 19. PubMed PMID: 25525962.

Dysphagia after anterior cervical discectomy

Dysphagia after anterior cervical discectomy

see MD Anderson Dysphagia Inventory.

Most ACDF patients fully recover their ability to swallow within a few days after surgery. Sometimes, however, dysphagia lingers for weeks, months, or even longer. Studies that have followed ACDF patients post-surgery for at least 2 years have found differing results regarding dysphagia.

No significant relationship was demonstrated between sex, age, number of operated segments, pre-existing dysphagia, gastroesophageal reflux disease, hypertension and the incidence of dysphagia after surgery 1)

The etiology is poorly understood but has been reported to be associated with vocal cord paralysis, dislodgement of instrumentation and unidentified causes, such as hematoma, adhesion formation and denervation of the pharyngeal plexus. A surgical treatment of dysphagia after ACIF has not been reported. Removal of the cervical instrumentation in patients will improve the dysphagia. This improvement with surgical management, as compared with the dissatisfaction before surgical treatment, documents that this surgical treatment is a reasonable option 2)

Soft tissue damage due to the use of automatic retractors in MACDF is not minor and leads to general discomfort in the patient in spite of good neurological results. These problems most often occur when automatic retractors are used continuously for more than 1 hour, as well as when they are used in multiple levels. Dysphagia, dysphonia and local pain decreased with the use of transient manual blades for retraction, and with intermittent release following minimally invasive principles 3).

Postoperative dysphagia is a significant concern.

Dexamethasone, although potentially protective against perioperative dysphagia and airway compromise, could inhibit fusion, a generally proinflammatory process.

While ACDF is the most commonly performed procedure for cervical spondylotic myelopathy in patients with Parkinson disease, it is associated with longer length of stay, higher incidence of postoperative dysphagia, and postprocedural pneumonia, as well as higher inpatient mortality compared with posterior cervical procedures 4)

Level of evidence: Level III.

Reported incidence of dysphagia after ACDFs has been as high as 79%. There, however, have been no studies that have specifically looked at developing a criteria for reducing the incidence of dysphagia for outpatient ACDFs.

Dysphagia is a common occurrence after anterior cervical approach but was also found after posterior cervical procedures. Intubation alone was not a risk factor for postoperative dysphagia in a cohort 5).

The etiology is so far unknown.

Using the Kaiser Permanente Spine registry database, between January 2009 and September 2013, we identified all inpatients (there were no outpatients) who underwent primary elective one-level ACDFs. A cohort of patients were identified with in-hospital length of stay (LOS) > 48 h in which the reason for continued admission was primarily significant dysphagia (DG). Patient’s demographics and intraoperative data (ACDF levels (upper [C2-3, C3-4], middle [C4-5, C5-6], lower [C6-7, C7-T1]), and operative times (<100, 100-199, ≥ 200, minutes)) was used to determine risk factors for dysphagia.

We found 747 single-level ACDF cases with a cohort of 239 (32.0%) who met the criteria for dysphagia (DG) with > 48 h admission. The DG group and non-dysphagia group (NDG) had similar demographics. Diabetes was excluded from regression analysis due to the low frequency. Compared to the lower spine level (C5-6, C7-T1), the upper spine level (C2-3, C3-4) ACDF had a higher likelihood for dysphagia (OR = 2.23, 95% CI = 1.35-3.68, p = 0.0016); no difference was found for middle spine level (C4-5, C5-6) ACDF.

Single-level ACDF at the upper cervical spine (C2-3, C3-4) was found to be the only risk factor for dysphagia with LOS > 48 h based on inpatient data from a spine registry. Age, BMI category, gender, ASA classification, smoking, and operative time were not predictive factors. These findings should be used for excluding patients who undergo outpatient single-level ACDF surgery to reduce significant postoperative dysphagia 6).

Patient age was found to be a significant predictor of postoperative dysphagia (p < .006), with an odds ratio of 1.113 (95% confidence limits, 1.04, 1.21) per year of age. Other factors studied were not found to be significant predictors. The overall incidence of these complications from the world literature was also calculated. The overall incidences of dysphagia, hoarseness, and unilateral true vocal fold motion impairment in the literature were calculated as 12.3%, 4.9%, and 1.4%, respectively. We conclude that dysphagia, hoarseness, and unilateral vocal fold motion impairment continue to remain significant complications of anterior cervical diskectomy with fusion. Older patients may be at higher risk for dysphagia 7).

There is a high incidence of subjective voice and swallowing complaints following transcervical anterior approaches to the spine, and such complaints can persist beyond 1 year in many patients. Exposure of more than 3 spinal levels or above level C4 are 2 factors significantly associated with outcome 8).

Results indicate that lordotic change in spinal alignment and longer operative times are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia 9).

The dC2-C7 angle may play an important role in the development of dysphagia in both anterior and PC spine surgery. Overenlargement of cervical lordosis should be avoided to reduce the development of postoperative dysphagia 10).

Heese et al. hypothesised that direct pressure induced by the medial retractor blade on pharynx/esophagus mucosal wall leads to local ischemia. Subsequently postoperative hyperemia and swelling of the pharynx/esophagus may result in swallowing disturbance. To prove the hypothesis local blood flow inside the pharynx/esophagus wall during anterior cervical surgery was measured using a laser Doppler (LD) perfusion monitor unit.

Fifteen patients underwent standard anterior cervical discectomy and fusion (ACDF). The LD probe was placed underneath the medial retractor blade in order to gain information at the maximum point of pressure applied onto the pharynx/esophagus wall. Local perfusion was measured prior to retractor opening (5 min), during spreading of the retractor and after its closure (5 min). Perfusion was measured semiquantitatively in perfusion units (PU). Local perfusion ranged from 30 to 210 PU (mean 107) prior to retractor opening, from 7 to 60 PU (mean 30) with open retractor and from 15 to 280 PU (mean 117) after retractor closure. In all 15 patients the open retractor led to hypoperfusion ranging from 21 to 93% compared to the baseline level. In seven patients a reactive hyperemia at the end of the procedure was detected (32-89% compared to baseline level). In four patients after hypoperfusion during spreading of the retractor the baseline levels were reached again and in four patients perfusion remained diminished even after retractor closure. To best of our knowledge, this is the first report on intraoperative measurement of local perfusion of the pharynx/esophagus wall during anterior cervical surgery. Diminished local perfusion was observed in all patients during spreading of the retractor and post-procedure hyperemia was recorded in 46% of the patients. The local ischemia of the pharynx/esophagus wall may be a crucial step in the development of postoperative dysphagia 11).

Pressure induced by retractor blades onto pharynx/esophagus were measured intraoperatively in order to gain more information regarding traumatization of the pharynx/esophagus wall. Thirty-one patients underwent anterior cervical discectomy and fusion (ACDF) for degenerative disc disease. An online pressure transducer was applied to the rear side of the medial retractor blade (epi-esophageal-pressure, epi-P) and a cylindric, inflatable transducer was preoperatively inserted into the pharynx/esophagus under fluoroscopic guidance at the level to be operated on (endo-esophageal-pressure, endo-P). Pressure values were recorded continuously during the operation. Mean arterial pressure (MAP) and endotracheal cuff pressure (ETCP) were recorded additionally. An in vitro model was developed in order to analyze the impact of the retractor blade design onto the epi-esophageal-pressure. Mean epi-P before and following adequate retractor opening for exposure of the disc space was 58.3 and 92.7 mmHg. Thirty, 60 and 90 min later the epi-P decreased to 79, 70 and 66%, respectively. Mean basal endo-P was 9.8 mmHg and increased to 20.6 mmHg after retractor placement. Thirty, 60 and 90 min later the endo-P decreased to 80, 71 and 62%, respectively. The mean MAP was 76 mmHg and the ECTP was adjusted to 25 mmHg during the procedures. In the in vitro model retraction pressure correlated inversely with the contact area between visceral wall and retractor blade. During ACDF the retraction pressure onto the pharyngeal/esophageal wall exceeds MAP and even more the mucosal perfusion pressure of 25 mmHg. Over time the pharynx/esophageal wall adapts to the applied pressure induced by the retractor blade. The contact area between them influences the retraction pressure 12).


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Fogel GR, McDonnell MF. Surgical treatment of dysphagia after anterior cervical interbody fusion. Spine J. 2005 Mar-Apr;5(2):140-4. doi: 10.1016/j.spinee.2004.06.022. PMID: 15749613.

Ramos-Zúñiga R, Díaz-Guzmán LR, Velasquez S, Macías-Ornelas AM, Rodríguez-Vázquez M. A microsurgical anterior cervical approach and the immediate impact of mechanical retractors: A case control study. J Neurosci Rural Pract. 2015 Jul-Sep;6(3):315-9. doi: 10.4103/0976-3147.158748. PubMed PMID: 26167011; PubMed Central PMCID: PMC4481782.

Avila MJ, Aguilar-Salinas P, Burket AR, Dumont TM. Parkinson Disease, Dysphagia, and Cervical Spine Surgery. Clin Spine Surg. 2021 May 24. doi: 10.1097/BSD.0000000000001197. Epub ahead of print. PMID: 34029260.

Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976). 2004 Jul 1;29(13):1441-6. PubMed PMID: 15223936.

Aguilar DD, Brara HS, Rahman S, Harris J, Prentice HA, Guppy KH. Exclusion criteria for dysphagia for outpatient single-level anterior cervical discectomy and fusion using inpatient data from a spine registry. Clin Neurol Neurosurg. 2019 Mar 11;180:28-33. doi: 10.1016/j.clineuro.2019.03.008. [Epub ahead of print] PubMed PMID: 30877898.

Baron EM, Soliman AM, Gaughan JP, Simpson L, Young WF. Dysphagia, hoarseness, and unilateral true vocal fold motion impairment following anterior cervical diskectomy and fusion. Ann Otol Rhinol Laryngol. 2003 Nov;112(11):921-6. PubMed PMID: 14653359.

Mehra S, Heineman TE, Cammisa FP Jr, Girardi FP, Sama AA, Kutler DI. Factors predictive of voice and swallowing outcomes after anterior approaches to the cervical spine. Otolaryngol Head Neck Surg. 2014 Feb;150(2):259-65. doi: 10.1177/0194599813515414. Epub 2013 Dec 23. PubMed PMID: 24367048.

Radcliff KE, Bennett J, Stewart RJ, Kepler CK, Sidhu GS, Hilibrand AS, Kane J, Albert TJ, Vaccaro AR, Rihn JA. Change in Angular Alignment Is Associated With Early Dysphagia After Anterior Cervical Discectomy and Fusion. Clin Spine Surg. 2016 Jul;29(6):248-54. doi: 10.1097/BSD.0b013e31828b39b4. PubMed PMID: 27137158.

Tian W, Yu J. The Role of C2-C7 Angle in the Development of Dysphagia After Anterior and Posterior Cervical Spine Surgery. Clin Spine Surg. 2017 Nov;30(9):E1306-E1314. doi: 10.1097/BSD.0000000000000493. PubMed PMID: 27930391.

Heese O, Fritzsche E, Heiland M, Westphal M, Papavero L. Intraoperative measurement of pharynx/esophagus retraction during anterior cervical surgery. Part II: perfusion. Eur Spine J. 2006 Dec;15(12):1839-43. Epub 2006 Feb 14. PubMed PMID: 16477447.

Heese O, Schröder F, Westphal M, Papavero L. Intraoperative measurement of pharynx/esophagus retraction during anterior cervical surgery. Part I: pressure. Eur Spine J. 2006 Dec;15(12):1833-7. Epub 2006 Feb 14. PubMed PMID: 16477448.
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