The Risk of Recurrent Laryngeal Nerve Inj ury with Laterality Of - - PowerPoint PPT Presentation

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The Risk of Recurrent Laryngeal Nerve Inj ury with Laterality Of Approach in Anterior Cervical Discectomy and Fusion Procedures: A Randomized, Prospective S tudy Over 10 Y ears William Beut ler, MD; S halin S hah, DO; Manminder Bhat ia, DO

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The Risk of Recurrent Laryngeal Nerve Inj ury with Laterality Of Approach in Anterior Cervical Discectomy and Fusion Procedures: A Randomized, Prospective S tudy Over 10 Y ears

William Beut ler, MD; S halin S hah, DO; Manminder Bhat ia, DO

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Introduction

Recurrent laryngeal nerve (RLN) inj ury potentially devastating complication ACDF

Incidence: 0.07%

  • 5.1%

Complications

Dysphonia, impaired phonat ion, impaired cough reflex, airway obst ruct ion, hoarseness, vocal fat igue, st ridor, permanent t racheot omy 

Controversy over laterality of approach

Training, comfort , hand dominance, cervical levels involved, hist ory of neck surgery 

First large-scale, randomized, prospective, single surgeon (neurosurgeon), single blinded study

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Materials & Methods

411 patients met inclusion

S ide of approach randomized based on contralateral symptoms

 i.e. left arm radicular symptoms  right-sided approach  Exception: Revision surgery  same as primary side

Outcome measured:

 Changes in voice (i.e. hoarseness) or swallowing at 2-week visit

 S

uspected RLN palsy received ENT evaluation

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S tatistics

S econdary measures

 Age, sex, procedure, levels, preoperative diagnosis, blood loss, use of allograft or

cage, history of palsy, use of neuromonitoring 

S tudent’s t-test, Chi-square, Fisher’s exact

All analyses done in S AS version 9.4 (S AS Institute, Cary, NC).

P-value <0.05 considered statistically significant

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Results

411 total cases

 397 ACDF vs. 14 cervical disc replacement

190 RIGHT sided approach vs. 221 LEFT sided approaches

41 revisions (370 primary)

 10 revisions from same side approach, 31 from opposite

232 involved ONE cervical level, 163 involved TWO levels, 16 involved THREE

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RLN inj ury

Total 14 palsies (13 from primary, 1 from revision)

 7 palsies from right sided approach  7 palsies from left sided approach

 RLN inj ury in revision was in left sided, two level, same sided approach

 All except one resolved within 3 months

Table 1: Summary Table Left (n=220) Right (n=189) p-Value Age - mean (SD), range 50.3 (11.6) 25 - 80 48.2 (9.8) 23 - 75 0.0524 Gender (Male) - no.% 109 49.55% 88 46.56% 0.5470 Complication - no.% 7 3.18% 7 3.70% 0.7723 Complications by Level Level 1 1 14.29% 5 71.43% 0.0997 Level 2 6 85.71% 1 14.29% 0.1293 Level 3 0.00% 1 14.29% 0.4621

No significant difference in RLN inj ury between laterality of approach

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Literature Review

Incidence in literature (0.07%

  • 5.1%

) may be underreported

 Minor symptoms, short duration, asymptomatic

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* Asympt omat ic pat ient s were 2-3x more common t han sympt omat ic pat ient s

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Anatomical considerations

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Proposed mechanisms

S tretch-induced neuropraxia

Aberrant retractor placement?

 generally more lateral  Irrespective of side, larynx retracted medially

Prolonged intubation  Adj acent to submucosal portion of nerve

Post-operative edema

 Inevitable condition rather than complication (similar to wound pain experienced

after an operation)

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RLN Inj ury

4 months post operatively, all but one dysphonia symptom resolved

 Clinically silent palsy?

(compensation from other vocal cord rather than true recovery)

Manski TJ, Wood MD, Dunsker S

  • B. Bilat eral vocal cord paralysis following ant erior cervical discect omy and fusion. J Neurosurg 1998;89:839-43

Patient satisfaction remains despite RLN inj ury

Winslow CP, Meyers AD. Ot olaryngologic complicat ions of t he ant erior approach t o t he cervical spine. Am J Ot olaryngol. 1999;20(1): 16-27

Although there is usually spontaneous resolution of hoarseness, it is important to remember that pat ient s wit h a vocal cord paresis may be asympt omat ic, and pat ient s wit h sympt omat ic dysphonia may have no vocal cord paresis.

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Conclusion

In a single surgeon randomized prospective study, there was no significant difference noted between the side of approach and the risk of recurrent laryngeal nerve palsy

Therefore the surgeon may safely operate from either side based on handedness, experience, training or anatomic considerations

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