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(A, B) A large osteophyte formation on C4-C5 and C7-T1 vertebra corpuses and esophageal compression of this formation in the cervical magnetic resonance (shown by the arrows).
Source publication
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatological disease affecting the axial skeleton with various extra-articular complications. Dysphagia due to a giant anterior osteophyte of the cervical spine in AS is extremely rare. We present a 48-year-old male with AS suffering from progressive dysphagia to soft foods and liquids. Esoph...
Citations
... A randomized comparative study of radiotherapy alone vs. chemoradiotherapy for the treatment of esophageal cancer that could not be treated radically in patients presenting with obstruction (TROG 03.01) revealed no significant difference in the percentage of patients who showed improvement in the dysphagia between the radiotherapy alone and chemoradiotherapy groups (35% vs. 45%, p = 0.13) and a significantly lower incidence of Grade 3-4 adverse events in the radiotherapy alone group (16% vs. 36%, p = 0.0017) [162,163]. There was no difference in the median survival time between the radiotherapy alone group (6.7 months) and chemoradiotherapy group (6.9 months). ...
... 4 Anterior cervical osteophytes in patients with AS may compress the esophagus and cause dysphagia; although such cases are rare, they are observed occasionally. [5][6][7] Herein, we present a case of rapidly progressing dysphagia after thoracic spinal cord injury (SCI) in a patient with AS and anterior cervical osteophytes. ...
... To the best of our knowledge, this is the first case of dysphagia that progressed rapidly after SCI in a patient with AS who had no dysphagia. Despite reports of dysphagia due to anterior cervical osteophytes, [5][6][7] there have been no reports of newly developed dysphagia in patients with pre-existing osteophytes following SCI. ...
... This is commonly observed in the anterior cervical region, and dysphagia due to the mechanical compression of cervical osteophytes and syndesmophytes has been described in the literature. 5,11 There are several mechanisms by which the anterior cervical pathological bone may cause dysphagia, including the following: 12 (1) large osteophytes may mechanically trigger blockage of the esophagus; (2) small osteophytes may compress and obstruct the esophageal segment attached to the cricoid cartilage, most commonly at C5-C6; ...
Introduction
Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease affecting the axial skeleton, including the sacroiliac joint, which causes vertebral fusion in the advanced stage. However, reports of anterior cervical osteophytes compressing the esophagus and causing dysphagia in patients with AS are rare. Here, we present the case of a patient with AS and anterior cervical osteophytes who exhibited rapidly progressing dysphagia after thoracic spinal cord injury (SCI).
Case Presentation
The patient, a 79-year-old man, was previously diagnosed with AS and had syndesmophytes at C2-C7 without dysphagia for several years. In 2020, he began to experience paraplegia, hypesthesia, and bladder and bowel dysfunction after a fall. He also had T9 SCI American Spinal Injury Association Impairment Scale grade A due to a T10 transverse fracture. Four months after SCI, he developed aspiration pneumonia, and a videofluoroscopic swallowing study indicated dysphagia with epiglottic closing problems due to syndesmophytes at the C2-C3 and C3-C4 levels. He received treatment for dysphagia and VitalStim therapy thrice (once daily); however, the recurrent pneumonia and fever continued. He further underwent bedside physical therapy and functional electrical stimulation once daily. However, he died from atelectasis and exacerbation of sepsis.
Discussion and Conclusion
General deterioration of the patient’s physical condition due to SCI, sarcopenic dysphagia, and compression of cervical osteophytes seemed to be involved in rapid exacerbation following SCI. Early screening for dysphagia is vital in bedridden patients with AS or SCI. Additionally, assessment and follow-up are important if the number of rehabilitation treatments or the out-of-bed movement activity decreases because of pressure ulcers.
... 1,2 ACD can result in marked impact on health-related quality of life (HRQL) by producing neck and arm pain, myelopathy, swallowing and breathing difficulties, and loss of horizontal gaze. [3][4][5][6] Historic studies indicated surgical treatment of ACD was associated with high complication rates. [7][8][9] More recently, however, there has been renewed interest in treating these often complex deformities. ...
Objective:
Adult cervical deformity (ACD) has high complication rates due to surgical complexity and patient frailty. Very few studies have focused on longer-term outcomes of operative ACD treatment. The objective of this study was to assess minimum 2-year outcomes and complications of ACD surgery.
Methods:
A multicenter, prospective observational study was performed at 13 centers across the United States to evaluate surgical outcomes for ACD. Demographics, complications, radiographic parameters, and patient-reported outcome measures (PROMs; Neck Disability Index, modified Japanese Orthopaedic Association, EuroQol-5D [EQ-5D], and numeric rating scale [NRS] for neck and back pain) were evaluated, and analyses focused on patients with ≥ 2-year follow-up.
Results:
Of 169 patients with ACD who were eligible for the study, 102 (60.4%) had a minimum 2-year follow-up (mean 3.4 years, range 2-8.1 years). The mean age at surgery was 62 years (SD 11 years). Surgical approaches included anterior-only (22.8%), posterior-only (39.6%), and combined (37.6%). PROMs significantly improved from baseline to last follow-up, including Neck Disability Index (from 47.3 to 33.0) and modified Japanese Orthopaedic Association score (from 12.0 to 12.8; for patients with baseline score ≤ 14), neck pain NRS (from 6.8 to 3.8), back pain NRS (from 5.5 to 4.8), EQ-5D score (from 0.74 to 0.78), and EQ-5D visual analog scale score (from 59.5 to 66.6) (all p ≤ 0.04). More than half of the patients (n = 58, 56.9%) had at least one complication, with the most common complications including dysphagia, distal junctional kyphosis, instrumentation failure, and cardiopulmonary events. The patients who did not achieve 2-year follow-up (n = 67) were similar to study patients based on baseline demographics, comorbidities, and PROMs. Over the course of follow-up, 23 of the total 169 enrolled patients were reported to have died. Notably, these represent all-cause mortalities during the course of follow-up.
Conclusions:
This multicenter, prospective analysis demonstrates that operative treatment for ACD provides significant improvement of health-related quality of life at a mean 3.4-year follow-up, despite high complication rates and a high rate of all-cause mortality that is reflective of the overall frailty of this patient population. To the authors' knowledge, this study represents the largest and most comprehensive prospective effort to date designed to assess the intermediate-term outcomes and complications of operative treatment for ACD.
... Anterior cervical osteophytes (ACOs) are bony protrusions of the spine seen primarily in the geriatric male population, often those 65 years and older, as a result of degenerative spinal changes, ankylosing spondylitis, or diffuse idiopathic skeletal hyperostosis (DISH) [1][2][3][4][5][6]. It is estimated that ACOs occur in 10-30% of the population, are typically benign, and are most often asymptomatic [7,8]. ...
... Individuals may initially report sticking of food in their throat that eventually leads to the need for softer solids and frequent liquid intake to help clear pharyngeal residue. If the dysphagia is not addressed patients begin to notice prolonged meals and subsequent weight loss, resulting in decreased quality of life [1,5,7]. Additionally if severe the dysphagia places patients at risk for aspiration. ...
Abstract
Anterior cervical osteophytes are common in the geriatric population. Dysphagia can occur in individuals suffering from these spinal abnormalities. Surgical intervention is an uncommon course of treatment for these patients, but is often utilized as a last resort with the hope of swallow recovery. The purpose of this article is to highlight a unique case study documenting the required treatment course for dysphagia associated with osteophytes and subsequent osteophytectomy. We review current literature of both conservative and surgical interventions, as well as discuss the rehabilitation course for a complex patient with persistent dysphagia. Various outcome measures were utilized during the patient’s inpatient stay to track progress including the Functional Oral Intake Scale (FOIS), the Bolus Residue Scale (BRS), Penetration Aspiration Scale (PenAsp), Dysphagia Outcome Severity Scale (DOSS), and a Modified Barium Swallow Study (MBSS). The patient received rehabilitative training including oral motor and pharyngeal strengthening exercises, respiratory strengthening, speech instruction, cognitive retraining, and instrumental assessment. Following osteophytectomy and dysphagia rehabilitation the patient did not show any change based on a repeat MBSS which revealed the necessity for the patient to remain nothing per oral (NPO). The patient demonstrated an inability to manage his secretions, requiring continual suctioning. Upon discharge the patient remained NPO with the exception of ice chips, utilized a PEG for nutrition, and had a red capped tracheostomy. He was on room air and independently utilized oral suction as needed for secretion management. Our patient’s clinical course was not aligned with typical osteophytectomy recovery as progress after his 25-day inpatient stay was limited. The goal of this case study is to contribute information to the limited and variable data available regarding treatment options, outcome measures and timelines for recovery as it pertains to patients who undergo an osteophytectomy.
... However, difficulty swallowing is rarely a symptom of AS. Moreover, dysphagia associated with cervical vertebral disease is usually observed in diffuse idiopathic skeletal hyperostosis (DISH) but is rarely related to AS with cervical spine involvement [4,5] . Therefore, it is necessary to distinguish the difference between DISH and AS. ...
Background:
Ankylosing spondylitis (AS) is a systematic and rheumatic disease, which causes multiple symptoms. However, dysphagia due to the formation of a giant anterior cervical osteophyte is rare in patients with AS.
Case summary:
We present the case of a 65-year-old male patient who was diagnosed with AS and visited the hospital with a complaint of progressive dysphagia. The appropriate imaging examinations indicated that a giant anterior cervical osteo-phyte at C3-4 caused esophageal compression, which led to dysphagia. An operation for resection was performed without complications.
Conclusion:
This case demonstrates that a large cervical osteophyte may be the cause of dysphagia in patients with AS, and early accurate diagnosis and surgical treat-ment are very important for the improvement of symptoms. Anterior cervical discectomy and fusion are extremely effective and should be taken into consideration.
... 4,22,23 When the extrinsic cause of the compression is the most prominent, surgical resection of the osteophytes via a standard anterior approach can be performed for more severe conditions and impairment of the quality of life. 4,[24][25][26][27][28] The results are less satisfactory the more the changes in the esophagus itself have progressed. 4,29 The resection of the osteophytes does not eliminate the underlying disease, so new ossification can develop. ...
... 24,53,[55][56][57] If the extrinsic cause is more prominent, in case of more severe problems and impairment of the quality of life, surgical resection of the osteophytes via a standard anterior approach is performed. 4,[24][25][26][27][28] This can achieve sufficient improvement with a low morbidity rate 4,17 ; regression of the symptoms can occur quickly (in up to 2 weeks) but may sometimes take months. 21,26,27,30,58 The results are more limited the more advanced the changes in the esophagus itself are (inflammation, fibrosis, impaired peristalsis, etc.). ...
Purpose::
Dysphagia due to anterior cervical osteophytes is a rare condition. However, it can become serious enough to permanently impair the quality of life up to making normal food intake impossible. If conservative treatment fails, there is the option of surgical resection of the osteophytes. The objective of this study was to assess the outcomes of resections of anterior cervical osteophytes causing spondylogenic dysphagia, taking literature into consideration.
Method::
Resection of anterior cervical osteophytes using a standard anterior approach was performed in 14 consecutive patients with spondylogenic dysphagia between 2009 and 2015. Indomethacin or radiation was used to prevent recurrence. Imaging and clinical data were collected in follow-up examinations over an average of 50 months.
Results::
The osteophytes were sufficiently resected in all cases. Anterior plates were placed in three patients due to pronounced segmental mobility. Five patients were given recurrence prevention in the form of indomethacin, nine with radiation. One patient required revision surgery for a hematoma. No other serious complications were observed. All patients had significant improvement of their symptoms. No recurrences or signs of increasing instability were found during the follow-up period.
Conclusion::
When conservative treatment fails, surgical resection of cervical osteophytes is a sufficient method for treating spondylogenic dysphagia. High patient satisfaction and improvement of the quality of life are achieved with a low complication rate. Routine additional stabilization has been discussed as recurrence prevention. Prophylaxis using indomethacin or radiation, known primarily from hip replacement, also appears to be an option.
... Moreover, the more prolonged the periods of esophageal compression, inflammation, and irritation, the more chronic the local tissues alterations and adhesions would logically be. [18] Usually, initially all cases, especially mild-to-moderate cases are treated with conservative methods, such as dietary modifications by changing their food habits toward softer diet, drinking plenty of water with food, taking more frequent meals with smaller quantity at a time, and taking enough time to complete the meal; [19] also, a prescription of nonsteroidal anti-inflammatory drugs in the early stage usually helps. ...
Introduction: Dysphagia in old patients secondary to diffuse idiopathic skeletal hyperostosis (DISH) syndrome is underdiagnosed. Surgical resection of the offending osteophytes is the definitive treatment. However, the timing of surgery in the course of the disease is still controversial. The study tries to find a correlation if any, between the timing of osteophytectomy surgery aimed to relieve DISH syndrome-induced dysphagia and the surgical outcome.
Methods: During the period from 2010 to 2015, clinical and radiological data of patients who presented with dysphagia attributed to DISH syndrome were retrospectively reviewed along with their management and outcome.
Results: One female and seven male patients were included in the study. Mean age was 71 years. Mean duration of dysphagia was 3 years and 10 months. Surgical resection was attempted through anterolateral cervical approach in five cases who were fit for surgery, in which four showed complete resolution of dysphagia (one experienced transient hoarseness of voice for 4 weeks postoperatively), and the fifth showed minimal improvement after limited resection due to intraoperative finding of marked esophageal adherence to osteophytes. The two unfavorable outcomes (subtotal resection and transient hoarseness of voice) occurred in relatively older patients (average: 75.5 years) with longer standing dysphagia (average: 7 years).
Conclusion: DISH syndrome as a cause of dysphagia is commonly underlooked. Surgical resection of the offending osteophytes through an anterolateral approach is a safe and effective procedure. For patients who are fit for surgery, older age or longer duration of dysphagia might be associated with less favorable surgical outcome.
... In present study 30% of the patients were found to have anterior cervical osteophytes after ruling out other common causes. The difference was found in study by Strasser G et al., caused due to large cervical osteophyte in a patient with ankylosing spondylitis [15]. ...
Introduction: Dysphagia is a common symptom seen in patients in ENT OPD. Gastro-oesophageal reflux, foreign body, mass lesions being the known common causes. Cervical spondylosis with large osteophytes is one of the causes of dysphagia, which can be easily diagnosed even with limited facilities available but it is less discussed in younger age group. Aim: To evaluate the clinical importance and significance of cervical osteophytes as a cause of dysphagia. Materials and Methods: Seventy patients of either sex, between the age group of 25-59 years, with dysphagia were evaluated with complete history and clinical examination followed by upper gastrointestinal endoscopy. All common causes of dysphagia were ruled out. Patients were evaluated with a digital X-ray of cervical spine in lateral view. The results were analysed statistically using chi-square test and Fischer’s-exact test. Results: Out of 70 patients evaluated, 40 (57.1%) were female patients and 30 (42.9%) male patients. About 21 (30%) patients were found to have cervical spine osteophytes. Conclusion: After ruling out common causes, anterior cervical osteophytes should be remembered as one of the causes of dysphagia by the otorhinolaryngologists for effective management. © 2018, Journal of Clinical and Diagnostic Research. All rights reserved.
... [1][2][3][4][5][6] The most common forms result from degenerative spondylotic and inflammatory arthropathies or iatrogenic conditions and can produce "chin-on-chest" deformities that can substantially impact fundamental functions, including horizontal gaze, swallowing, and breathing. [7][8][9] In contrast to thoracolumbar deformities, considerably less progress has been made in the study of ACSD. Early reports on ACSD predominantly focused on small series of patients treated with what were considered high-risk procedures, and these patients often experienced high rates of major complications. ...
Background:
Although adult cervical spine deformity (ACSD) is associated with pain and disability, its health impact has not been quantified in comparison to other chronic diseases.
Objective:
To perform a comparative analysis of the health impact of symptomatic ACSD to US normative and chronic disease values using EQ-5D (EuroQuol-5 Dimensions questionnaire) scores.
Methods:
ACSD patients presenting for surgical treatment were identified from a prospectively collected multicenter database. Baseline demographics and EQ-5D scores were collected and compared with US normative and disease state values.
Results:
Of 121 ACSD patients, 115 (95%) completed the EQ-5D (60% women, mean age 61 years, previous spine surgery in 44%). Diagnoses included kyphosis with mid-cervical (63.4%), cervico-thoracic (23.5%), or thoracic (8.7%) apex and primary coronal deformity (4.3%). The mean ACSD EQ-5D index was 0.511 (standard definition = 0.224), which is 34% below the bottom 25th percentile (0.780) for similar age- and gender-matched US normative populations. Mean ACSD EQ-5D index values were worse than the bottom 25th percentile for several other disease states, including chronic ischemic heart disease (0.708), malignant breast cancer (0.708), and malignant prostate cancer (0.708). ACSD mean index values were comparable to the bottom 25th percentile values for blindness/low vision (0.543), emphysema (0.508), renal failure (0.506), and stroke (0.463). EQ-5D scores did not significantly differ based on cervical deformity type ( P = .66).
Conclusion:
The health impact of symptomatic ACSD is substantial, with negative impact across all EQ-5D domains. The mean ACSD EQ-5D index was comparable to the bottom 25th percentile values for blindness/low vision, emphysema, renal failure, and stroke.
... [1][2][3][4] The most severe forms, such as those associated with spondylotic arthropathies, can produce "chin-on-chest" deformities, which can compromise horizontal gaze, swallowing, and breathing. [5][6][7] In contrast to thoracolumbar deformities, less progress has been made for ACD with regard to characterization of clinical presentations, development of standardized classification systems, definition of optimal treatment approaches, assessment of operative complication rates, and rigorous study of clinical outcomes after treatment. [8][9][10][11][12][13][14][15] Smith et al 16 recently reported substantial variability in the surgical planning for treatment of adult cervical deformities among a group of experienced spine surgeons from across North America. ...
