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
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
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
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
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
RLN inj ury No significant difference in RLN inj ury between laterality of Total 14 palsies (13 from primary, 1 from revision) 7 palsies from right sided approach 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), 50.3 range (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 0.00% 1 14.29% 0.4621
Literature Review Incidence in literature (0.07% - 5.1% ) may be underreported Minor symptoms, short duration, asymptomatic
* Asympt omat ic pat ient s were 2-3x more common t han sympt omat ic pat ient s
Anatomical considerations
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)
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 .
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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