The effect of local vs. intravenous steroids on dysphagia and dysphonia following anterior cervical discectomy and fusion (ACDF): a single-blinded, prospective, randomized control trial

Study Design: Prospective randomized controlled studyIntroduction: Dysphagia and dysphonia are the most common complications following anterior cervicaldiscectomy and fusion (ACDF). Fortunately, most post‐ACDF dysphagia is mild and transient, but in thelimited number of patients that develop severe dysphagia it will have profound effects on overall healthand surgical outcomes. Severe dysphagia places the patient at higher risk for dehydration, malnutrition,social isolation, aspiration, pneumonia, and death. Previous studies have demonstrated that intravenous(IV) and local steroids can decrease prevertebral soft‐tissue swelling, however, no standardized studieshave compared the efficacy of local steroid application to controls during ACDF on post‐operativedysphagia and dysphonia. We conducted a prospective randomized clinical trial to assess the efficacyof intra‐operative steroid administration (intravenous or local) on dysphagia and dysphonia after ACDF.Methods: 72 patients undergoing ACDF for the treatment of cervical degenerative disease wererecruited. Inclusion criteria were patients greater than 18 years undergoing ACDF for the treatmentof radiculopathy or myelopathy. Exclusion criteria included: age under 18 years, operations fortrauma/infection/tumor/revision, or general metabolic diseases (diabetes, heart disease, renaldisease). Patients were randomized into three cohorts: control (no steroid), IV steroid (10 mg one‐timeintraoperative dose of IV dexamethasone), or local steroid groups (40 mg of triamcinolone placed in theretropharyngeal space directly on the cervical plate). Subjects were blinded from which treatment armthey received. Primary outcomes were measured for dysphagia (Bazaz, Eat‐10) and dysphonia (VHI‐10)[6‐8]. Secondary outcomes include Neck Disability Index (NDI) and Visual Analog Scale (VAS) for neckpain. Patient outcomes were collected pre‐operatively, post‐operative day 1, week 2, and week 6.Statistical analysis was completed with significance set at p < 0.05.Results: Baseline patient reported outcomes for dysphagia, dysphonia, and neck pain were notsignificantly different between the groups. Day 1 post‐operative patient outcomes scores showed asignificant improvement in dysphonia (VHI‐10 p = 0.026) and neck pain (p = 0.025) in the local steroidgroup (Table 1, Figure 1). There was also a trend towards significant improvement of post‐operative Day1 dysphagia with the local steroid group (Bazaz p = 0.057). The local steroid cohort showed significantimprovement in dysphagia (Bazaz p = 0.026; Eat‐10 p = 0.011) and neck pain (p = 0.042) at 2 weekspost‐operative when compared to the other treatment groups. At 6 weeks post‐operative the local grouphad significantly less severe dysphagia (Bazaz p= 0.001; Eat‐10 p< 0.001) when compared to the othertreatment groups.