Is cervical stenosis a risk factor for aspiration?

Cervical Stenosis as a Risk Factor for Aspiration

Yes, cervical stenosis is a significant risk factor for aspiration, particularly in patients who have undergone cervical spine surgery or have traumatic cervical spinal cord injuries.

Evidence for Cervical Stenosis and Aspiration Risk

Cervical Spine Surgery and Aspiration

• According to the American College of Chest Physicians guidelines, cervical spinal surgery significantly increases aspiration risk 1
• In a study of 83 consecutive patients who underwent cervical spine operations, 42% of patients undergoing anterior cervical operations and 20% of those undergoing posterior cervical procedures experienced aspiration after the procedure, while none of the lumbar surgery patients aspirated 1
• The level of anterior cervical operation is a marked risk factor for aspiration and penetration following cervical spinal cord injury 2

Traumatic Cervical Spinal Cord Injury (TCSCI) and Aspiration

• In a prospective study of 46 patients with TCSCI, 33% aspirated and 41% experienced laryngeal penetration during videofluoroscopic swallowing studies 3
• Of those who aspirated, 73% had silent aspiration (aspiration without triggering a cough reflex) 3
• Another study found that 51.4% of patients with acute TCSCI were penetrator-aspirators, with 71.4% experiencing silent aspiration 2

Mechanisms of Aspiration in Cervical Stenosis

Cervical stenosis can lead to aspiration through several mechanisms:

1. Neurological impairment: Damage to cervical spinal nerves can affect the coordination of swallowing muscles and protective reflexes
2. Impaired laryngeal sensation: Decreased laryngeal sensation is a significant risk factor for penetration-aspiration, particularly in patients who undergo head and neck or esophageal surgery 1
3. Swallowing dysfunction: Dysphagia occurs frequently in patients with cervical cord injuries and is accompanied by aspiration with a high risk of pneumonia 4
4. Silent aspiration: Many patients with cervical spinal injuries experience silent aspiration, where material enters the airway without triggering protective cough reflexes 3

Clinical Indicators of Aspiration Risk

Key clinical signs that indicate aspiration risk in patients with cervical stenosis include:

• Coughing, throat clearing, or choking related to swallowing 2
• Changes in voice quality related to swallowing 2
• Necessity of bronchoscopies 2
• Wet or "gurgly" voice after swallowing 5
• Need for frequent oral/pharyngeal suctioning 5

Management Implications

For patients with cervical stenosis who are at risk for aspiration:

1. Screening: All patients with cervical stenosis, especially those undergoing cervical spine surgery, should be screened for dysphagia and aspiration risk 5

2. Diagnostic evaluation: Videofluoroscopic swallowing study (VFSS) is highly recommended to rule out silent aspiration and determine safe nutrition consistency 3

3. Preventive measures:

   • Early placement of a percutaneous endoscopic gastrostomy (PEG) tube has shown preventive effects against aspiration pneumonia in patients with dysphagia following cervical cord injury (27% pneumonia rate with PEG vs. 67% without) 4
   • Liquid thickening based on VFSS assessment can reduce aspiration risk 1

4. Monitoring: Patients with decreased laryngeal sensation should be considered a pre-aspiration pneumonia population and monitored carefully 1

Pitfalls and Caveats

1. Silent aspiration: Up to 73% of aspiration in cervical spinal cord injury patients may be silent (without cough) 3, making clinical detection difficult without instrumental assessment

2. History of aspiration pneumonia: A previous history of aspiration pneumonia significantly increases the risk of recurrence (adjusted OR 7.00) even with proper liquid-thickening guidance 1

3. Performance status: Poor performance status is independently associated with developing pneumonia despite proper liquid-thickening guidance (adjusted OR 1.85) 1

4. Post-surgical timing: The risk of aspiration is highest in the immediate post-operative period after cervical spine surgery 1

The evidence clearly demonstrates that cervical stenosis, particularly when associated with cervical spine surgery or traumatic injury, significantly increases the risk of aspiration and subsequent pneumonia, with potentially serious implications for patient morbidity and mortality.