What is the recommended imaging test for a patient with dysphagia (difficulty swallowing) after cervical spine (c spine) surgery?

Recommended Imaging for Post-Cervical Spine Surgery Dysphagia

Order a single-contrast esophagram with water-soluble contrast initially, followed by barium if no leak is detected, as this is the study of choice for evaluating dysphagia after cervical spine surgery. 1

Initial Diagnostic Approach

Primary Test: Single-Contrast Esophagram

• Begin with water-soluble contrast to evaluate for potential esophageal perforation or leak, which is a critical early complication that requires immediate identification 1
• Follow with barium contrast if the water-soluble study shows no leak, as barium provides superior mucosal detail for detecting strictures, extrinsic compression from displaced hardware or bone graft, and anatomic abnormalities 1
• This fluoroscopic study effectively defines postoperative anatomy and assesses the caliber of the pharynx and esophagus, which is essential for identifying structural causes of dysphagia after cervical spine surgery 1

When to Add CT Imaging

• Order CT neck/chest with IV contrast if clinical suspicion remains high after a negative esophagram, as the combination of esophagography and CT achieves 100% sensitivity for detecting complications 1
• CT with IV contrast is particularly valuable for assessing surgical hardware position, detecting postoperative fluid collections (hematomas, abscesses), and evaluating soft tissue structures 1
• CT alone has 86% sensitivity but only 33% specificity for detecting leaks, compared to esophagography's 79% sensitivity and 73% specificity 1
• The combination approach prevents missed diagnoses, as esophagrams can miss up to 21% of clinically significant leaks 1

Timing-Based Considerations

Immediate Postoperative Period (< 2 weeks)

• Dysphagia in this timeframe may indicate acute complications including esophageal injury, prevertebral swelling, or hardware malposition 1, 2
• Water-soluble contrast esophagram is mandatory first to rule out perforation before using barium 1
• Consider adding CT with IV contrast early if there are signs of infection, fever, or severe symptoms suggesting abscess formation 1

Late Postoperative Period (weeks to months)

• Dysphagia occurring weeks or months after surgery suggests different etiologies: dysmotility, stricture formation, displaced hardware, or bone graft complications 1
• A modified barium swallow (videofluoroscopy) should be added if oropharyngeal dysmotility with aspiration or penetration is suspected, as this evaluates functional swallowing mechanics 1, 3
• Biphasic (double-contrast) esophagram may provide additional mucosal detail if structural abnormalities are suspected but not clearly identified on single-contrast study 1

Critical Pitfalls to Avoid

• Do not order a modified barium swallow as the sole initial test, as it does not evaluate the entire esophagus and will miss retrosternal pathology, which is common after cervical spine surgery 1
• Do not skip the water-soluble contrast phase in the immediate postoperative period, as using barium first when a leak is present can cause severe mediastinitis 1
• Do not rely solely on CT without esophagography, as CT has poor specificity (33%) and will generate many false positives, leading to unnecessary interventions 1
• Do not assume normal swallowing function will persist—dysphagia can recur after an initial period of normal swallowing, requiring reassessment 4

Algorithmic Decision Tree

1. Start with single-contrast esophagram: water-soluble contrast first, then barium if no leak 1

2. If esophagram is negative but clinical suspicion is high: Add CT neck/chest with IV contrast to evaluate hardware position, soft tissue collections, and achieve 100% sensitivity 1

3. If oropharyngeal symptoms predominate (coughing with swallowing, sensation of food sticking in throat, aspiration symptoms): Add modified barium swallow to assess swallowing mechanics and aspiration risk 1, 3

4. If late presentation with suspected motility disorder: Consider biphasic esophagram for enhanced mucosal detail and motility assessment 1

Understanding the Evidence Strength

The ACR Appropriateness Criteria provide Level A guideline evidence that esophagography is the study of choice for post-cervical spine surgery dysphagia 1. The specific performance characteristics (sensitivity 79%, specificity 73% for esophagography alone; 100% sensitivity when combined with CT) come from high-quality comparative studies 1. This represents the strongest available evidence for this clinical scenario, with the 2019 ACR guidelines being the most recent comprehensive guideline addressing this specific question.