Is dysphagia a potential post-operative complication in middle-aged to older adults undergoing a C6 Corpectomy (cervical spine surgery)?

Dysphagia After C6 Corpectomy: A Common and Expected Complication

Yes, dysphagia is a well-established and frequent post-operative complication following C6 corpectomy, occurring in up to 71% of patients within the first two weeks after anterior cervical spine surgery, though most cases improve over time with 12-14% experiencing persistent symptoms at one year. 1

Incidence and Natural History

• Early post-operative dysphagia (within 2 months) is extremely common, affecting the majority of patients undergoing anterior cervical spine procedures including corpectomy 2, 1
• The incidence gradually decreases over subsequent months, with most patients experiencing significant improvement by 2-6 months post-operatively 1
• Approximately 12-14% of patients will have some degree of persistent dysphagia at one year, representing a chronic complication that requires ongoing management 1
• Aspiration occurs in approximately 50% of patients in the early post-operative period, decreasing to 18% in the late post-operative period (>2 months) 2

Mechanisms of Dysphagia After Cervical Corpectomy

Multiple biomechanical and structural alterations occur that impair swallowing function:

• Prevertebral soft tissue swelling near the surgical site creates mechanical obstruction and restricts pharyngeal wall movement 3
• Significantly increased pharyngeal wall thickness is characteristic of both early and late post-operative groups compared to normal controls 2
• Poor epiglottic inversion occurs in both early and late phases, impairing airway protection during swallowing 2
• Deficient posterior pharyngeal wall movement and impaired upper esophageal sphincter opening contribute to bolus transit difficulties 3
• Esophageal retraction during surgery alters blood flow and causes tissue trauma 1
• Neurological injury to the recurrent laryngeal nerve or superior laryngeal nerve can cause pharyngeal phase weakness or absence, resulting in aspiration 3, 4

Clinical Presentation Patterns

Dysphagia after C6 corpectomy manifests in several distinct patterns:

• Pharyngeal phase dysfunction is most common, with absent or very weak pharyngeal swallow in approximately 38% of cases, often accompanied by aspiration 3
• Oral preparatory and oral phase deficits occur in approximately 31% of patients, including deficient bolus formation and reduced tongue propulsive action 3
• Combined oral and pharyngeal deficits with prevertebral swelling represent approximately 15% of cases 3
• Unilateral pharyngeal dysfunction can occur, creating asymmetric pharyngeal residue that requires specific compensatory strategies 5

Risk Factors for Post-Operative Dysphagia

Certain patient and surgical factors increase the likelihood and severity of dysphagia:

• Female gender is associated with higher risk 1
• Advanced age increases susceptibility 1
• Multilevel surgery (C6 corpectomy often involves multiple levels) significantly elevates risk 1
• Longer operating time correlates with increased dysphagia 1
• Severe pre-operative neck pain may predict post-operative swallowing difficulties 1

Diagnostic Approach

The American College of Radiology provides clear guidance on evaluating post-operative dysphagia after cervical spine surgery:

Immediate Post-Operative Period (First Days to Weeks)

• Start with single-contrast esophagram using water-soluble contrast first to rule out esophageal perforation or leak, which is a surgical emergency 6
• Follow with barium contrast if no leak is detected, as barium provides superior mucosal detail for detecting strictures, extrinsic compression, and anatomic abnormalities 6
• This approach defines postoperative anatomy and assesses the caliber of the pharynx and esophagus 7, 6

Late Post-Operative Period (Weeks to Months)

• Single-contrast esophagram with barium is the study of choice for evaluating delayed dysphagia, as leak is no longer a concern and barium provides optimal visualization 6
• Add modified barium swallow if oropharyngeal dysmotility with aspiration or penetration is suspected, particularly when clinical examination suggests functional swallowing impairment 6
• Modified barium swallow focuses on the oral cavity, pharynx, and cervical esophagus to assess oral and pharyngeal phase abnormalities 7

When Initial Studies Are Negative

• Order CT neck/chest with IV contrast if clinical suspicion remains high after negative esophagram, as the combination achieves 100% sensitivity for detecting complications 6
• CT is valuable for assessing surgical hardware position, detecting postoperative fluid collections, and evaluating soft tissue structures 7, 6
• CT has 86% sensitivity but only 33% specificity for detecting leaks, making it complementary rather than primary 6

Critical Pitfalls to Avoid

Several common errors can delay diagnosis or lead to inappropriate management:

• Never use water-soluble contrast for delayed dysphagia evaluation—it provides inferior mucosal detail and is only indicated when acute leak is suspected in the immediate postoperative period 6
• Do not order modified barium swallow as the sole initial test, as it does not evaluate the entire esophagus and will miss retrosternal pathology common after cervical spine surgery 6
• Never skip the water-soluble contrast phase in the immediate postoperative period, as using barium first when a leak is present can cause severe mediastinitis 6
• Do not rely solely on CT without esophagography, as CT has poor specificity and generates many false positives leading to unnecessary interventions 6

Management and Rehabilitation

Evidence-based approaches to treating post-operative dysphagia:

• Dysphagia therapy and patient education are useful treatment adjuncts that can improve outcomes 2
• Compensatory strategies based on videofluoroscopic findings are effective, such as head rotation to the weak side and head tilting to the robust side for unilateral dysfunction 5
• Multidisciplinary approach involving speech-language pathology is essential for addressing physiologic problems and initiating therapeutic interventions promptly 4
• Most patients experience gradual improvement over 2-6 months with appropriate rehabilitation 2, 1

Prognostic Considerations

Understanding the expected trajectory helps set realistic expectations:

• Significant alterations in swallowing mechanics accompany anterior cervical spine surgery with plating, but many changes improve over time, leaving patients with relatively minor impairment 2
• Some swallowing deficits appear to be long-lasting, particularly in the 12-14% with persistent symptoms at one year 2, 1
• Early intervention with swallowing assessment and rehabilitation may improve long-term outcomes, though definitive evidence is limited 5, 4