Dysphagia and Cervical Hyperostosis: A Multidisciplinary Team

Dysphagia and Cervical
Hyperostosis: A Multidisciplinary
Team Approach
Dana Hanifan, M.A., CCC
Department of Speech-Language Pathology
Paul M. Knechtges, M.D.
Department of Radiology
Stephen Sullivan, M.D.
Department of Neurosurgery
Speech-Language Pathologist=
Diagnostician=Paradigm Shift:
• Value of diagnostic skills
• Value of cervical-pharyngeal sweep
• Value of pre-operative dysphagia
counseling
• Value of collaborative team efforts
Key Points
• Consider cervical osteoarthropathy as an
important though uncommon cause of dysphagia
● Diagnosed by cervical spine x-rays or a barium
swallow
● Cervical osteophytes should not be accepted as
the cause of dysphagia until other causes have
been excluded
● If dysphagia is severe and fails to resolve with
conservative measures, surgery can be effective
Forestier’s Disease
• Calcification of the
anterolateral aspects
of the perivertebral
ligaments
• Resnick, 1975, coined
the term, diffuse
idiopathic skeletal
hyperostosis (DISH).
Forestier’s Disease
• A form of
degenerative
arthritis
• Associated with
inflammation of
tendons at the
point of attachment
to bone
Epidemiology and Prevalence
• Affects males more than females
• 3.8% of males and 2.6% females over the
age of 40
• C4-7 cervical involvement occurs in 75% of
DISH population
• 17% of patients with DISH have dysphagia
• Thoracic involvement occurs in 99% of
cases
Common Associations
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Diabetes mellitus
Obesity
Gout
Dyslipidemia
Hypocalcemia
Clinical Manifestations
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Back pain
Limited cervical mobility
Dysphagia: solids > than liquids
Dysphonia
Stridor/Dyspnea
Sleep Apnea
Risk for fractures, endoscopic problems
and intubation difficulties
Etiology of Dysphagia
• Mechanical obstruction
• Impingement at sites where
esophagus is anchored to the cricoid
cartilage
• Inflammation provoking obstruction
• Pain and spasm
• Secondary neurological lesions
Osteophyte Level Correlates
• C5 to C6 (40%), C4 to C5 (23%), C3
to C4 (14%), C2 to C3 (14%)
● C4, C5, C6 esophageal tethering at
cricoid level
● C2, C3 oropharyngeal impingement
TW’s Medical Course
• 1995: Decreased
neck range of
motion
• 1998: Progressive
worsening neck
range of motion
• 4/9/98: C-spine
series notable for
calcification c/w
DISH
TW’s Medical Course
• 1995: Decreased
neck range of
motion
• 1998: Progressive
worsening neck
range of motion
• 4/9/98: C-spine
series notable for
calcification c/w
DISH
TW’s Medical Course
• 4/17/98: PMR referral
• 8/4/00: Neurology referral
• 5/15/01: Severe OSA; started CPAP
• 10/17/01: Back pain; severe restriction
TW’s Medical Course
• 7/13/04: Cortisone injection
• 9/3/04: Dysphagia; esophagram
• 8/4/06: Worsening dysphagia;
dyspnea; SLP referral
Anatomical Correlates
TW’s Medical Course
• 8/31/06: CT Cspine without
contrast
• 9/15/06:
Neurosurgery
referral
• 10/18/06:
Neurosurgery preop evaluation
Axial
TW’s Medical Course
• 8/31/06: CT Cspine without
contrast
• 9/15/06:
Neurosurgery
referral
• 10/18/06:
Neurosurgery preop evaluation
Axial
TW’s Medical Course
• 8/31/06: CT Cspine without
contrast
• 9/15/06:
Neurosurgery
referral
• 10/18/06:
Neurosurgery preop evaluation
Sagittal 3-D Reformat
TW’s Medical Course
• 8/31/06: CT Cspine without
contrast
• 9/15/06:
Neurosurgery
referral
• 10/18/06:
Neurosurgery preop evaluation
Sagittal 3-D Reformat
Anterior Osteophytectomy
Anterior Approach
Anterior Approach
TW’s Medical Course
• 10/24/06: Anterior
C2 to C5
osteophytectomy
• 10/24/06 Postoperative CT Cspine without
contrast
• 10/24/06: IP SLP
referral
Axial
TW’s Medical Course
• 10/24/06: Anterior
C2 to C5
osteophytectomy
• 10/24/06 Postoperative CT Cspine without
contrast
• 10/24/06: IP SLP
referral
Axial
TW’s Medical Course
• 10/24/06: Anterior
spinal
osteophytectomy
from C2 to C5
• 10/24/06 Postoperative CT Cspine without
contrast
• 10/24/06: SLP
referral for clinical
swallow evaluation
Sagittal 3-D Reformat
TW’s Medical Course
• 10/24/06: Anterior
spinal
osteophytectomy
from C2 to C5.
• 10/24/06 Postoperative CT Cspine without
contrast
• 10/24/06: SLP
referral for clinical
swallow evaluation
Sagittal 3-D Reformat
Sagittal 3-D Reformatted Image
Pre-op CT
Post-op CT
Post-Op Sagittal Image
Surgical Risk Factors
Sagittal 3-D Reformatted Images
Pre-op CT
Post-op CT
Mechanisms of Post-Op Dysphagia
TW’s Follow-Up
• 1/11/07: SLP clinic appointment
• 1/11/07: MPU for PEG tube removal
DISH Management Review
• Conservative
therapies:
– NSAIDS
– Steroids
– Anti-Reflux
Regimes
– Physical Therapy
– Diet Modifications
• Surgical
Intervention
Post-Operative Dysphagia Study
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Increasing age
Not level, instrumentation
47% AC initially
70% recovered by 2 months
23% dysphagia at 10 months
Smith-Hammmond, CA. Spine 2004; 29: 1441-6.
Post-Operative RLN Palsies
• Prospective,
laryngoscopy
• 24% early (16%
symptomatic)
• 11% late (2.5%
symptomatic)
Jung A et al. J Neurosurg Spine
2005; 2(2): 123-7
UMHS Study
• 2001-2006; 8M, 1F;
3 ACD, 4 DISH
• Mean 6 months
• 3/9 partial
resolution
• 5/9 complete
resolution
• Longest 2 years
Neurosurgery and Speech-Language Pathology
Collaboration
Speech-Language Pathologist=
Diagnostician=Paradigm Shift:
• Value of diagnostic skills
• Value of cervical-pharyngeal sweep
• Value of pre-operative dysphagia
counseling
• Value of collaborative team efforts
“for our triumphs are not in
research alone, nor in the
hands of a single doctor but
rather, in the rewards realized
from working together”
University of Michigan Hospitals and Health Centers