Effects of retractor application on cuff pressure and vocal cord function in patients undergoing anterior cervical discectomy and fusion

Garg, Rakesh; Rath, Girija Prasad; Bithal, Parmod K.; Prabhakar, Hemanshu; Marda, Manish

doi:10.4103/0019-5049.68370

Cited by 16 publications

(5 citation statements)

References 13 publications

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“…This retractor is placed between the carotic sheath laterally, and the trachea and esophagus medially. Previous studies showed that after positioning and opening the retractor, the endotracheal tube (ETT) cuff pressure increases significantly [ 1 , 2 ]. Structures trapped between the retractor and the endotracheal tube cuff, like the recurrent laryngeal nerve, may be compromised.…”

Section: Introductionmentioning

confidence: 99%

Maintaining endotracheal tube cuff pressure at 20 mm Hg to prevent dysphagia after anterior cervical spine surgery; protocol of a double-blind randomised controlled trial

Arts

Rettig

Vries

et al. 2013

BMC Musculoskelet Disord

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BackgroundIn anterior cervical spine surgery a retractor is obligatory to approach the spine. Previous studies showed an increase of endotracheal tube cuff pressure after placement of a retractor. It is known that high endotracheal tube cuff pressure increases the incidence of postoperative dysphagia, hoarseness, and sore throat. However, until now no evidence supports the fact whether adjusting the endotracheal tube cuff pressure during anterior cervical spine surgery will prevent this comorbidity. We present the design of a randomized controlled trial to determine whether adjusting endotracheal tube cuff pressure after placement of a retractor during anterior cervical spine surgery will prevent postoperative dysphagia.Methods/design177 patients (aged 18–90 years) scheduled for anterior cervical spine surgery on 1 or more levels will be included. After intubation, endotracheal tube cuff pressure is manually inflated to 20 mm Hg in all patients. Patients will be randomized into two groups. In the control group endotracheal tube cuff pressure is not adjusted after retractor placement. In the intervention group endotracheal tube cuff pressure after retractor placement is maintained at 20 mm Hg and air is withdrawn when cuff pressure exceeds 20 mm Hg. Endotracheal tube cuff pressure is measured after intubation, before and after placement and removal of the retractor. Again air is inflated if cuff pressure sets below 20 mmHg after removal of the retractor. The primary outcome measure is postoperative dysphagia. Other outcome measures are postoperative hoarseness, postoperative sore throat, degree of dysphagia, length of hospital stay, and pneumonia. The study is a single centre double blind randomized trial in which patients and research nurses will be kept blinded for the allocated treatment during the follow-up period of 2 months.DiscussionPostoperative dysphagia occurs frequently after anterior cervical spine surgery. This may be related to high endotracheal tube cuff pressure. Whether adaptation and maintaining the pressure after placement of the retractor will decrease the incidence of dysphagia, has to be determined by this trial.Trial registrationNetherlands Trial Register (NTR) 3542: http://www.trialregister.nl.

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Section: Introductionmentioning

confidence: 99%

Maintaining endotracheal tube cuff pressure at 20 mm Hg to prevent dysphagia after anterior cervical spine surgery; protocol of a double-blind randomised controlled trial

Arts

Rettig

Vries

et al. 2013

BMC Musculoskelet Disord

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“…This is particularly true for multilevel ACDF surgery. [13][14][15][16][17] To address the concerns associated with anterior plating, stand-alone interbody cage devices have been developed including low-profile or zero-profile constructs with integrated screws. This design has been shown to provide a similar degree of biomechanical stability conferred by anterior plating, while avoiding increased retraction and anterior bulk associated with plating.…”

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confidence: 99%

“…Furthermore, plate fixation requires additional manipulation and retraction of the tissue of the anterior neck and creates additional anterior “bulk,” thereby potentially increasing the risk of transient or long-term dysphagia, or dysphonia. This is particularly true for multilevel ACDF surgery 13–17…”

mentioning

confidence: 99%

Stand-Alone Cage Versus Anterior Plating for 1-Level and 2-Level Anterior Cervical Discectomy and Fusion

Zavras

Nolte

Sayari

et al. 2022

Clinical Spine Surgery: A Spine Publication

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Study Design: Prospective, randomized controlled trial. Objective: The aim was to compare perioperative and radiographic outcomes between stand-alone and anterior plated 1 and 2-level anterior cervical discectomy and fusion (ACDF). Summary of Background Data: ACDF with interbody spacer and separate plate/screw construct (PLATE) may be associated with a higher incidence of postoperative dysphagia, increased operative time, and other complications. Therefore, some have opted to utilize an interbody cage with integrated screws and no plate (CAGE) with good results. Materials and Methods: Patients with 1-level to 2-level degenerative disease were prospectively enrolled and randomized into 1 of 2 treatment arms consisting of either PLATE or CAGE reconstruction. Patients were followed for a minimum of 1 year postoperatively. Primary endpoints included improvement on patient-reported outcome metrics, construct integrity, cervical alignment, successful arthrodesis, and subsequent revision surgeries. Results: Forty-six patients were included: 12 with 1-level PLATE, 12 with 1-level CAGE, 12 with 2-level PLATE, and 10 with 2-level CAGE. For 1-level ACDF, PLATE patients reported worse swallow function on Swallowing Quality of Life Questionnaire at 6 weeks (P=0.050) and 6 months (P=0.042). Pseudarthrosis requiring revision was observed in one PLATE patient. For 2-level ACDF CAGE patients reported worse disability on neck disability index (P=0.037) at 6 weeks, as well as worse neck disability index (P=0.017) and visual analog scale neck (P=0.010) at 6 months. However, PLATE patients reported worse swallow function on Swallowing Quality of Life Questionnaire at 6 weeks (P=0.038). There were no differences in the rates of fusion, loss of disc height correction, subsidence, or in sagittal parameters between cohorts for both 1-level and 2-level ACDF. Conclusion: There was greater incidence of transient postoperative dysphagia in both single and 2-level PLATE cohorts. However, early postoperative outcomes were worse for 2-level CAGE in certain patient-reported metrics. This suggests that although anterior instrumentation may be associated with a higher likelihood of dysphagia, it may also lead to higher short-term stability and improved patient-reported outcomes for 2-level fusion.

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“…Significant increase in cuff pressure (168% of baseline values) and airway pressure of tracheal tube during cervical retraction in anterior cervical discectomy was observed by Garg et al . [ 7 ]…”

Section: Discussionmentioning

confidence: 99%

Bilateral vocal cord edema following anterior cervical discectomy-usefulness of bonfils retromolar fiberscope

Tripathy

Sivashanmugam

et al. 2014

Anesth Essays Res

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We present a case of a 40-year-old male patient who presented to us with radicular pain in arm for anterior cervical discectomy with fusion. The preanesthetic checkup including indirect laryngoscopy was normal with routine investigations within normal limits. The patient was induced and intubated with the established routine technique without any obvious airway problems. Prophylactic dexamethasone was administered, and the intraoperative course was uneventful. Immediately after extubation, it was noticed that the patient had inspiratory stridor and whispered voice on the operation theater table itself. Assessment by Bonfils retromolar fiberscope under fentanyl sedation revealed bilateral vocal cord edema. The patient was re intubated and put on T piece with humidified O2. After 72-h, patient was extubated after confirming normal vocal cord movement under flexible fiberscope guidance. This case is presented to alert anesthesiologist about the possibility of vocal cord edema even though other potential airway complications are possible. We would also highlight the importance of Bonfils retromolar fiberscope in awake vocal cord examination and flexible fiberscope use in managing patients presenting with airway problems during extubation.

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Effects of retractor application on cuff pressure and vocal cord function in patients undergoing anterior cervical discectomy and fusion

Cited by 16 publications

References 13 publications

Maintaining endotracheal tube cuff pressure at 20 mm Hg to prevent dysphagia after anterior cervical spine surgery; protocol of a double-blind randomised controlled trial

Maintaining endotracheal tube cuff pressure at 20 mm Hg to prevent dysphagia after anterior cervical spine surgery; protocol of a double-blind randomised controlled trial

Stand-Alone Cage Versus Anterior Plating for 1-Level and 2-Level Anterior Cervical Discectomy and Fusion

Bilateral vocal cord edema following anterior cervical discectomy-usefulness of bonfils retromolar fiberscope

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