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Dysphagia caused by cervical osteophytes: Three cases treated successfully by surgery
CASE REPORTS SERGE A. MARTINEZ, MD Case Report Editor
Dysphagia caused by cervical osteophytes: Three cases treated successfully by surgery RITU GOEL, MD, PRAKASH SAMPATH, MD, and DIRAN O. MIKAELIAN, MD, Philadelphia, Pennsylvania,
and Baltimore, Maryland
Degenerative disease of the cervical spine (so-called cervical spondylosis) is a relatively common disease, especially in elderly patients. Bony changes associated with this condition frequently occur on the posterior surface of the cervical vertebral body and often present with nerve root or spinal cord compression with resultant neurologic symptoms.1 Anterior osteophytes are also seen in many of these patients but are usually asymptomatic. Dysphagia and, less often, dysphonia caused by osteophytic spurring of the anterior cervical spine have been described sporadically in the otolaryngologic and neurosurgical literature,2-5 but the causal relationship between anterior cervical osteophytes and dysphagia has not been clearly established.6,7 Because the incidences of both dysphagia and cervical spondylosis increase with advancing age, the two may coexist, posing a diagnostic and therapeutic dilemma. In this article we present three cases of dysphagia in patients who underwent anterior cervical surgery with burring and resection of the osteophytes. Conservative treatment had failed in all patients, and all had clear radiographic evidence of compressive disease. We focus on the diagnosis and management of patients with dysphagia caused by cervical osteophytes and the indications for surgical treatment. We also briefly describe the surgical technique.
From the Department of Otolaryngology–Head and Neck Surgery (Drs. Goel and Mikaelian), Thomas Jefferson University; and the Department of Neurological Surgery (Dr. Sampath), Johns Hopkins School of Medicine. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, D.C., Sept. 29–Oct. 2, 1996. Reprint requests: Ritu Goel, MD, Department of Otolaryngology– Head and Neck Surgery, 909 Walnut St., Thomas Jefferson University, Philadelphia, PA 19107. Otolaryngol Head Neck Surg 1999;120:92-6. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/4/82444 92
CASE REPORTS Case 1. A 61-year-old man had a several-year history of increasing difficulty swallowing with spasm regurgitation and odynophagia. The patient had a 20 lb weight loss during the same period. Findings during physical examination of the ear, nose, and throat revealed prominence of the sublingual soft tissues and decreased neck mobility. Barium swallow demonstrated marked posterior impression on the cervical esophagus from C4 through C7 (Fig. 1A). A plain lateral radiograph (Fig. 1B) revealed extensive anterior osteophytosis consistent with diffuse idiopathic skeletal hyperostosis (DISH). CT scan of the cervical spine showed large anterior cervical osteophytes from C4 through T1 causing displacement of the anterior laryngeal and tracheal structures toward the right. This was most prominent from C4 through C6 (Fig. 1C). No other nonskeletal pathologic condition was noted. The patient’s symptoms progressed with conservative treatment. He underwent removal of the offending cervical osteophytes and burring of cervical prominences until the spine was flush with the surrounding tissue through an anterior approach. Four years after surgery he has no dysphagia and has improved neck mobility. Case 2. A 76-year-old man had symptoms of progressive dysphagia and aspiration for 2 years in association with axial neck pain. He noted greater discomfort with solids. He has been in good general health with no weight loss. Findings during physical examination of the ear, nose, and throat were normal, and fiberoptic examination of the larynx revealed normal findings. Barium swallow was performed (Fig. 2A), which demonstrated compression of the esophagus at the level of C4-C5, along with aspiration. CT of the neck (Fig. 2B) confirmed a large cervical osteophyte at the corresponding level. The patient was taken to surgery after conservative treatment failed. He underwent an anterior approach for removal of the C4-C5 osteophyte. His postoperative course was unremarkable, and his dysphagia resolved completely. Case 3. A 79-year-old man had a 1-year history of dysphagia, increasing episodes of coughing, and left-sided neck
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A
B
C Fig. 1. A, Barium swallow with marked cervical compression. B, Scout film: Lateral radiograph depicting soft tissue displacement and spondylitic disease. C, Coronal CT scan with prominent C4 osteophyte.
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B
A
pain. He also had a history of Bell’s palsy and well-controlled asthma. Physical examination was remarkable for only decreased range of motion in the cervical spine. Barium swallow demonstrated marked impression on the cervical esophagus by a large osteophyte at the C4-C5 level with distortion of the hypopharynx, laryngeal penetration, and trace aspiration (Fig. 3A). A CT scan confirmed a single large osteophyte at C4-C5 (Fig. 3B). The patient underwent resection of the large osteophyte through an anterior approach. After surgery the patient’s symptoms immediately resolved. A postoperative lateral cervical radiograph demonstrated a marked reduction of extrinsic impression on the esophagus (Fig. 3C). DISCUSSION Dysphagia caused by mechanical obstruction from anterior cervical osteophytes has been described by numerous authors, but the relationship is poorly established.3-7 Some authors believe dysphagia in a patient with cervical osteophytic disease is a purely incidental finding.8,9 Others believe that because the esophagus begins at C6, it is impossible to establish a cause-and-effect relationship between dysphagia and cervical osteophytes above this level.10 Because both dysphagia and cervical osteophytic disease increase with advancing age, the two may coexist, posing a diagnostic and therapeutic dilemma. The challenge remains to find patients who clearly have dysphagia caused by mechanical obstruction from cervical osteophytes so that appropriate treatment can be instituted. The causes of dysphagia are quite varied (Table 1):
Fig. 2. A, Barium swallow depicting aspiration caused by obstruction by the cervical osteophyte located at C4. B, CT scan demonstrating a large C4 osteophyte.
Table 1. Causes of dysphagia Caustic strictures Esophagitis Cardiospasm Esophageal motility disorders (e.g., achalasia) Esophageal diverticula (e.g., Zenker’s, traction, epiphrenic) Aberrant vessel Plummer-Vinson syndrome Tumors (benign and malignant) Of esophagus Of larynx Of mediastinum Of vertebral body Cervical spine disease Trauma Congenital bony bars Anterior herniated calcified intervertebral disk Forestier’s disease (DISH) Anterior cervical osteophytes?
benign and malignant tumors, caustic strictures, esophageal motility disorders (achalasia, scleroderma), diverticular diseases (Zenker’s, epiphrenic), esophagitis, aberrant vessels, Plummer-Vinson syndrome, and cervical spine diseases.2,8,11 Dysphagia caused by cervical spine disorders has also been described, with cervical spine trauma,12 vertebral tumors, ankylosing hyperostosis (Forestier’s disease),11,13,14 and anterior protrusion of calcified cervical disks being the most common causes.5 Although most patients previously described with this disease have diffuse idiopathic skeletal hyperostosis (e.g., patient 1),11,13,14 in our experience this disease can occur even with a single large anterior osteophyte (e.g., patient 3).
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B
A
D
Fig. 3. A, Barium swallow with a large C4-C5 osteophyte with distortion of the hypopharynx. B, CT scan depicting cortex of the spur at C4. Preoperative (C) and postoperative (D) lateral neck films showing difference after surgery.
C
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Before definitively establishing the diagnosis of dysphagia caused by cervical spondylitic disease, it is very important to exclude other more common causes of dysphagia. All patients should have a thorough diagnostic workup including an otolaryngologic examination, barium swallow, and indirect or flexible laryngoscopy. When extraluminal compression of the esophagus is noted on cineesophagogram, plain lateral radiographs of the cervical spine should be obtained. In addition, CT scanning can show more accurate detail of the threedimensional relationship between the esophagus and the anterior cervical spine. Esophagoscopy should be used with great caution in these patients because posterior pharyngoesophageal wall thinning increases the risk of perforation. Before any intervention is considered in patients with dysphagia and anterior cervical osteophytes, three criteria must be fulfilled: (1) all other causes of dysphagia must be excluded, (2) there must be clear radiographic evidence of extrinsic esophageal compression with coexisting anterior cervical osteophytic disease, and (3) a reasonable course of conservative treatment should have failed. All the patients in this study had undergone a course of conservative treatment consisting of a soft mechanical diet and antiinflammatory drugs without resolution of their symptoms before surgical intervention was considered. Surgery was performed through a standard anterolateral extrapharyngeal approach as previously described.15,16 A transverse incision was made preferentially on the left side to decrease recurrent laryngeal nerve injury. Sharp dissection deep to the medial border of the sternocleidomastoid muscle exposes the prevertebral fascia in a relatively avascular fashion. The carotid sheath should be retracted laterally. Identification of the longus coli muscle on each side of the vertebra helps to identify the midline structures. Great care should be taken to avoid inadvertent injury to the esophagus, which can be inflamed and sometimes displaced. The osteophytes can then be removed with a drill or rongeurs. A neurosurgeon should be available in the event that removal of the osteophyte uncovers a herniated disk giving way to an unstable cervical spine. In this case, as in patients with DISH, it may be necessary to perform a cervical fusion with autologous bone graft.4,9,11,17 This is especially true in younger patients and in patients in whom multiple levels are involved because it may prevent recurrence of cervical spondylitic disease or cervical instability.1,17
CONCLUSION The relationship between dysphagia and cervical osteophytic disease is difficult to both diagnose and treat. It should be considered when all other causes of dysphagia are excluded and there is clear radiographic evidence of extrinsic esophageal compression. These patients should be considered for surgery only after a course of conservative treatment has failed. Surgery can be a safe and highly effective treatment in appropriately selected patients. REFERENCES 1. Clark CR. Degenerative conditions of the spine: differential diagnosis and non-surgical treatment. In: Frymoyer JW, editor. The adult spine. New York: Raven Press; 1991. p. 1145-65. 2. Bauer F. Dysphagia due to cervical spondylosis. J Laryngol Otol 1953;67:615-30. 3. Gohel VK, Karasick K, Canino C. Cervical spondylotic dysphagia. JAMA 1976;235:935-6. 4. Brandenberg G, Leibrock LG. Dysphagia and dysphonia secondary to anterior cervical osteophytes. Neurosurgery 1986;18: 90-3. 5. Stuart D. Dysphagia due to cervical osteophytes. Int Orthop 1989;13:95-9. 6. Parker MD. Dysphagia due to cervical osteophytes: a controversial entity revisited. Dysphagia 1989;3:157-60. 7. Weinshel SS, Maiman DJ, Mueller WM. Dysphagia associated with cervical spine disorders: pathologic relationship? J Spinal Disord 1989;1:312-6. 8. Saunders WH. Cervical osteophytes and dysphagia. Ann Otol Rhinol Laryngol 1970;79:1091-7. 9. Hirano H, Suzuki H, Sakakiara T, et al. Dysphagia due to hypertrophic cervical osteophytes. Clin Orthop 1982;167:168-72. 10. Lambert JR, Tepperman PS, Jimenez J, Newman A. Cervical spine disease and dysphagia. Am J Gastroenterol 1981;76:3540. 11. McCafferty RR, Harrison MJ, Tamas LB, et al. Ossification of the anterior longitudinal ligament and Forestier’s disease: an analysis of seven cases. J Neurosurg 1995;83:13-7. 12. Kissel P, Youmans JR. Posttraumatic anterior cervical osteophyte and dysphagia: surgical report and review of the literature. J Spinal Disord 1992;5:104-7. 13. Resnick D, Shapiro RF, Wiesner KB, et al. Diffuse idiopathic skeletal hyperostosis (DISH) (ankylosing hyperostosis of Forestier and Rotes-Querol). Semin Arthritis Rheum 1978;7: 153-87. 14. Kmucha ST, Cravens RB. DISH syndrome and its role in dysphagia. Otolaryngol Head Neck Surg 1994;110:431-6. 15. Saffouri MH, Ward PH. Surgical correction of dysphagia due to cervical osteophytes. Ann Otol Rhinol Laryngol 1974;83:65-70. 16. Sobol SM, Rigual NR. Anterolateral extrapharyngeal approach for cervical osteophyte-induced dysphagia. Ann Otol Rhinol Laryngol 1984;93:498-504. 17. Whitecloud TS III. Cervical spondylosis: the anterior approach. In: Frymoyer JW, editor. The adult spine. New York: Raven Press; 1991. p. 1165-87.
Dysphagia caused by cervical osteophytes: Three cases treated successfully by surgery RITU GOEL, MD, PRAKASH SAMPATH, MD, and DIRAN O. MIKAELIAN, MD, Philadelphia, Pennsylvania,
and Baltimore, Maryland
Degenerative disease of the cervical spine (so-called cervical spondylosis) is a relatively common disease, especially in elderly patients. Bony changes associated with this condition frequently occur on the posterior surface of the cervical vertebral body and often present with nerve root or spinal cord compression with resultant neurologic symptoms.1 Anterior osteophytes are also seen in many of these patients but are usually asymptomatic. Dysphagia and, less often, dysphonia caused by osteophytic spurring of the anterior cervical spine have been described sporadically in the otolaryngologic and neurosurgical literature,2-5 but the causal relationship between anterior cervical osteophytes and dysphagia has not been clearly established.6,7 Because the incidences of both dysphagia and cervical spondylosis increase with advancing age, the two may coexist, posing a diagnostic and therapeutic dilemma. In this article we present three cases of dysphagia in patients who underwent anterior cervical surgery with burring and resection of the osteophytes. Conservative treatment had failed in all patients, and all had clear radiographic evidence of compressive disease. We focus on the diagnosis and management of patients with dysphagia caused by cervical osteophytes and the indications for surgical treatment. We also briefly describe the surgical technique.
From the Department of Otolaryngology–Head and Neck Surgery (Drs. Goel and Mikaelian), Thomas Jefferson University; and the Department of Neurological Surgery (Dr. Sampath), Johns Hopkins School of Medicine. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, D.C., Sept. 29–Oct. 2, 1996. Reprint requests: Ritu Goel, MD, Department of Otolaryngology– Head and Neck Surgery, 909 Walnut St., Thomas Jefferson University, Philadelphia, PA 19107. Otolaryngol Head Neck Surg 1999;120:92-6. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/4/82444 92
CASE REPORTS Case 1. A 61-year-old man had a several-year history of increasing difficulty swallowing with spasm regurgitation and odynophagia. The patient had a 20 lb weight loss during the same period. Findings during physical examination of the ear, nose, and throat revealed prominence of the sublingual soft tissues and decreased neck mobility. Barium swallow demonstrated marked posterior impression on the cervical esophagus from C4 through C7 (Fig. 1A). A plain lateral radiograph (Fig. 1B) revealed extensive anterior osteophytosis consistent with diffuse idiopathic skeletal hyperostosis (DISH). CT scan of the cervical spine showed large anterior cervical osteophytes from C4 through T1 causing displacement of the anterior laryngeal and tracheal structures toward the right. This was most prominent from C4 through C6 (Fig. 1C). No other nonskeletal pathologic condition was noted. The patient’s symptoms progressed with conservative treatment. He underwent removal of the offending cervical osteophytes and burring of cervical prominences until the spine was flush with the surrounding tissue through an anterior approach. Four years after surgery he has no dysphagia and has improved neck mobility. Case 2. A 76-year-old man had symptoms of progressive dysphagia and aspiration for 2 years in association with axial neck pain. He noted greater discomfort with solids. He has been in good general health with no weight loss. Findings during physical examination of the ear, nose, and throat were normal, and fiberoptic examination of the larynx revealed normal findings. Barium swallow was performed (Fig. 2A), which demonstrated compression of the esophagus at the level of C4-C5, along with aspiration. CT of the neck (Fig. 2B) confirmed a large cervical osteophyte at the corresponding level. The patient was taken to surgery after conservative treatment failed. He underwent an anterior approach for removal of the C4-C5 osteophyte. His postoperative course was unremarkable, and his dysphagia resolved completely. Case 3. A 79-year-old man had a 1-year history of dysphagia, increasing episodes of coughing, and left-sided neck
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A
B
C Fig. 1. A, Barium swallow with marked cervical compression. B, Scout film: Lateral radiograph depicting soft tissue displacement and spondylitic disease. C, Coronal CT scan with prominent C4 osteophyte.
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A
pain. He also had a history of Bell’s palsy and well-controlled asthma. Physical examination was remarkable for only decreased range of motion in the cervical spine. Barium swallow demonstrated marked impression on the cervical esophagus by a large osteophyte at the C4-C5 level with distortion of the hypopharynx, laryngeal penetration, and trace aspiration (Fig. 3A). A CT scan confirmed a single large osteophyte at C4-C5 (Fig. 3B). The patient underwent resection of the large osteophyte through an anterior approach. After surgery the patient’s symptoms immediately resolved. A postoperative lateral cervical radiograph demonstrated a marked reduction of extrinsic impression on the esophagus (Fig. 3C). DISCUSSION Dysphagia caused by mechanical obstruction from anterior cervical osteophytes has been described by numerous authors, but the relationship is poorly established.3-7 Some authors believe dysphagia in a patient with cervical osteophytic disease is a purely incidental finding.8,9 Others believe that because the esophagus begins at C6, it is impossible to establish a cause-and-effect relationship between dysphagia and cervical osteophytes above this level.10 Because both dysphagia and cervical osteophytic disease increase with advancing age, the two may coexist, posing a diagnostic and therapeutic dilemma. The challenge remains to find patients who clearly have dysphagia caused by mechanical obstruction from cervical osteophytes so that appropriate treatment can be instituted. The causes of dysphagia are quite varied (Table 1):
Fig. 2. A, Barium swallow depicting aspiration caused by obstruction by the cervical osteophyte located at C4. B, CT scan demonstrating a large C4 osteophyte.
Table 1. Causes of dysphagia Caustic strictures Esophagitis Cardiospasm Esophageal motility disorders (e.g., achalasia) Esophageal diverticula (e.g., Zenker’s, traction, epiphrenic) Aberrant vessel Plummer-Vinson syndrome Tumors (benign and malignant) Of esophagus Of larynx Of mediastinum Of vertebral body Cervical spine disease Trauma Congenital bony bars Anterior herniated calcified intervertebral disk Forestier’s disease (DISH) Anterior cervical osteophytes?
benign and malignant tumors, caustic strictures, esophageal motility disorders (achalasia, scleroderma), diverticular diseases (Zenker’s, epiphrenic), esophagitis, aberrant vessels, Plummer-Vinson syndrome, and cervical spine diseases.2,8,11 Dysphagia caused by cervical spine disorders has also been described, with cervical spine trauma,12 vertebral tumors, ankylosing hyperostosis (Forestier’s disease),11,13,14 and anterior protrusion of calcified cervical disks being the most common causes.5 Although most patients previously described with this disease have diffuse idiopathic skeletal hyperostosis (e.g., patient 1),11,13,14 in our experience this disease can occur even with a single large anterior osteophyte (e.g., patient 3).
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B
A
D
Fig. 3. A, Barium swallow with a large C4-C5 osteophyte with distortion of the hypopharynx. B, CT scan depicting cortex of the spur at C4. Preoperative (C) and postoperative (D) lateral neck films showing difference after surgery.
C
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Before definitively establishing the diagnosis of dysphagia caused by cervical spondylitic disease, it is very important to exclude other more common causes of dysphagia. All patients should have a thorough diagnostic workup including an otolaryngologic examination, barium swallow, and indirect or flexible laryngoscopy. When extraluminal compression of the esophagus is noted on cineesophagogram, plain lateral radiographs of the cervical spine should be obtained. In addition, CT scanning can show more accurate detail of the threedimensional relationship between the esophagus and the anterior cervical spine. Esophagoscopy should be used with great caution in these patients because posterior pharyngoesophageal wall thinning increases the risk of perforation. Before any intervention is considered in patients with dysphagia and anterior cervical osteophytes, three criteria must be fulfilled: (1) all other causes of dysphagia must be excluded, (2) there must be clear radiographic evidence of extrinsic esophageal compression with coexisting anterior cervical osteophytic disease, and (3) a reasonable course of conservative treatment should have failed. All the patients in this study had undergone a course of conservative treatment consisting of a soft mechanical diet and antiinflammatory drugs without resolution of their symptoms before surgical intervention was considered. Surgery was performed through a standard anterolateral extrapharyngeal approach as previously described.15,16 A transverse incision was made preferentially on the left side to decrease recurrent laryngeal nerve injury. Sharp dissection deep to the medial border of the sternocleidomastoid muscle exposes the prevertebral fascia in a relatively avascular fashion. The carotid sheath should be retracted laterally. Identification of the longus coli muscle on each side of the vertebra helps to identify the midline structures. Great care should be taken to avoid inadvertent injury to the esophagus, which can be inflamed and sometimes displaced. The osteophytes can then be removed with a drill or rongeurs. A neurosurgeon should be available in the event that removal of the osteophyte uncovers a herniated disk giving way to an unstable cervical spine. In this case, as in patients with DISH, it may be necessary to perform a cervical fusion with autologous bone graft.4,9,11,17 This is especially true in younger patients and in patients in whom multiple levels are involved because it may prevent recurrence of cervical spondylitic disease or cervical instability.1,17
CONCLUSION The relationship between dysphagia and cervical osteophytic disease is difficult to both diagnose and treat. It should be considered when all other causes of dysphagia are excluded and there is clear radiographic evidence of extrinsic esophageal compression. These patients should be considered for surgery only after a course of conservative treatment has failed. Surgery can be a safe and highly effective treatment in appropriately selected patients. REFERENCES 1. Clark CR. Degenerative conditions of the spine: differential diagnosis and non-surgical treatment. In: Frymoyer JW, editor. The adult spine. New York: Raven Press; 1991. p. 1145-65. 2. Bauer F. Dysphagia due to cervical spondylosis. J Laryngol Otol 1953;67:615-30. 3. Gohel VK, Karasick K, Canino C. Cervical spondylotic dysphagia. JAMA 1976;235:935-6. 4. Brandenberg G, Leibrock LG. Dysphagia and dysphonia secondary to anterior cervical osteophytes. Neurosurgery 1986;18: 90-3. 5. Stuart D. Dysphagia due to cervical osteophytes. Int Orthop 1989;13:95-9. 6. Parker MD. Dysphagia due to cervical osteophytes: a controversial entity revisited. Dysphagia 1989;3:157-60. 7. Weinshel SS, Maiman DJ, Mueller WM. Dysphagia associated with cervical spine disorders: pathologic relationship? J Spinal Disord 1989;1:312-6. 8. Saunders WH. Cervical osteophytes and dysphagia. Ann Otol Rhinol Laryngol 1970;79:1091-7. 9. Hirano H, Suzuki H, Sakakiara T, et al. Dysphagia due to hypertrophic cervical osteophytes. Clin Orthop 1982;167:168-72. 10. Lambert JR, Tepperman PS, Jimenez J, Newman A. Cervical spine disease and dysphagia. Am J Gastroenterol 1981;76:3540. 11. McCafferty RR, Harrison MJ, Tamas LB, et al. Ossification of the anterior longitudinal ligament and Forestier’s disease: an analysis of seven cases. J Neurosurg 1995;83:13-7. 12. Kissel P, Youmans JR. Posttraumatic anterior cervical osteophyte and dysphagia: surgical report and review of the literature. J Spinal Disord 1992;5:104-7. 13. Resnick D, Shapiro RF, Wiesner KB, et al. Diffuse idiopathic skeletal hyperostosis (DISH) (ankylosing hyperostosis of Forestier and Rotes-Querol). Semin Arthritis Rheum 1978;7: 153-87. 14. Kmucha ST, Cravens RB. DISH syndrome and its role in dysphagia. Otolaryngol Head Neck Surg 1994;110:431-6. 15. Saffouri MH, Ward PH. Surgical correction of dysphagia due to cervical osteophytes. Ann Otol Rhinol Laryngol 1974;83:65-70. 16. Sobol SM, Rigual NR. Anterolateral extrapharyngeal approach for cervical osteophyte-induced dysphagia. Ann Otol Rhinol Laryngol 1984;93:498-504. 17. Whitecloud TS III. Cervical spondylosis: the anterior approach. In: Frymoyer JW, editor. The adult spine. New York: Raven Press; 1991. p. 1165-87.