Outcomes of Open Osteophytectomy in Dysphagia Related to Cervical Osteophytes: A Systematic Review

Abstract

Objective:

This study investigates the efficacy of open osteophytectomy in patients with dysphagia associated with cervical osteophytes, stratified by C-spine level and presence of diffuse idiopathic skeletal hyperostosis (DISH).

Data Sources:

PubMed and ScienceDirect.

Review Methods:

We conducted a systematic review of published literature pertaining to osteophyte-related dysphagia. Patients with objective measurements of dysphagia severity who underwent an open surgical approach for osteophytectomy were included. Demographics, symptomatology, and patient outcomes were analyzed.

Results:

A total of 44 articles with 214 cases (mean age = 67, 85% male) were included. Outcomes after osteophytectomy were analyzed in DISH vs non-DISH groups, as well as stratified by demographics and cervical levels affected. Patients with osteophytes at or above C4 were more likely to demonstrate pre-operative aspiration (P = .018). Short- and long-term outcomes among patients with DISH and non-DISH osteophytes were similar (P = .269 and .476). Outcomes among patients with osteophytes at or above C4, at or below C4, and diffuse presentations were also similar. Among all cases, 84% of patients experienced significant short-term initial improvement in their dysphagia. At long-term follow-up, 82% of patients had continued significant improvement in their dysphagia outcome.

Conclusion:

Open surgical approaches for osteophytectomy demonstrate good short- and long-term efficacy. Patients with osteophytes at or above C4 were more likely to aspirate pre-operatively, but osteophyte level, age, sex, and presence of DISH did not impact likelihood of operative success.

Keywords

dysphagia osteophytectomy aspiration

Introduction

Osteophytes of the anterior cervical vertebrae are a common finding in the general population, affecting approximately 20% to 30% of elderly patients.¹ Although cervical osteophytes are typically asymptomatic, they may be an etiology of dysphagia in symptomatic patients. Prior studies have reported that 1% to 10% of patients presenting with dysphagia were diagnosed with an anterior cervical osteophyte.^2,3

Common causes of cervical osteophytes include osteoarthritis, ankylosing spondylitis, and diffuse idiopathic skeletal hyperostosis (DISH).^4-6 Specifically, a diagnosis of DISH requires osteophyte involvement over at least 4 contiguous vertebrae.⁷ The prevalence of DISH reported in the literature ranges from 3.8%-25%, where the degree of uncertainty is attributed to the incomplete diagnosis of DISH using X-ray alone in some studies.⁸ Treatment of osteophyte-related dysphagia can be approached conservatively or surgically, the former of which consists of anti-inflammatory medications, muscle relaxants, speech therapy, and dietary changes. In patients who fail conservative therapy, osteophytectomy is considered to be an effective treatment modality for osteophyte-related dysphagia.⁹

Prior systematic reviews have assessed different treatment modalities for patients with osteophyte-related dysphagia, specifically in the setting of DISH.^10,11 Cherfane et al¹⁰ analyzed 236 patients with DISH and found no significant difference in surgical versus conservative treatment. However, no prior studies have evaluated the impact of patient factors such as age, sex, and osteophyte location on outcomes following surgical treatment of osteophyte-related dysphagia.

Different mechanisms for dysphagia have been proposed by vertebral level. Osteophytes at C3 to C4 have been shown to impair epiglottic retroflexion, causing increased aspiration,¹² whereas osteophytes at C5 to C6 have been shown to reduce upper esophageal sphincter opening.¹³ The diffuse vertebral involvement of DISH could lead to dysphagia through both mechanisms. The aim of this systematic review is to characterize postoperative outcomes after open osteophytectomy in patients with dysphagia caused by anterior cervical osteophytes when compared across different patient demographics and osteophyte characteristics. With an improved understanding of how osteophyte location and the presence of DISH affect outcomes after osteophytectomy, physicians will be able to better individualize management, assess patient candidacy for osteophytectomy, and inform patients on outcomes.

Methods

Search Strategy

The reporting guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed for this systematic review.¹⁴ This review was exempt from Rutgers Institutional Review Board approval. PubMed and ScienceDirect databases were searched from inception to 2024. The search terms used were as follows: osteophyte AND (dysphagia OR (trouble swallowing) OR (difficulty swallowing)).

Study Selection

Two reviewers (R.M. and H.K.) independently screened all full-text articles identified by the online database search. Rayyan, a systematic review collaboration platform, was used to facilitate unbiased review of records.¹⁵ Articles that contained a diagnosis of osteophyte-induced dysphagia, managed with open osteophytectomy, with an objective measure of both preoperative and postoperative dysphagia (eg, swallow study) were included. Animal studies, articles unrelated to the topic of the study, articles without original data, and articles with restricted access were excluded (Figure 1). Any conflict between the reviewers’ evaluations was resolved through discussion among the reviewers and the senior author until a consensus was reached. Each article included was subjected to a bias assessment as described by the Agency for Healthcare Research and Quality (AHRQ).¹⁶ The AHRQ bias assessment evaluates the following forms of bias: selection, performance, attrition, detection, and reporting.

Data Extraction and Analysis

Patient demographics, presenting symptoms, objective measures of dysphagia, treatment, complications, and outcomes were extracted. Pre- and post-operative objective measures of dysphagia included swallow studies, endoscopic evaluations, and established swallow function scales. Swallow studies included barium swallow studies, modified barium swallow studies, and fiberoptic endoscopic evaluation of swallowing (FEES). Endoscopies included laryngoscopy, esophagoscopy, and video laryngeal stroboscopy (VLS); dysphagia scoring systems included the functional outcome swallowing scale (FOSS),¹⁷ functional oral intake scale (FOIS),¹⁸ and eating assessment tool (EAT-10).¹⁹ Some patients were evaluated with multiple modalities.

Postoperative outcomes were defined according to patient-reported progression or resolution of symptoms, with corroboration by described objective studies. Symptom improvement was categorized as significant, mild, none, worse, or recurrent. Objective descriptors were not used because of variable reporting across studies. Patients categorized as significant improvement based on swallow studies showed smoother bolus passage, decreased transit time, and/or less residue retained. For patients with aspiration seen on pre-operative swallow evaluation, improvement was considered significant if the post-operative swallow study demonstrated that aspiration was eliminated or significantly improved with a tolerated diet advancement. Other post-operative measures of significant improvement were patient weaning from gastrostomy tube, weight gain, and diet advancement. FOIS scores were considered significant if they improved to a 7/7, which represents a regular diet and no oral restrictions. FOSS score improvement was considered significant if the FOSS score improved to 0, representing normal function. If FOIS or FOSS scores only partially improved or did not improve, patients were categorized as having mild improvement or no improvement, respectively. EAT-10 scores were considered mild (score of 3-9), moderate (score of 10-19), severe (score of 20-29), and very severe (score of 30-40). Significant improvement in EAT-10 was based on the score improving to the 3 to 9 score category, whereas lesser improvement was categorized as mild improvement. Postoperative endoscopic evaluation was considered significant if a pre-operative mass lesion at the pharyngeal wall disappeared, widening the pharyngeal space. A patient was categorized as having worsened symptoms if any post-operative measure was recorded as worse than the pre-operative measure. Patients were categorized as having recurrent symptoms at long-term follow-up if their symptoms initially improved post-operatively but returned during the follow-up period. Two reviewers (RM and HK) independently judged post-operative outcomes for each patient, and any conflicts were resolved by a third reviewer (JC).

Patients with osteophytes were categorized by the range affected: at or above C4 only, at or below C4 only, or diffuse involvement, defined as osteophytes present both above and below C4. For example, a patient with osteophytes at levels C2 to C4 was categorized in the at or above C4 only group, a patient with osteophytes at levels C4 to C5 was categorized in the at or below C4 group, and a patient with osteophytes at levels C2 to C5 was categorized in the diffuse group. If osteophytes were most prominent at a level and confirmed by obstructive symptoms on swallow evaluation, that level was used to categorize appropriately. Patients were separately grouped by meeting DISH criteria, with >3 contiguous levels classified as DISH and ≤3 contiguous levels as non-DISH. When absent from the text or tables, levels were identified using images, if provided, to determine osteophyte(s) location. Categorical variable comparisons were performed with chi-square analysis; for samples less than or equal to 5, Fisher’s Exact Test was performed. Continuous variable comparisons were performed with t-test and ANOVA analyses for 2 and 3 groups, respectively. Kaplan-Meier curves were generated to compare postoperative outcomes across the follow-up period in different groups. Figures 3 and 4 represent the length of time that patients were dysphagia-free after osteophytectomy, based on descriptions of timing of dysphagia recurrence across the follow-up period. Whether the patient met DISH criteria, the vertebral levels affected, and the presence of post-operative symptoms were obtained from the respective articles. All statistical tests were 2-tailed and performed at the 5% significance threshold. The statistical analysis was performed using IBM SPSS Statistics for Windows Version 25.0 (IBM Corp., Armonk, NY).

Results

Article Extraction

Of 1150 unique articles initially identified, 44 were ultimately included (Figure 1).^20-63 Included articles presented original findings pertaining to osteophyte-induced dysphagia diagnosis, treatment, and outcomes. All 44 articles were included based on the results of the bias assessment (Supplemental Table 1).

Patient Characteristics

Among the 44 studies, 214 patients (85% males, 15% females) were included (Supplemental Table 2). The mean age was 67. The most common presenting symptoms were dysphagia (n = 214, 100%), dysphonia (n = 34, 16%), neck pain (n = 27, 13%), and dyspnea (n = 26, 12%). Others included reduced neck range of motion (n = 16, 8%), weight loss (n = 12, 6%), subjective aspiration (n = 7, 3%), globus sensation (n = 8, 4%), and odynophagia (n = 6, 3%).

Patient Management

Objective pre- and post-operative dysphagia measurements were completed on all patients. Swallow studies were most used to measure pre-operative dysphagia (n = 142, 66%), followed by dysphagia scoring systems (n = 110, 51%), and endoscopy (n = 49, 23%). Dysphagia scoring systems were most used to measure post-operative dysphagia (n = 124, 58%), followed by swallow studies (n = 87, 41%), diet changes (n = 38, 18%), and endoscopy (n = 6, 3%).

Osteophyte levels were reported in 175/214 (82%) patients. The most common osteophyte levels among these patients were C4 (n = 139, 79%), C5 (n = 135, 77%), and C3 (n = 108, 62%) (Figure 2). Patients were grouped according to the range of osteophytes affected: involvement at or above C4 only (n = 32, 18%), involvement at or below C4 only (n = 70, 40%), or diffuse involvement (n = 73, 42%). All patients (n = 214, 100%) underwent an open osteophytectomy via an anterior or anterolateral transcervical approach.⁶⁴ Post-operative complications were recorded. 185/214 (86%) patients experienced no complications. Major complications included dysphagia requiring a feeding tube (n = 5, 2%), reoperation for hematoma evacuation or hemorrhage (n = 5, 2%), aspiration pneumonia (n = 3, 1%), tracheostomy (n = 3, 1%), and esophageal injury (n = 2, 1%). Minor complications included self-resolving dysphagia (n = 10, 5%), dysphonia (n = 6, 3%), and hematoma not requiring surgical intervention (n = 1, <1%). Other complications included CVA (n = 1, <1%), central cord syndrome (n = 1, <1%), vocal cord paralysis (n = 2, 1%), jugular vein thrombosis (n = 1, <1%), bacteremia (n = 1, <1%), prevertebral swelling (n = 1, <1%), and pulmonary embolism (n = 1, <1%). Analysis of complication rates at different osteophyte levels was not performed given the low complication rate.

Overall Patient Outcomes

We classified outcomes as short-term (<6 weeks) or long-term (average 34 months, range 1.5 months-13 years) from osteophytectomy. 175/214 (82%) patients had documented short-term outcomes. Of these patients, most experienced significant improvement in their pre-operative symptoms (n = 147, 84%), while some experienced mild improvement (n = 14, 8%), no improvement (n = 10, 6%), or worsened symptoms (n = 4, 2%). 176/214 (82%) patients had documented long-term outcomes. Of these patients, most experienced significant improvement of symptoms (n = 144, 82%), while some experienced mild improvement (n = 18, 10%), no improvement (n = 5, 3%), worsened symptoms (n = 1, 1%), or recurrence in symptoms (n = 8, 5%).

Of the studies that discussed the results of the patients’ swallow studies, 29 patients had aspiration visualized. Five patients had aspiration pneumonia. In the short-term, 20 of 27 (74%) patients with initial aspiration with recorded outcomes experienced total resolution of symptoms. Similar long-term outcomes (average follow-up time: 35 months) were seen with 18 of 24 (75%) patients experiencing continued total resolution. When compared to patients without objective aspiration, this finding was not statistically significant (P = .135 and .360, respectively).

Patient Characteristics and Outcomes by Presence of DISH

A subset analysis was performed to compare demographics, management, and outcomes of DISH (n = 87) versus non-DISH (n = 79) patients (Table 1). Dysphonia was the only symptom experienced significantly more in the DISH group (P = .007; Table 1). Short-term and long-term dysphagia resolution were similar between the groups (85% vs. 91%, P = .269; 79% vs. 74%, 0.476, respectively). Dysphagia-free survival was similar between the groups for the reported follow-up period (P = .523) (Figure 3).

Table 1.

Pre and Postoperative Characteristics of Patients With Osteophyte-Induced Dysphagia, Stratified by DISH (>3 Contiguous Levels Affected) and Non-DISH (≤3 Contiguous Levels Affected) Patients.

	DISH	Non-DISH	P-values
Total, n	80	71
Age, mean ± SD	68 ± 10	66 ± 10	.222
Sex
Male, n (%)	71 (89)	56 (79)	.098
Total, n	87	79
Presenting symptoms
Dysphagia	87 (100)	79 (100)	1.000
Neck pain	13 (15)	13 (16)	.789
Dysphonia	19 (22)	5 (6)	.007
Dyspnea	14 (16)	8 (10)	.258
Reduced neck ROM	8 (9)	9 (11)	.641
Weight loss	9 (10)	9 (11)	.828
Globus sensation	5 (6)	6 (8)	.758
Aspiration	7 (8)	3 (4)	.335
Odynophagia	8 (9)	1 (1)	.036
Other symptoms^a	1 (1)	12 (15)
Short-term outcomes
Significant improvement	62 (85)	61 (91)	.269
Mild improvement	7 (10)	2 (3)	.169
No improvement	2 (3)	4 (6)	.426
Worsened	2 (3)	0 (0)	.497
Long-term outcomes
Significant improvement	60 (79)	48 (74)	.476
Mild improvement	9 (12)	10 (15)	.539
No improvement	2 (3)	4 (6)	.414
Worsened	1 (1)	0 (0)	1.000
Recurrence	4 (5)	3 (5)	1.000

Note. Patients included if data was provided by the respective report.

Other symptoms include sleep changes, upper extremity weakness, lower extremity weakness, paresthesia, shoulder pain, fatigue, reflux, pharyngeal irritation, radiculopathy, and myelopathy.

Patient Characteristics and Outcomes by Osteophyte Levels Affected

A similar subset analysis was performed to compare patients with osteophyte involvement at or above C4, involvement at and below C4, and diffuse involvement (Table 2). The group with osteophytes at or above C4 had a higher incidence of globus sensation compared to the group with diffuse osteophyte involvement (18% vs. 1%, P = .006; Table 2). A larger proportion of patients with osteophytes at or above the level of C4 had aspiration (n = 9, 32%) compared to patients with osteophytes below C4 (n = 9, 14%) or diffuse disease (n = 10, 14%; P = .018). Short-term outcomes and long-term outcomes, including osteophyte regrowth, were similar among the 3 groups (87% vs. 85% vs. 90%, P = .807; 64% vs. 74% vs. 69%, P = .623, respectively). Dysphagia-free survival was similar between the 3 groups; however, there was a lack of very long-term follow-up data (beyond 5 years) in the at or above C4 group (P = .389) (Figure 4).

Table 2.

Pre and Postoperative Characteristics of Patients With Osteophyte-Induced Dysphagia, Stratified by osteophyte Group Affected.

Osteophyte group affected
	Diffuse	Above C4	C4 and below	P-values
Total, n	68	24	59
Age, mean ± SD	68 ± 10	67 ± 11	65 ± 9	.227
Sex
Male, n (%)	58 (85)	17 (71)	52 (88)	.139
Total, n	73	28	65
Presenting symptoms
Dysphagia	73 (100)	28 (100)	65 (100)	1.000
Neck pain	12 (16)	5 (18)	10 (16)	.956
Dysphonia	11 (15)	3 (11)	10 (14)	.825
Dyspnea	12 (16)	4 (14)	6 (8)	.453
Reduced Neck ROM	4 (5)	6 (21)	7 (11)	.060
Weight loss	6 (8)	5 (18)	7 (10)	.378
Globus sensation	1 (1)	5 (18)	5 (6)	.011
Aspiration	3 (4)	2 (7)	5 (8)	.652
Odynophagia	4 (5)	1 (4)	3 (3)	.918
Other symptoms^a	4 (5)	7 (25)	5 (8)
Short-term outcomes
Significant improvement	47 (87)	23 (85)	53 (90)	.807
Mild improvement	3 (6)	1 (4)	3 (5)	.936
No improvement	4 (7)	2 (7)	2 (3)	.600
Worsened	0 (0)	1 (4)	1 (2)	.542
Long-term outcomes
Significant improvement	44 (64)	17 (74)	34 (69)	.623
Mild improvement	18 (26)	4 (17)	10 (20)	1.000
No improvement	2 (3)	1 (4)	2 (4)	.919
Worsened	1 (1)	0 (0)	0 (0)	1.000
Recurrence	4 (6)	1 (4)	3 (6)	.953

Note. Patients included if data was provided by the respective report.

Other symptoms include sleep changes, upper extremity weakness, lower extremity weakness, paresthesia, shoulder pain, fatigue, reflux, pharyngeal irritation, radiculopathy, and myelopathy.

Patient Characteristics and Outcomes by Sex and Age

A subset analysis comparing characteristics between males (n = 152) and females (n = 26) was performed, as well as stratifying patients below (n = 86) and above (n = 83) the age of 68 years (Tables 3 and 4). Men were significantly older (P = 0.011). Women were 3 times more likely to have reduced neck range of motion and globus sensation (Table 3). Significantly more patients under 68 were affected by osteophytes at C4 and below (P = .029) (Table 4). No difference was seen in the short- and long-term significant improvement rates by sex (P = .309 and .499, respectively) or age (P = .142 and .388, respectively).

Table 3.

Pre and Postoperative Characteristics of Patients With Osteophyte-Induced Dysphagia, Stratified by Sex.

	Male	Female	P-values
Total, n	152	26
Age, mean ± SD	68 ± 9	63 ± 10	.011
Presenting symptoms
Dysphagia	152 (100)	26 (100)	1.000
Neck pain	13 (9)	5 (19)	.149
Dysphonia	15 (10)	2 (8)	1.000
Dyspnea	20 (13)	1 (4)	.320
Reduced neck ROM	6 (4)	3 (12)	.128
Weight Loss	16 (11)	4 (15)	.501
Globus sensation	7 (5)	4 (15)	.060
Aspiration	10 (7)	1 (4)	1.000
Odynophagia	7 (5)	1 (4)	1.000
Other symptoms^a	6 (4)	5 (19)
Osteophyte group affected
Diffuse	58 (43)	10 (42)	.929
Above C4	21 (15)	7 (29)	.103
C4 and below	57 (42)	7 (29)	.240
Short-term outcomes
Significant improvement	99 (83)	19 (95)	.309
Mild improvement	8 (7)	1 (5)	1.000
No improvement	8 (7)	0 (0)	.602
Worsened	4 (3)	0 (0)	1.000
Long-term Outcomes
Significant improvement	93 (78)	15 (71)	.499
Mild improvement	15 (13)	4 (19)	.488
No improvement	4 (3)	1 (5)	.562
Worsened	1 (1)	0 (0)	1.000
Recurrence	6 (5)	1 (5)	1.000

Note. Patients included if data was provided by the respective report

Other symptoms include sleep changes, upper extremity weakness, lower extremity weakness, paresthesia, shoulder pain, fatigue, reflux, pharyngeal irritation, radiculopathy, and myelopathy.

Table 4.

Pre and Postoperative Characteristics of Patients With Osteophyte-Induced Dysphagia, Stratified by Older/Younger Than Age of 68.

	Age <68	Age ≥68	P-values
Total, n	86	83
Sex
Male, n (%)	69 (80)	74 (89)	.108
Presenting Symptoms
Dysphagia	86 (100)	83 (100)	1.000
Neck pain	12 (14)	6 (7)	.157
Dysphonia	10 (12)	7 (8)	.490
Dyspnea	15 (17)	7 (8)	.082
Reduced neck ROM	5 (6)	4 (5)	1.000
Weight Loss	14 (16)	7 (8)	.122
Globus sensation	6 (7)	5 (6)	1.000
Aspiration	3 (3)	8 (10)	.127
Odynophagia	6 (7)	2 (2)	.278
Other symptoms^a	7 (8)	4 (5)
Osteophyte group affected
Diffuse	32 (41)	36 (49)	.306
Above C4	9 (12)	15 (21)	.130
C4 or below	37 (47)	22 (30)	.029
Short-term outcomes
Significant improvement	65 (92)	49 (83)	.142
Mild improvement	3 (4)	6 (10)	.298
No improvement	2 (3)	3 (5)	.673
Worsened	1 (1)	1 (2)	1.000
Long-term outcomes
Significant improvement	52 (79)	47 (72)	.388
Mild improvement	9 (14)	9 (14)	.972
No improvement	1 (2)	4 (6)	.208
Worsened	0 (0)	1 (2)	.496
Recurrence	4 (6)	4 (6)	1.000

Note. Patients included if data was provided by the respective report.

Other symptoms include sleep changes, upper extremity weakness, lower extremity weakness, paresthesia, shoulder pain, fatigue, reflux, pharyngeal irritation, radiculopathy, and myelopathy.

Discussion

In this systematic review, we analyzed 214 published cases of symptomatic cervical osteophytosis managed by open osteophytectomy. We uniquely examine the clinical course of these patients, considering both the location of osteophytes and their meeting DISH criteria. The purpose of this study is to help clinicians identify patients with osteophyte-induced dysphagia and select ideal candidates for open osteophytectomy by considering patient age, sex, osteophyte location, and presence of DISH. This study is novel in that past reviews have not commented on specific patient factors that impact symptomatology or likelihood of dysphagia resolution after open osteophytectomy.

The most notable finding of our study is the observation of increased pre-operative objective aspiration findings in patients with osteophytes at C4 and above. At the same time, success rate of osteophytectomy did not vary based on the presence of aspiration, nor did it differ based on osteophyte level. Therefore, our study argues that the patients with higher level osteophytes may be the best candidates for open osteophytectomy, with similar short- and long-term postoperative outcomes despite worse preoperative symptoms.

The mechanism by which osteophytes cause dysphagia is poorly understood. Consistent with our results, impaired epiglottic closure has been implicated as a mechanism of aspiration during swallowing in patients with C3 to C5 involvement.^38,65 Another study suggests that the “shelf” formed by osteophytes at C3 to C5 can direct a food bolus into the open larynx, causing aspiration.⁶⁶ Conversely, in patients with lower cervical osteophytes (C5-C7), post-swallow aspiration may be attributed to bolus fragment retention.^51,65 Lower cervical involvement (C5-C6) has been suggested to cause dysphagia by reducing upper esophageal sphincter opening and elevating the intrabolus pressure gradient across the osteophytes.¹³ This may cause a “stuck” sensation; however, our analysis demonstrated more subjective globus sensation in the at or above C4 group. This may be due to bolus accumulation in the vallecula. This finding may be clinically significant, as the combination of subjective globus sensation and objective osteophyte presence at C4 may indicate that the patient’s dysphagia is secondary to the cervical osteophyte. However, it is important to note that in our study and others, globus sensation did have a female predominance.

Long-term postoperative resolution of symptoms has been reported in 80% to 90% of patients, consistent with our analysis showing 82% overall resolution. Our analysis showed no significant difference in long-term outcomes in DISH and non-DISH patients, as well as patients with osteophytes above and below the C4 level. This suggests that level of vertebral involvement and number of levels involved may not impact prognosis after osteophytectomy. We had hypothesized that, given the different mechanisms of dysphagia dependent on osteophyte level, a difference in outcomes would be expected after open osteophytectomy. However, this was not observed. These findings imply that physicians should not consider vertebral level or number of levels affected when considering if a patient is a candidate for open osteophytectomy.

Osteophyte regrowth is a common occurrence after surgery; however, regrowth is rarely symptomatic. One series noted symptomatic regrowth in 1 of 7 DISH patients managed with osteophytectomy 15 months after surgery.⁵⁹ The presence of DISH or the affected osteophyte level did not affect the numbers of patients experiencing symptomatic regrowth on long-term follow-up in our analysis.

Osteophyte resection has demonstrated improved short and long-term outcomes in patients with symptoms refractory to conservative management.^59,67,68 A kinematic study of pre- and post-operative pharyngeal function demonstrated improved upper esophageal sphincter opening via enhanced hyoid movement after osteophytectomy.³⁶ Although osteophytectomy has demonstrated improved morbidity, major surgical complications observed included dyspnea necessitating tracheostomy, worsened swallowing function necessitating gastrostomy tube placement, aspiration pneumonia, esophageal injury, and reoperation for hematoma evacuation or hemorrhage. 9% of patients in our analysis suffered a major postoperative complication. Given this complication rate, we encourage clinicians to establish a clear surgical indication for osteophytectomy with an objective evaluation such as a modified barium swallow prior to moving forward with the procedure.³

In our cohort, post-operative dysphagia that had either not improved or worsened was seen in 8% of patients in the short-term and 4% in the long-term. In this group, it is difficult to discern if the outcome was due to insufficient resection, a different etiology of dysphagia, or a consequence of the surgical intervention itself. The anterior cervical approach is commonly used by otolaryngologists in collaboration with spine surgeons during an anterior cervical discectomy and fusion (ACDF). Interestingly, we found that short-term dysphagia rates after osteophytectomy and ACDF are similar. A 2017 systematic review demonstrated an overall 8.5% rate (range = 2%-39%) of dysphagia post-ACDF across all follow-up periods.⁶⁹ The highest rate of post-ACDF dysphagia was observed in the first 12 months, with rates up to 39% in the first 6 weeks, whereas the overall rate dropped to 7% after 12 months. This suggests dysphagia soon after these procedures may be attributable to post-operative edema or transient complications. Other studies have also suggested that short-term post-ACDF dysphagia occurs largely secondary to cervical soft tissue edema.^70,71 Therefore, we suggest that in the short term, a similar rate of dysphagia may be related to the operation itself.

In the long term, dysphagia appears to persist at a higher rate in ACDF compared to osteophytectomy. This is an interesting result that suggests that other factors that are not present following osteophytectomy, such as impingement of the pharynx by cervical hardware, likely play a role in long-term post-operative dysphagia following ACDF. Regardless, patients with post-operative dysphagia should be evaluated with a repeat swallow evaluation with a broad differential including post-operative edema, complications, insufficient resection, and regrowth, among other etiologies.

There are several limitations to our study. A major limitation to studies of this type is reporting bias, whereas authors only report cases with successful outcomes, representing an overestimation in the efficacy of osteophytectomy. However, conversely, patients with improved symptoms may not present for a post-operative swallow evaluation, in which case, they would not be included in this analysis. Our review did not evaluate patient comorbidities, namely autoimmune or neurologic, that contribute to swallowing. Patient history of head and neck malignancy, radiation treatment, or prior tracheostomy was not evaluated. Furthermore, cervical spine abnormalities, such as kyphosis and lordosis, may confound the results. Another limitation is possible variability in laryngeal vertebral level due to age, gender, and height. In addition, osteophytes may grow from the top or bottom of a given vertebral body, sometimes spanning a level with prominence at the joint space, making characterization of the osteophyte based on a single vertebral level difficult. Since original swallow studies could not be evaluated from the available literature, anatomic complexities such as these could not be evaluated. We also did not comment on additional anatomic barriers that may affect swallowing, such as cricopharyngeal dysfunction or the presence of esophageal strictures or diverticula. Baseline laryngeal function was also not evaluated, including vocal cord paralysis and other types of glottic insufficiency (presbyphonia or posterior glottic diastasis). The follow-up period in the at or above C4 group was underreported compared to the other groups, which may confound the analysis of long-term outcomes. Finally, our review did not discuss osteophyte size, which may affect management and outcomes, namely recurrence rate.

Conclusion

Our systematic review was aimed at helping clinicians identify patients with osteophyte-induced dysphagia and those who may benefit from open osteophytectomy. Our analysis demonstrated that patients with osteophytes at or above the level of C4 were more likely to present with pre-operative aspiration, but osteophyte level, as well as age, sex, and presence of DISH did not impact likelihood of operative success. Therefore, patients with higher osteophyte levels may be considered better candidates for osteophytectomy. However, given the risk of major operative complications, clinicians should identify a clear indication prior to proceeding with surgery.

Supplemental Material

sj-docx-1-aor-10.1177_00034894251383821 – Supplemental material for Outcomes of Open Osteophytectomy in Dysphagia Related to Cervical Osteophytes: A Systematic Review

Supplemental material, sj-docx-1-aor-10.1177_00034894251383821 for Outcomes of Open Osteophytectomy in Dysphagia Related to Cervical Osteophytes: A Systematic Review by Raj Malhotra, Hamza Khan, Joseph Celidonio, Keshav Kumar, Rohan Suresh and Kenneth Yan in Annals of Otology, Rhinology & Laryngology

Supplemental Material

sj-docx-2-aor-10.1177_00034894251383821 – Supplemental material for Outcomes of Open Osteophytectomy in Dysphagia Related to Cervical Osteophytes: A Systematic Review

Supplemental material, sj-docx-2-aor-10.1177_00034894251383821 for Outcomes of Open Osteophytectomy in Dysphagia Related to Cervical Osteophytes: A Systematic Review by Raj Malhotra, Hamza Khan, Joseph Celidonio, Keshav Kumar, Rohan Suresh and Kenneth Yan in Annals of Otology, Rhinology & Laryngology

Footnotes

Acknowledgements

None.

ORCID iDs

Raj Malhotra

Hamza Khan

Joseph Celidonio

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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