Revealing Spine-tingling Changes in Pharyngeal Swallowing

Title: The Impact of Cervical Spinal Disease on Pharyngeal Swallowing Function
Authors: Walters, Gudipudi, Davidson, Cooke, Barengo, Smyre, Garand, Martin-Harris, Matheus, Nguyen & O’Rourke
Journal: American Journal of Speech-Language Pathology
Year of Publication: 2022
Design Type: retrospective case-control study
Purpose: “This study evaluates how cervical spinal pathology may impact swallowing function in dysphagic individuals observed during videofluoroscopic swallowing studies (VFSSs)”
Population: 100 subjects with dysphagia and age/gender-matched healthy control subjects
Inclusion criteria: outpatients at tertiary care nonhospital clinics >18 years old who completed VFSS due to dysphagia (2020-2021)
Exclusion criteria: patients who had no age-matched control available; unable to complete study due to patient immobility

---

Here’s hoping your Dysphagia Course was more in depth than mine when it came to the wide-ranging topics and areas for discussion, debate, and discovery! My journey began with this sub-population population after recently starting at a hospital that is very much geared towards geriatrics. Even though I was on the big learning curve for VFSS, I still had many stroke, trach, and other general diagnoses under my belt. But generally healthy older adults? Panic started to creep in as I had to debate daily if their dysphagia was simply due to presbyphagia, related to another diagnosis, OR impacted by the many spinal deviations we constantly saw across this population; not to mention a possible combination!😓

These anatomical changes and resulting swallowing impairments definitely threw me for a loop but made me realize the huge difference between acutely-related impairments and general geriatric swallowing. Of course, if I could turn back time I would’ve had this article in hand while staring at that spinal curvature. But now that it’s here it is100% worth giving a full read and sharing it to to anyone and everyone in the same boat!😍

What is a Spinal Disease?

Fortunately for us this team of authors recognize how common these issues are–“approximately 60% for 40⁺, and 75-90% for 60⁺ adults”–and decided to finally add to the (limited) evidence for us fluoro-filming clinicians:

“A proposed mechanism for degenerative cervical spine-associated dysphagia (SAD) is the mechanical compression on the posterior pharynx, leading to altered swallowing function and poor bolus clearance, which may cause bolus airway invasion and adverse health outcomes. Seidler et al. found that C3– C4 osteophytes can restrict epiglottic mobility and more inferior cervical osteophytes can cause mechanical obstruction and limit the elevation and anterior movement of the larynx.” p.2

They did their due diligence by not only defining what a “spinal disease/pathology” is for their specific study–“bony anatomical malformations such as osteophyte formation, spinal curvature abnormalities, degenerative disease, and/or prior cervical spine surgery“–but also reviewing the general findings that include the following “comprehensive and easily recognizable” spinal abnormalities🩻:

While the VFSS videos of all the healthy control subjects were taken from a larger normative dataset from a previous study by Garand et al. (2019) on aging and the effect on swallow function, the dysphagic subjects were taken from previous years at outpatient settings.

From the general list above, the authors worked with a radiologist trained in head/neck pathology to classify all these into 2 main groups based on its impact on swallow function:

• Spinal-Associated Dysphagia (SAD)
  • those with cervical spinal pathology without any other identifiable etiology of dysphagia
• Non-Spinal Associated Dysphagia (NSAD)
  • those with either normal spinal anatomy or spinal changes with another established cause of dysphagia on VFSS (e.g. stroke, stricture, diverticula, etc.)

What tools did they use and How?

You better believe they utilized some top tools and stayed with standardization as best they could for their studies. From following MBSImP protocol with Varibar products, using 30 fps and recording imaging, to the Penetration Aspiration Scale (PAS) and EAT-10 to quantify the patient-reported outcomes and symptoms (not to mention the FOIS for pre-level oral intake and DIGEST, though not used for healthy controls), they were on it!🤩

Even better, the partnering laryngologist and radiologist independently reviewing the spinal images for spinal categories were blinded to the other raters’ categorization as well as the final consensus categorization. Plus, the 2 trained SLP raters for VFSS completed their swallowing-related ratings before the spinal categorization process and were also blinded to these final categorizations. So basically, everyone did their own thing using the best tools and their expertise, before they knew what anyone else found.😎

On to What They Found:

As far as all the divided groups go:

• Dysphagia patients: n=100
  • average age = 67.7 years
    • SAD group: n=15
      • average age = 71.3 years
    • NSAD group: n=85
      • average age = 67.1 years
• Healthy Controls (HC): n=100
  • average age = 66.8 years

If some of those numbers look a little wonky or uneven, take a mental note because we’ll coming back to that!😉

Reliability:

• Categorizing spinal categories:
  • Inter-rater reliability: 92% overall and moderate-strong agreement for the spinal classifications
• Strongest agreement spinal classifications:
  • normal cervical spine, osteophytes, DISH, pronounced lordosis, and history of ACDF

Spinal abnormalities:

While no individuals in the healthy control group had any identified spinal pathologies that significantly impacted their swallow function (while consuming a FOIS 7), there were some surprising results as far as the actual total spinal abnormalities:

“Abnormal spinal anatomy was observed in 89 of the 100 dysphagic individuals and 84 of the 100 matched HCs. Spine disease was identified as impacting swallowing for 36 individuals. Spine disease was determined to be the sole etiology of dysphagia in 15 individuals (SAD group).” p.4

“Osteophytes were the most common spinal pathology identified on VFSS and were present in six of 15 (40%) individuals with SAD, 38 of 85 (45%) individuals with NSAD, and 49 of 100 (49.0%) HCs. Degenerative disc disease was also common with four of 15 (27%) of the SAD group, 43 of 85 (51%) of the NSAD group, and 63 of 100 (63%) of the HC group.”

“History of anterior cervical discectomy and fusion (ACDF) was present in six of 15 (40%) of the SAD group, five of 85 (6%) of the NSAD group, and none of the HCs as this was an exclusion criterion. The SAD cohort was significantly more likely to have a history of ACDF than the NSAD or HC cohorts (p < .001). The remaining comparisons were not statistically significant.” p.5

PAS:

Unsurprisingly, the max (presumably meaning the worst/highest?) PAS scores were different (higher) only in the median scores for both dysphagia groups (SAD/NSAD) when compared the the healthy controls.

EAT-10:

Believe it or not, all 3 groups had statistically significant median EAT-10 scores with NSAD having the highest (13), SAD with 6, and HC a goose egg 0. (And in case you’re wondering post study FOIS comparisons were not statistically significant between the 2 dysphagia groups).

MBSImP Components:

The authors lay it all out on the table (literally) for you to glaze over and maybe even check if your spidey-SLP predictions were right:

• SAD/NSAD components worse than HC:
  • Tongue Control (2)
  • Initiation of pharyngeal swallow (6)
  • Epiglottic movement (10)
  • Pharyngeal stripping wave (12)
  • Pharyngeal contraction (13)
  • Esophageal clearance (17)

Bolus prep/mastication (3) and Soft palate elevation (7) were only significantly different between NSAD and HC groups; while the HC group were actually found to have worse Lip closure (1), Oral residue (5), and Anterior hyoid excursion (9) compared to both SAD/NSAD dysphagic groups!? Surprisingly, the results did not show any significant differences in Pharyngeal Total scores nor Pharyngeal residue (16) across the groups.🤯🤯

Laymens terms & Limitations

Before we start knocking down certain parts of the study that really can’t be brushed aside, let’s look closer at some of those findings again and what they might mean…

I don’t know about you but when I think of spinal abnormality my SLP-brain automatically starts imagining those pointy, obtrusive little (or big) osteophytes always propelling that darn bolus right into the airway like a water slide or pinball flippers. The authors were on the same page in hypothesizing those participants with osteophytes at C3-4 would have worse epiglottic inversion (and pharyngeal esophageal opening for C4-6) with impacted swallowing, especially according to Choi et al.(2019) and Seidler et al. (2009).

None of that happened (in this study)!

“these results were not statistically significant. MBSImP and PAS scores were similar between both dysphagic groups and, in some cases, better in the SAD group. We concluded that although spine disease can play an important role in dysphagia, it is not necessarily worse than other forms of dysphagia.” p.8

Shaking your head confused or shocked beyond your SLP core?!😱

Again, when we take a step back and think about the patient as a whole AND the swallowing mechanism as a whole we can see those trees that make up the forest😉.

“These results may suggest that the progressive nature of spine disease allows for increased compensation over time, whereas the sudden onset of some neurogenic issues (e.g., stroke) does not. For example, a dysphagic patient in the NSAD group with lower cervical osteophytes incidentally utilized a self-learned Mendelsohn maneuver-like swallow (volitionally holding the hyolaryngeal complex at its maximum height during the swallow) that improved passage of the bolus through the pharyngoesophageal segment.” p.8

And if those spinal abnormalities are making a big splash into the airway or impacting how that bolus clears out? The article also shares some quick options that always come with different risks/rewards and ultimately get deferred to physician(s):

• Diet modification (sometimes even the patients do this themselves!)
• Compensatory strategies (e.g. head turn, hard swallow)
• Surgical treatment
  • anterior cervical osteophyte resection (usually C3-4 level per Kolz et al, 2021)
  • partial epiglottoplasty
• ^{_{(I’ve also heard some rumblings about physical therapy and other non-surgical interventions?)}}

But before we start recommending patients get their spine chipped away or doing wonky head turns, remember we can’t generalize all these interesting results due to the following limitations:

• Differences in group sample sizes making it hard to fairly compare differences
• Simplifying the degenerative disc changes into 2 separate categories (early/late) since changes are on a spectrum and often inter-related
• Inherent bias from VFSS judgements
• VFSS taken solely from Outpatient (nonhospital) settings

Moving forward, because swallowing doesn’t happen in the vacuum (ok, maybe a “tube”😒), there’s got to be more to consider than just “this caused that.”

“Because spine changes are commonly seen in asymptomatic individuals, it is imperative to consider the clinical context and investigate other etiologies thoroughly before attributing dysphagia to spine disease alone.” p. 8

My takeaway? 🤔

Look a lil closer, review a lil slower, and really think critically if any of those bony protrusions are impacting swallowing, if it’s really something else going on, or just another “normal” swallow that can be left alone.😊

---

---

Article Referenced: 💥FREE ASHA ACCESS💥

Walters, R., Gudipudi, R., Davidson, K., Cooke, M., Barengo, J., & Smyre, D. et al. (2023). The Impact of Cervical Spinal Disease on Pharyngeal Swallowing Function. American Journal Of Speech-Language Pathology, 32(2), 565-575. doi: 10.1044/2022_ajslp-22-00257

• And checkout this cool Youtube freebie from one of the authors, Dr. O’Rourke herself that goes over it all too!!!🤩