Abstract
BackgroundImproper occipitocervical alignment after occipitocervical fusion (OCF) may lead to devastating complications, such as dysphagia and/or dyspnea. The occipital to C2 angle (O-C2a), occipital and external acoustic meatus to axis angle (O-EAa) have been used to evaluate occipitospinal alignment. However, it may be difficult to identify the inferior endplate of the C2 vertebra in patients with C2–3 Klippel-Feil syndrome (KFS). The purpose of this study aimed to compare four different parameters for predicting dysphagia after OCF in patients with C2–3 KFS.MethodsThere were 40 patients with C2–3 KFS undergoing OCF between 2010 and 2019. Radiographs of these patients were collected to measure the occipital to C3 angle (O-C3a), O-C2a, occipito-odontoid angle (O-Da), occipital to axial angle (Oc-Axa), and narrowest oropharyngeal airway space (nPAS). The presence of dysphagia was defined as the patient complaining of difficulty or excess endeavor to swallow. Patients were divided into two groups according to whether they had postoperative dysphagia. We evaluated the relationship between each of the angle parameters and nPAS and analyzed their influence to the postoperative dysphagia.ResultsThe incidence of dysphagia after OCF was 25% in patients with C2–3 KFS. The Oc-Axa, and nPAS were smaller in the dysphagia group compared to non-dysphagia group at the final follow-up (p < 0.05). Receiver-operating characteristic (ROC) curves showed that dO-C3a had the highest accuracy as a predictor of the dysphagia with an area under the curve (AUC) of 0.868. The differences in O-C3a, O-C2a, O-Da, and Oc-Axa were all linearly correlated with nPAS scores preoperatively and at the final follow-up within C2–3 KFS patients, while there was a higher R2 value between the dO-C3a and dnPAS. Multiple linear regression analysis showed that the difference of O-C3a was the only significant predictor for dnPAS (β = 0.670, p < 0.001).ConclusionsThe change of O-C3a (dO-C3a) is the most reliable indicator for evaluating occipitocervical alignment and predicting postoperative dysphagia in C2–3 KFS patients. Moreover, dO-C3a should be more than − 2° during OCF to reduce the occurrence of postoperative dysphagia.
Highlights
Improper occipitocervical alignment after occipitocervical fusion (OCF) may lead to devastating complications, such as dysphagia and/or dyspnea
The incidence of dysphagia in patients with C2–3 Klippel-Feil syndrome (KFS) after OCF was 25% (10/40). 6 patients were diagnosed as basilar invagination (BI), 4 atlantoaxial subluxation (AS), 26 BI with AS, 3 rheumatoid arthritis (RA) with AS, 1 malunion of odontoid fracture with AS
After patients were divided into two groups according to whether they had developed postoperative dysphagia, we found that the preoperative occipital to C3 angle (O-C3a), occipital to C2 angle (O-C2a), odontoid angle (O-Da), occipital to axial angle (Oc-Axa), and narrowest oropharyngeal airway space (nPAS) values were not significantly
Summary
Improper occipitocervical alignment after occipitocervical fusion (OCF) may lead to devastating complications, such as dysphagia and/or dyspnea. Dysphagia has been recognized as a catastrophic complication after OCF, with an incidence ranging from 15.8 to 26.6% [3, 9,10,11] This situation may sacrifice the quality of life of patients and sometimes poses a serious threat to their daily life [7, 8, 12]. Some researchers have revealed a correlation between a reduction in the occipital to C2 angle (O-C2a) and a decrease in the pharyngeal airway space They thought that a reduction in the O-C2a was considered a risk factor for dysphagia after OCF [8, 14, 15]. Morizane et al [16] proposed the occipital and external acoustic meatus to axis angle (O-EAa) to indicate craniocervical junction alignment, which could reflect the translation of the cranium in relation to C2 and may affect the narrowest oropharyngeal airway space (nPAS). Maintenance of the O-C2a and O-EAa at an appropriate level is a practical and effective method to prevent postoperative dysphagia
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