Episode Transcript
[00:00:03] Speaker A: Welcome to the Ortho Joe Podcast, a joint production of the Journal of Bone and Joint Surgery and Ortho Evidence.
[00:00:10] Speaker B: Join hosts Mohit Bhandari and Mark Swankowski as they discuss current topics and publications in the world of orthopedics and beyond.
[00:00:19] Speaker C: Well, good morning. Good morning. How are you?
[00:00:22] Speaker A: All right.
[00:00:24] Speaker C: Okay.
[00:00:24] Speaker A: We're competing versus Duncan.
[00:00:26] Speaker C: I don't know. I don't know. I'm sure that's a pretty significant.
That's a pretty significant interaction. I don't know. I don't know who would win that battle. I mean, a lot of Die Hard I have.
[00:00:35] Speaker A: I have to admit, Mo, just based on the cup. Hold yours up again one more time.
[00:00:40] Speaker C: Sure.
[00:00:42] Speaker A: I think. I think the colors and the font and everything.
I will have to concede defeat to Tim. There you go.
[00:00:52] Speaker C: It's all there. It's all there. We go, right? We're all in. We're all in. But that being said, you know, just
[00:00:59] Speaker A: for that listening audience, you showed the back of the cup that had the Olympic rings, and we're. We won't talk about hockey in this podcast.
[00:01:08] Speaker C: Yeah, right. My bad. My bad. Yes. It's a wound we're still dealing with.
The wound we're still dealing with.
So today, Mark, you know, you had suggested we talk about a paper in the journal that was published on cervical spine surgery, particularly an issue that follows spine surgery, aphasia. And I thought, well, you and I could certainly speak to it at a very general level, but it would be helpful to have someone who can actually help us out here. So we have Dr. Mark Behuda, who is an associate professor in the Department of surgery at McMaster University and also holds the W.H. kwok chair in spine surgery research at McMaster. He's been doing lots and lots of trials and thinking a little bit about how do we actually improve the quality of the overall evidence base in spine. So we're grateful to have Mark here. Mark, thanks very much for joining us.
[00:01:59] Speaker B: Thanks for having me, guys. And I guess I lose the competition here with my claim cup.
[00:02:04] Speaker C: Oh, we will change that. We will change that, my friend. You will be getting a cup. We guarantee you it'll be branded porcelain Joe. So don't you worry about that.
[00:02:14] Speaker A: And please understand, if you try to sell it on ebay or something, we will find you, because these are very
[00:02:20] Speaker C: exclusive cups, and actually, it's usually me buying them all back.
[00:02:23] Speaker B: I have.
[00:02:23] Speaker C: I have hundreds. I have hundreds, so, you know, they're an asset.
So the paper we're talking about today, Mark, is Entitled the Subjective and functional dysphasia after Anterior Cervical Spine surgery. A prospective controlled study.
This was an investigation performed at the Virginia Mason Medical center in Seattle, Washington. And if I could maybe for those who probably haven't had a chance to look at it, I'll give you a bit of a precis and then maybe I'll let Dr. Szoukowski maybe come in with a question here. This was a prospective study, followed about 134 patients, roughly half having anterior cervical surgery and the other half as a control having lumbar surgery. And the goal was to track dysphagia with a couple of questionnaires. One was called the Eat10 questionnaire, guessing it's more of a subjective measure of dysphagia. And then the Yale swallow protocol.
Now basically the cervical patients, those who had cervical spine surgery reported very high rates of subjective dysphagia, especially in the first week. But every patient passed functional swallow testing at the time points.
Now the radiographs did show retropharyngeal swelling that mostly resolved by follow up. Basically I think what they're saying here is that the findings suggest that dysphagia after acdf, in this case anterior cervical discectomy infusion is a common but self limited and not functionally significant, in fact suggested that it should be framed more as an expected postoperative symptom than a complication.
[00:03:56] Speaker A: Right, so that's the basics of it and neither MO nor I are anywhere close to knowledgeable in this field.
My first question, actually I'll have a two part question mark. Number one, is this a clinical question of relevance to your practice? And number two, is a lumbar control group, the right control group.
[00:04:20] Speaker B: Thanks for the question. I think this is a very important topic.
Recently there was a trial that was published in the last six years or so comparing anterior and posterior approaches for degenerative cervical myelopathy, which would be the condition where ACD apps would frequently be conducted.
The study was motivated by concerns around the morbidity and the comparative morbidity of anterior procedures and posterior procedures. Certainly dysphagia would be one of the most common complications with anterior procedures that we tend not to see with the posterior. And so this is an important topic and I think it's highlighting that it is under recognized and surgeons may minimize the risk of dysphagia.
And in terms of the control group, I can understand that they wanted to control for the length of procedure and the extent of procedure. And so posterior cervical procedures are often done because pathology is more extensive and so it may be difficult to match for that, but I would argue that that would probably be a more appropriate control, especially relative to that clinical context of trying to decide whether to do an anterior posterior procedure.
[00:05:40] Speaker A: Mo, if I could just follow up. So, Mark, is this the results of this trial, helpful for you in your practice today?
[00:05:49] Speaker B: I think it will impact on how I counsel patients. The rate of subjective dysphagia is higher than what's frequently cited in the literature, and so that's important to know.
Now, there are comments about functional dysphagia. Just looking at this Yale Swallow protocol, it's only looking at liquids and they're not looking at solids. And at least in my experience,
[00:06:20] Speaker A: only
[00:06:21] Speaker B: severe dysphagia will result in difficulty swallowing liquids. And so I think it'd be important to still tease out the functional implications on solids. And so I wouldn't minimize this finding as just a symptom and it being subjective, I do think many of these patients probably had some functional limitations, such as they weren't picked up by that Yale Swallow protocol.
[00:06:46] Speaker C: Mark, you talked a lot about that. There have been other studies that have looked at this. When you look at the body of literature looking at this complication or symptom as it's being framed, what would be the ideal way? And I know I'm putting on a spot here, but what do you think would be the ideal? So you decide that you have funding, as much funding as you need, and you want to resolve this question, what would be the approach you would take?
[00:07:12] Speaker B: So I think a matched cohort study would be the way I would pursue this and the trial, the Genocide cervical myelopathy, they had a nice approach where when they recruited patients, these patients had to be deemed by a panel of surgeons as being appropriately treated, either with an anterior or posterior approach, so that there was equipoise. And so I would recruit a cohort of patients that could be treated either way and compare those patients both with subjective scale, but then also a functional, more objective measure that does include solids. And I'll be honest, I'm not familiar with the functional measures that would do that, but. But that would be something to include and then again just follow them over time, as in this case.
[00:08:10] Speaker A: So. So one of the findings of the study as, as I understand it, as, as a non cervical spine surgeon, is that the incidence of this issue is more common than thought to be. So it's a question for you both because I know Mo knows a lot about patient reported outcomes, et cetera, from his experience. So does the act of Asking a patient about a symptom increase the incidence of the symptom.
[00:08:43] Speaker C: I would say yes, absolutely, it does. And, you know, because. And it gets back to, you know, phenomena that are personal, cultural, you know, perception in that. Oh, I didn't think that was important. I didn't think that would be something that need to tell you about or they weren't aware of that situation. So the mere fact of asking will definitely lead. And that in many ways is why controlled trials are so important in a way, because you can really try to tease out, you know, the efficacy. That being said in the real world, how does all this, you know, do these symptoms really result in any form of real morbidity is really, I think, the issue that we'd have to resolve across all these. They're making the argument here, I guess, Mark, that, you know, this is more of a symptom. It's not, it's. It's. It's benign. So why do we call it a complication?
[00:09:32] Speaker A: Well, thanks for that. Yeah. I imagine if we gave each of us a. A questionnaire on the incidence of itching in our feet, the we might be thinking more about itching in our feet.
[00:09:45] Speaker C: So that.
[00:09:46] Speaker A: That's a tough methodologic thing to get around. I'm not sure if there's a way to get around it. Maybe, maybe including questionnaires that were focused on other issues that weren't of interest might be a way to deal with it. But then you've got issues with respondent burden, and people are less likely to respond to multiple questionnaires and lengthy questionnaires and things like that. That's more of a methodologic question rather than a clinical implication issue. I'm raising, I think, I suppose.
[00:10:16] Speaker B: I don't think we know what clinically significant dysphagia is.
They have a functional measure. But, you know, perhaps defining what clinically significant dysphagia is would be helpful, such as a change in diet or weight loss or something along those lines. So it might require a newer measure.
[00:10:37] Speaker C: Yeah, and I would have thought too, Mark, that you talked about a controlled cohort, but what if there was just a very well designed, you know, large single cohort. Right. Like a large group of patients that you're really evaluating and then you're looking for factors prognostic of, you know, any of the things that you come up with. Right. Like dysphagia and a bunch of them. But you'd have to be powered for each of those. But very similar to what you're saying is, I think this is an observational study. The question is, you know, it's an outcomes question. It's not looking at two different treatments and affecting outcome. So I think this is an observational study design for sure, in my mind.
Mark, can I just. Because I know a little bit of information here about some of the things you're interested in, and I don't want to put you on the spot, but, you know, but I am.
Here we go. No, can you talk a little bit about the issue of one of the trials that you are really trying to resolve and some of the challenges with resolving a trial in which potentially the perception that non operative treatment is not the optimal approach, when in fact the evidence would suggest surgery isn't better, potentially could even be harmful.
[00:11:47] Speaker B: Yeah. So the condition I'm particularly interested in is mild cervical myelopathy. And there's concern in this condition that it can really lead to progressive neurologic decline that's irreversible and as well places patients at risk of a catastrophic spinal cord injury should they fall in an awkward way.
And there's debate in the surgical community about whether to treat these patients operatively.
And certainly the statistics would indicate that surgeons tend to favor surgery for this condition.
And I think there's often perception that some of the smaller cervical procedures are fairly benign, such as an acdf. And I think this paper certainly does point out that they aren't. And, you know, dysphagia is a significant complication that can impact quality of life. And so we do have to really look at the morbidity of these procedures in comparison to the theoretical morbidity of treating patients nonoperatively with these spinal cord conditions.
[00:12:55] Speaker C: And the hypothesis right at this point in a trial you would have the null would be, in fact, there is no difference in mild cervical myelopathy and operating or not. And then, you know, trying to prove that, I guess, is going to be the next phase. But that's an interesting. It's a very interesting approach. And I guess it gets right down to this issue of how do you define a complication and how do you define what is a symptom and what is meaningful for patients? And if we're getting to that, I presume, I mean, has there been work done on this, Mark, where.
I'm sure there has been, but I'm just curious if it's been done in the specific area of cervical myelopathy or cervical disease in general, around some utility measures, around a host of symptoms, and how individual patients rank these symptoms, because things that we think are Benign may be very, very important to patients.
[00:13:45] Speaker B: Yeah. So our group has done some work on this. And so we surveyed patients with degenerative cervical disease who have not had surgery, those who've had surgery, spinal surgeons and non spinal surgeon physicians.
And we asked them, and we did what's called a discrete choice experiment to assess the importance of the neurological consequences of cervical myelopathy and some of the potential complications of surgery, including dysphagia.
And what we found was that patients actually rated the potential complications as much more important than non specialist physicians and surgeons. And so there's definitely a difference in how patients and individuals weigh the various treatment factors.
[00:14:39] Speaker C: So back to this particular paper and maybe a way to close this out is that when someone's. When the paper might be recommending, written by practitioners in this case, that we should think of this as a symptom and not a complication, asking that same question to patients may come up with a very different response than our perception of what this is.
[00:14:59] Speaker B: Absolutely.
[00:15:00] Speaker C: Yeah.
On that note, I can't thank you enough. You've in, what is it, 15 minutes, provided Mark Zinkowski and I have mini fellowship. I call it a mini fellowship. And knowledge on dysphagia. I feel confident now I'm going to look for spine surgeons and chat about this topic today. And I urge all those listening to do the same. So thank you, Dr. Bahuda, for taking time with us and we look forward to hosting you again.
[00:15:23] Speaker B: Okay, thanks so much for having me today. I enjoyed the conversation.
[00:15:26] Speaker C: Take care.
[00:15:27] Speaker A: Thanks for the education, Mark. Greatly appreciated.
[00:15:29] Speaker B: Thanks so much.
