BioMedicine

Volume 11 Issue 1 Article 6

2021

Contralateral recurrent laryngeal nerve palsy in revision anterior

cervical discectomy and fusion (ACDF): A cautionary tale

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Recommended Citation
Wu, Chenghan; Yang, Eugene Wei Ren; and Lor, Kelvin Kah Ho (2021) "Contralateral recurrent laryngeal
nerve palsy in revision anterior cervical discectomy and fusion (ACDF): A cautionary tale," BioMedicine:
Vol. 11 : Iss. 1 , Article 6.
DOI: 10.37796/2211-8039.1114

This Case Reports is brought to you for free and open access by BioMedicine. It has been accepted for inclusion in
BioMedicine by an authorized editor of BioMedicine.
 CASE REPORT
Contralateral recurrent laryngeal nerve palsy in
revision anterior cervical discectomy and fusion
(ACDF): A cautionary tale

Cheng Han Wu a, Eugene Wei Ren Yang b, Kelvin Kah Ho Lor a

a
Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
b
Division of Neurosurgery, Department of Surgery, Khoo Teck Puat Hospital, Singapore

Abstract

Revision anterior cervical spine surgery has a higher risk of recurrent laryngeal nerve palsy (RLNP). We describe a
unique case of an isolated RLNP contralateral to the side of the surgical approach in a patient who underwent revision
anterior cervical discectomy and fusion (ACDF) for cervical myelopathy, and in whom pre-operative laryngoscopic
evaluation had excluded a pre-existing occult RLNP. Scarring around the recurrent laryngeal nerve at the previous
surgical site may have rendered it less mobile, resulting in it being more susceptible to compression from an inflated
endotracheal tube (ETT) cuff or traction from surgical retractors. This case illustrates that acute RLNP can rarely occur
contralateral to the side of surgical approach in the setting of revision surgery. Surgeons performing revision ACDF can
consider approaching from the same side as the index surgery or a posterior approach to reduce the risk of developing
bilateral RLNP.

Keywords: anterior cervical spine surgery, recurrent laryngeal nerve palsy, revision surgery

1. Introduction describe a rare case of isolated contralateral RLNP

in a patient who underwent revision ACDF for

R ecurrent laryngeal nerve palsy (RLNP) is a

well-recognised complication of anterior
cervical myelopathy and discuss its pathophysi-
ology and implications on the clinical manage-
cervical spine surgery with an incidence ranging ment of patients undergoing revision ACDF.
from 0.9% to 8.3% [1]. RLNP usually presents as
dysphonia after surgical intervention and has
been attributed to intra-operative compression by 2. Case study
high endotracheal cuff pressure and/or surgical A 72- year-old female presented to the spine
retractors, traction and less commonly, direct surgery clinic following a fall, with a history of
trauma to the nerve [2,3]. Revision surgery has a progressive gait unsteadiness requiring support for
ambulation and bilateral hand numbness over
higher risk of subsequent post-operative RLNP
2 months. 25 years before presentation, she had
due to the presence of scar tissue and difficulty in
undergone a C5eC6 ACDF with autologous bone
dissection [4]. While cases of ipsilateral or even grafting for symptoms of right-sided cervical radi-
bilateral RLNP post anterior cervical spine sur- culopathy, which had completely resolved post-
gery have been documented in current literature, operatively. Notably, she did not complain of any
to the best of our knowledge, there has been no post-operative voice abnormalities following her
case report of an isolated RLNP contralateral to index surgery.
the side of the surgical approach following ante- Clinical examination revealed normal motor
power and sensation, with positive signs of cervical
rior cervical discectomy and fusion (ACDF). We
myelopathy as evidenced by upper and lower limb

Received 14 July 2020; revised 23 August 2020.

Available online 01 March 2021
E-mail address: chenghan.wu@mohh.com.sg (C.H. Wu).

https://doi.org/10.37796/2211-8039.1114
2211-8039/Published by China Medical University 2021. © the Author(s). This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
 52 C.H. WU ET AL BioMedicine
CONTRALATERAL RLN PALSY IN REVISION ACDF 2021;11(1):51e55
CASE REPORT

hyper-reflexia, positive Hoffman's sign and inverted minimise dissection through scar tissue (Fig. 4).
supinator reflexes bilaterally. Imaging confirmed Intra-operative findings were that of a large soft
the presence of adjacent level degeneration in central prolapsed intervertebral disc compressing
C3eC5 and C6eC7 levels, with significant spinal the spinal cord at C3eC4 and severe disc degener-
canal stenosis and T2-weighted cord signal change ation with reduced disc height at C4eC5. Surgery
most evident at the C3eC4 level. The previously was uneventful, with an estimated blood loss of
operated level was well fused (Figs. 1e3). 200 ml.
In view of her previous history of anterior cervical On post-operative day 1, the patient was noted
spine surgery, a pre-operative otorhinolaryngology to have marked dysphonia and difficulty toler-
consult was obtained to rule out an occult vocal cord ating thin fluids and regular diet. Formal otorhi-
palsy. Laryngoscopy revealed normal function of nolaryngological assessment by flexible
the vocal cords bilaterally. nasoendoscopy revealed a right vocal cord palsy
The patient underwent C3eC5 ACDF via a left- (the side of the previous surgery) in an abducted
sided approach, contralateral to the index surgery to position on phonation, while the left vocal cord

Fig. 1. Plain radiographs of the cervical spine demonstrating good bony fusion of C5eC6 and adjacent level degeneration from C3eC7.

Fig. 2. MRI T2-weighted sequences showing multilevel degenerative pathology most significant at C3eC4, where there is severe spinal canal stenosis
with cord signal change suggesting myelomalacia.
BioMedicine C.H. WU ET AL 53
2021;11(1):51e55 CONTRALATERAL RLN PALSY IN REVISION ACDF

CASE REPORT
Fig. 3. CT cervical spine demonstrating good bony fusion of C5eC6 and adjacent level degeneration from C3eC7.

Fig. 4. Immediate post op X-rays after C3eC5 ACDF demonstrating satisfactory placement of the implants.

speech therapist. The patient's dysphagia improved

over the course of her admission and did not require
nasogastric tube feeding, although her severe
dysphonia persisted on discharge.
By 3 months post-operatively, the patient reported
that her swallowing dysfunction and dysphonia had
resolved. At 1 year, the patient remained satisfied
with her post-operative recovery, reporting im-
provements in her gait disturbances and ambula-
tory status. She had only minimal voice hoarseness
and was able to tolerate a normal diet with normal
Fig. 5. Right vocal cord paralysed in abducted position on phonation,
with left vocal cord demonstrating good movement from abduction (a) to
swallowing function.
adduction (b).
3. Discussion
(the acutely operated side) exhibited normal RLNP is a well-recognised complication of ACDF
movement (Fig. 5). [1]. Most commonly, it presents as hoarseness,
The patient was managed conservatively with a cough and dysphagia post operatively. Most symp-
1 week course of dexamethasone, dietary modifica- tomatic RLNP present immediately post-opera-
tions with thickened fluids to prevent aspiration and tively, although there have been descriptions of
intensive daily swallowing and voice exercises by a delayed presentations [5].
 54 C.H. WU ET AL BioMedicine
CONTRALATERAL RLN PALSY IN REVISION ACDF 2021;11(1):51e55
CASE REPORT

Patients undergoing revision anterior cervical did not occur to our patient, the possibility of an
spine surgery are at a higher risk of suffering from acute RLNP on the side of the revision surgery
RLNP [4]. Bilateral RLNP is a devastating and life- combined with a similarly acute contralateral RLNP
threatening complication that may require emer- at the site of the index surgery represents a distinct
gent airway management post-operatively. It is risk that must be considered.
commonly attributed to surgery performed on the Intra-operative measures to mitigate the risk of
contralateral side of an unrecognised occult vocal RLNP have been described in the literature,
cord palsy (e.g. from a previous surgery). Pre- including monitoring of the ETT cuff pressure and
operative laryngoscopy has been recommended to intra-operative EMG monitoring of the recurrent
reduce such occurrences in this patient group [6]. laryngeal nerve [10,11], although evidence for these
Various mechanisms underlying the development interventions are limited. Neither of these measures
of RLNP have been proposed by authors, including were specifically performed for our patient. There
1) direct pressure by the inflated cuff of the endo- are a variety of treatment described for unilateral
tracheal tube (ETT) on the submucosal course of the RLNP [12], fortunately most symptoms are often
nerve causing ischemia, 2) traction on the nerve by transient with only a minority of patients experi-
retraction resulting in neuropraxia, 3) airway encing permanent residual symptoms. Majority of
trauma during intubation and 4) traumatic division patients will experience complete resolution with
of the nerve [2,3,7]. Unfortunately, as evident from time [13].
previous studies, it is often difficult to determine the In conclusion, this is a novel case study reporting
exact mechanism of injury resulting in post-opera- an isolated RLNP contralateral to the side of the
tive RLNP in revision anterior ACDF surgeries [7]. surgical approach in a patient undergoing revision
Our patient had a pre-operative laryngoscopy that ACDF. It highlights the possibility that despite
showed bilateral functional vocal cords, confirming functional bilateral vocal cords pre-operatively, a
that this complication only occurred during the bilateral RLNP may potentially occur in patients
second surgery. To our knowledge, isolated undergoing revision anterior cervical spine surgery
contralateral RLNP because of anterior cervical if surgery is performed from the contralateral side to
spine surgery has not been described in the the original procedure. The mechanism behind the
literature. development of this complication, in our above case,
With regards to the proposed mechanisms dis- is likely compression and/or traction to the nerve
cussed above, it is less likely that a direct injury to from the ETT cuff and surgical retractors. Surgeons
the nerve is responsible for the patient's presenta- performing revision anterior cervical spine surgery
tion. Traumatic surgical division of the nerve is not should be aware of this potential complication and
likely as the surgical approach did not extend to the adequately counsel patients on this risk. Using a
contralateral side. Direct injury during orotracheal surgical approach on the same side as the initial
intubation can also lead to a vocal cord hematoma surgery or a posterior approach can be considered
resulting in a vocal cord palsy [8]. However, this is to reduce the risk of developing a bilateral RLNP.
unlikely in our patient as a formal postoperative
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