Hyoid position as a novel predictive marker for postoperative dysphagia and dysphonia after anterior cervical discectomy and fusion



The purpose of this study is to investigate the predictive value of the hyoid horizontal positional change on the severity of dysphagia and dysphonia (PDD) after anterior cervical discectomy and fusion (ACDF) comparing pre-vertebral soft-tissue thickness (PVST).


This is a retrospective observational study with prospectively collected data at a single academic institution. ACDF patients between 2015 to 2018 who had complete self-reported PDD surveys and pre- and postoperative lateral cervical radiographs were included in the analysis. PDD was assessed utilizing the Hospital for Special Surgery Dysphagia and Dysphonia Inventory (HSS-DDI). The hyoid-vertebral distance (HVD) and PVST (the averages of C2 to C7 levels (PVSTC2–7) and all operating levels (PVSTOP)) were assessed preoperatively and upon discharge. The associations among postoperative changes of HVD, PVSTs, and the 4-week HSS-DDI score were evaluated.


Of the 268 patients with a HSS-DDI score assessment, 209 patients had complete data. In univariate analyses, HVD and PVSTC2–7 changes demonstrated significant correlations with HSS-DDI, whereas PVSTOP showed no significant association. After adjusting with sex and operating level, the changes in HVD (p = 0.019) and PVSTC2–7 (p = 0.009) showed significant associations with the HSS-DDI score and PVSTOP showed no significant association. PVSTC2-7 could not be evaluated in 12% of patients due to measurement difficulties of PVST at lower levels.


We introduce a novel potential predictive marker for PDD after ACDF. Our results suggest that HVD can be utilized for the risk assessment of PDD, especially in PVST unmeasurable cases, which accounts for over 10% of ACDF patients.

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Availability of data and material

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


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Corresponding author

Correspondence to Alexander P. Hughes.

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Conflict of interest

YH, IO, EC, SNS, COM, and JS report that they have no potential conflict of interest.

AAS reports royalties from Ortho Development Corp., stock ownership of Paradigm Spine, LLC, Spinal Kinetics, Inc., Vestia Ventures MiRusInvestment, LLC, and Integrity Implants, consulting fee from Clariance, Inc., Kuros Biosciences AG, OrthoDevelopment Corp.,DePuy Synthes Products, Inc., Medical Device Business Services, Inc., and 4WEB, Inc.,membership of scientific advisory board/other office of Clariance, Inc., Kuros Biosciences AG, DePuySynthes Products, Inc.,and Medical Device Business Services, Inc, research support from Spinal Kinetics, Inc., and MiMedx Group, Inc., fellowship support from AOSpine North America, outside the submitted work.

FPC reports royalties from NuVasive, Inc., stock ownership of VBVP VI, LLC (originally Centinel Spine), private investments for Spinal Kinetics, Inc., Ivy Healthcare Capital Partners, LLC, ISPH II, LLC, Vertical Spine, LLC, Bonovo Orthopedics, Inc., Viscogliosi Brothers, LLC, Liventa Bioscience (fka AF Cell Medical), Paradigm Spine, LLC, Tissue Differentiation Intelligence, LLC, Woven Orthopedic Technologies, Orthobond Corporation, and Healthpoint Capital Partners, LP, consulting fees from Vertical Spine, LLC, and 4WEB Medical, membership of scientific advisory board/other office of Spinal Kinetics, Inc., Paradigm Spine, LLC, Woven Orthopedic Technologies, Orthobond Corporation, and Healthpoint Capital Partners, LP, research support from 4WEB Medical, NuVasive, Inc., Mallinckrodt Pharmaceuticals, Pfizer, Inc., Spinal Kinetics, Inc., Centinel Spine, Inc. (fka Raymedica, LLC), Beatrice & Samuel A. Seaver Foundation, Paradigm Spine, LLC, 7D Surgical, Inc., Woven Orthopedic Technologies, and Depuy Synthes, outside the submitted work.

FPG reports royalties from NuVasive, Inc., Ortho Development Corp, and Zimmer Biomet Holdings, Inc., stock ownership of Bonovo Orthopedics, Inc., Liventa Bioscience (fka AF Cell Medical), Paradigm Spine, LLC, Tissue Differentiation Intelligence, LLC, Alphatec Holdings, LLC, LANX, Inc., Healthpoint Capital Partners, LP, Centinel Spine, Inc. (fka Raymedica, LLC), and Spinal Kinetics, Inc., consulting fee from DePuy Synthes Spine, NuVasive, Inc., EIT Emerging Implant Technologies, Spineart USA, Inc., and Ethicon, Inc., grants from NuVasive, Inc., outside the submitted work.

APH reports research support from NuVasive, Inc., 4WEB Medical, and Pfizer, Inc., outside the submitted work.

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This study was approved by the Institutional Review Board at Hospital for Special Surgery.

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Hoshino, Y., Okano, I., Chiapparelli, E. et al. Hyoid position as a novel predictive marker for postoperative dysphagia and dysphonia after anterior cervical discectomy and fusion. Eur Spine J (2020). https://doi.org/10.1007/s00586-020-06484-7

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  • Hyoid
  • Anterior cervical discectomy and fusion
  • Dysphagia
  • Dysphonia
  • Hospital for special surgery dysphagia and dysphonia inventory