Anterior cervical discectomy and fusion is the standard surgery for the cervical disc disease as well as myelopathy, but it has certain complications like difficulty in swallowing and breathing Which can lead to aspirarion, pneumonia and later malnutrition. The rate of incidence varies and there are many risk factors including females, approach of surgery,the implant used, the number of levels of surgery.[1]  Low profile plates are known to reduce the complications of breathing and swallowing.

Perioperative steroid injections are known to reduce inflammation and inturn the swallowing and breathing difficulties.The speech and language therapy is known to help in early rehabilitation.[2]

Dyspnea or difficulty in breathing following the anterior cervical discectomy and fusion surgery is a rare but catastrophic complication.[3][4]It usually follows after a retropharyngeal hematoma after the Anterior cervical discectomy and fusion. It is of utmost importance that the formation of retropharyngeal hematoma must be diagnosed as early as possible and intervened.[5] Sagi et al. reported on 19 patients who developed RC and identified exposure of ≥ 3 vertebral bodies, blood loss ≥ 500 milliliters, operative duration > 5 hours, and upper cervical spine exposure as risk factors. In contrast, a case report by Emery et al. on 7 myelopathic patients who developed difficulty in breathing[6]. identified corpectomies, smoking history, and preoperative respiratory disease as risk factors.[7][8]

OBJECTIVES
The study aims to assess the amount of difficulty in breathing and swallowing following the anterior cervical spine surgeries using the SWAL-QOL questionnaire

Study Design: Prospective cohort design Study group: The study involves the population of 30 patients with age of 18-60 years undergoing anterior cervical spine surgeries Inclusion Criteria: Adults of both sexes (aged 18–60 years) diagnosed with anterior cervical pathologies spondylosis or soft disc herniation that was unresponsive to conservative treatment Exclusion Criteria: Non-degenerative pathology, such as trauma, infection, tumor, and autoimmune disorders, those with a history of preoperative dysphagia, and those with conditions that might cause postoperative neurogenic dysphagia Methodology: Patients consented to participate in the study. None of the patients had dysphagia preoperatively based on the evaluation using the Swallowing-Quality of Life (SWAL-QOL) questionnaire. The difficulty in breathing was assessed immediately after surgery. The dysphagia survey was conducted by the author who was not directly involved in the care of the study patients. The survey was repeated at 1, 3, 6, 12 week, and 6 months after surgery. The surveys were performed during regularly scheduled follow-up visits. Surgical technique: General endotracheal anesthesia was given to all patients. shoulder roll was put to provide cervical extension. A right-sided Smith-Robinson approach was performed through a 3–4 cm transverse incision. The skin and platysma were incised horizontally, followed by a full longitudinal release of the inferior fascia. The prevertebral fascia was then carefully incised while undermining the longus colli muscle. Surgical exposure was facilitated by placing two retractors beneath the longus colli muscles on both the sides. Cervical discectomy was then performed at the two required levels. Drains were removed on postoperative day 1. Postoperative immobilization with a hard cervical collar was maintained for 2 weeks in all patients. Baseline patient characteristics were identified for each patient. Patient-specific characteristics included patient age, gender, ethnicity (white, black, other), body mass index (BMI, calculated from patient height and weight), medical comorbidities (hypertension, smoking history, diabetes mellitus, dyspnea, chronic obstructive pulmonary disease [COPD], preoperative corticosteroid use, bleeding disorders, congestive heart failure), baseline functional status, and a diagnosis of preoperative myelopathy. Operative characteristics included operative duration, procedure performed (ACDF [1-, 2-, and 3-levels], ACCF [1- and 2-levels], and CDA), anterior plate instrumentation, ambulatory surgery (defined as a length of stay of zero days), and American Society of Anesthesiologists (ASA) classification. SWAL-QOL questionnaire The SWAL-QOL questionnaire is a validated patient-based measure of difficulty in swallowing and is commonly used in otolaryngology. The items in this portion of the SWAL-QOL were scored 1–5, corresponding to symptoms occurring almost always, often, sometimes, hardly ever, or never. The scores of the 14 items were summed and transformed into a scale that ranged from 0 to 100, with lower scores indicating more frequent symptoms of difficulty in swallowing.[9]

A total of 60 patients of age 18-60years were registered for study, of which 37 were male and 33 were female. The mean BMI was around 25.The mean duration of surgery was around 85 minutes.

1 patient developed sudden onset of difficulty in breathing and the wound was explored to have seen retropharyngeal hematoma.

The SWAL-QOL score was calculated for all patients in the 1^st week, 3^rd week, 6^th week, 12^th week, 6^th month in their respective followup. The mean SWAL-QOL score at 1^st week was 81,at 3^rd week was 90,at 6^th week was 92 at 12^th week was 94,at 6^th month was 97.

After Anterior cervival discectomy and fusion, there are numerous complications but difficulty in breathing is one of the dreaded and rare complication, identifying and treating it is an emergency. While previous studies have identified the incidence and risk factors for difficulty in breathing ,only some have fully defined the short-term clinical course of patients who develop breathing difficulty.[10] A compressive hematoma may be the most common etiology of difficulty in breathing reported between 0.6% and 1.3% in Anterior cervical surgeries, and may be due to vascular injury, inadequate hemostasis, or for unknown etiologies.[11,12] .A case study by Song et al. corroborates this association as they had 9 patients develop compressive hematomas with respiratory symptoms at an average of 33 hours after index ACSS, however, none had preoperative coagulopathy.[13] In 3 patients who underwent hematoma evacuation in that case report, the sources of bleeding were identified as the jugular vein, an intramuscular vessel, and the superior thyroid artery. The SWAL-QOL scores improved gradually with time, and reached their preoperative levels at 6 months follow-up. Although validated, the SWAL-QOL is lengthy and cumbersome to complete, particularly for patients undergoing Anterior cervical surgeries with relatively minor swallowing impairment

Difficulty in swallowing is a known complication of Anterior cervical surgery with varying incidence rates but difficulty in breathing is rare complication,but an emergency. Many factors affected the outcome among them females, multilevel surgery are one of them. The SWAL-QOL score is an effective tool to assess the dysphagia following anterior cervical surgeries. The SWAL-QOL score reached almost the previous levels at around 6 months.

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11.Yu F, Wang X, Yang H, Chen Y, Liu X, Chen D. Dysphagia after anterior cervical discectomy and fusion: A prospective study comparing two anterior surgical approaches. Eur Spine J. 2013;22(5):1147–1151.

12. Bertalanffy H, Eggert HR. Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir (Wien). 1989;99(1-2):41–50.
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