Laird Harrison

October 25, 2013

SAN FRANCISCO — Patients having spinal fusion surgery were able to swallow better and spent less time in the hospital when treated with dexamethasone, a new study shows.

And in the end the steroid did not affect fusion rates as much as investigators had feared.

"Dexamethasone appears to delay fusion but does not appear to ultimately influence fusion outcomes in the long term," said Shiveindra Jeyamohan, MD, a researcher at Albany Medical Center in New York.

Dr. Jeyamohan presented the findings here at the Congress of Neurological Surgeons (CNS) 2013 Annual Meeting.

Session moderator Mohammed Shamji, MD, PhD, an assistant professor of spinal surgery at the University of Toronto, Ontario, Canada, told Medscape Medical News that the findings were important because this was one of the first studies to look at the pros and cons of giving steroids to patients undergoing spinal fusion.

"It could be practice-changing because right now we don't have any other way of reducing postoperative dysphagia," he said.

An anterior approach to spinal fusion offers some advantages over a posterior approach: less neck pain, lower infection rates, and better opportunities for improving lordosis than a posterior approach, said Dr. Jeyamohan. On the other hand, an anterior approach increases the risk for dysphagia and airway edema.

Many surgeons use dexamethasone to relieve these swallowing and breathing problems. But researchers have speculated that this anti-inflammatory could slow fusion, which is a proinflammatory process.

To explore the pros and cons of dexamethasone used this way, Dr. Jeyamohan and his colleagues enrolled 118 patients requiring cervical discectomy and fusion for their radiculopathy or myelopathy.

They randomly assigned the patients to receive a dexamethasone or a saline solution placebo perioperatively. Patients and surgeons didn't know which patients were getting the steroid.

The dexamethasone dose was a bolus of 0.2 mg/kg of body weight and 4 doses of 0.6 mg/kg every 6 hours up to a maximum of a 10-mg bolus and 4 mg every 6 hours. Most patients received the maximum dose.

The surgeons performed consecutive discectomies and used bone graft mixed with bone marrow for each level fused. They placed screws at every level of the fusion unless they performed corpectomy.

Of these patients, they analyzed those with fusions at levels 3 to 5. Forty of these received dexamethasone and 45 received placebo.

After the operations, the investigators found that 40.00% of the dexamethasone patients had dysphagia compared with 72.50% of the placebo recipients, a difference that was statistically significant (P = .002).

The placebo recipients also spent 4.5 days in the hospital compared with only 2.44 days for patients receiving dexamethasone, also a statistically significant difference (P = .002).

Functional Outcome Swallowing Scale scores were significantly lower for the dexamethasone group (P = .001) postoperatively. The difference diminished at 1-month follow-up.

There was also a tendency toward a lower proportion of patients with postoperative airway difficulty in the dexamethasone group (P = .056).

Functional and pain outcomes did not significantly differ between the 2 groups.

At 6 months, 56.67% of the placebo group had fusion, compared with only 31.03% of the dexamethasone group, a statistically significant difference (P = .048).

But that difference quickly diminished, with 74.19% of the placebo group and 72.22% of the dexamethasone group achieving fusion at 12 months, a difference that was not statistically significant (P = .859). The fusion rates were similar at 24 months as well.

Few complications occurred in either group, but more were seen in the placebo group than in the dexamethasone group.

In the question-and-answer period, one person in the audience asked whether the dysphagia rate was related to the number of levels fused.

"I haven't looked at that data yet, but cursory examination of that data indicates there is no significant difference," said Dr. Jeyamohan.

Dr. Jeyamohan and Dr. Shamji have disclosed no relevant financial relationships.

Congress of Neurological Surgeons (CNS) 2013 Annual Meeting. Abstract #158.

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