ACDF volumes are falling and dysphagia rates are climbing

Design

retrospective analysis of the US Nationwide Inpatient Sample 2016-2022 with multivariable logistic regression and nomogram development

Population

496,425 adult elective anterior cervical discectomy and fusion hospitalisations

Primary outcome

national trends in ACDF volume and postoperative dysphagia, and independent risk factors for dysphagia

Effect

dysphagia 7.7%; ACDF volume -57.3%; dysphagia odds +11.4% annually (OR 1.11, 95% CI 1.09-1.13); cervical DISH OR 5.41 (3.81-7.67)

This analysis of the Nationwide Inpatient Sample covered 496,425 elective anterior cervical discectomy and fusion hospitalisations between 2016 and 2022. Dysphagia occurred in 7.7% overall. The trend is the finding: inpatient ACDF volume fell by 57.3% across the period, while the odds of postoperative dysphagia rose by an estimated 11.4% each year (OR 1.11, 95% CI 1.09 to 1.13).

The most likely explanation sits in the risk factors. Cervical diffuse idiopathic skeletal hyperostosis carried an odds ratio of 5.41 (95% CI 3.81 to 7.67), cervical spine fracture 1.73 (1.31 to 2.30) and pseudarthrosis 1.36 (1.15 to 1.61) — all indications for which surgery is harder and unlikely to shift to an outpatient setting. As straightforward degenerative cases move out of the inpatient dataset, what remains is progressively enriched for difficulty, and a rising complication rate in a shrinking denominator is what you would expect. The study cannot distinguish that from a genuine deterioration in care, and it does not claim to.

What it does establish is that dysphagia after these operations is not a nuisance: it travelled with aspiration pneumonia, gastrostomy placement and tracheostomy. For an ENT service, the operational implication is that referrals for post-ACDF swallowing problems will keep rising even as the operation itself becomes less common, and that the highest-risk group — cervical DISH — is identifiable before the operation rather than after it.

• Flag cervical diffuse idiopathic skeletal hyperostosis preoperatively as the strongest single predictor
• Interpret the rising rate as case-mix enrichment as easier cases move outpatient, not necessarily worsening care
• Plan for swallowing assessment pathways to stay busy even as ACDF volume falls
• Take post-ACDF dysphagia seriously — it tracked with aspiration pneumonia, gastrostomy and tracheostomy
• Administrative inpatient data cannot capture outpatient or ambulatory ACDF, which is where the missing volume went

The statistics, in plain English

An annual odds ratio of 1.11 compounds: over seven years that is roughly a doubling of the odds, which is why a small-looking number matters here. The very tight interval (1.09 to 1.13) reflects nearly half a million admissions and describes precision, not freedom from bias — administrative coding of dysphagia may itself have become more thorough over the same period, which would produce exactly this trend without any change in patients. The DISH odds ratio of 5.41 has a wide interval (3.81 to 7.67) because the condition is uncommon, but the effect is unambiguous in direction.

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