Early inpatient airway and swallowing events after primary four-level ACDF: characterizing the index hospitalization.

PURPOSE: Four-level primary anterior cervical discectomy and fusion (ACDF) remains controversial, with variable reports regarding complication and revision rates. Most studies emphasize 90-day complications and longer-term reoperations, while events occurring during the index hospitalization are not routinely captured. As a result, the early inpatient postoperative course remains largely uncharacterized. This study aimed to evaluate early inpatient airway- and swallowing-related events following primary four-level ACDF, focusing on airway management and dysphagia severity.

METHODS: We performed a retrospective single-center cohort study of patients undergoing primary four-level ACDF for degenerative pathology. Early inpatient events were identified through structured review of discharge summaries using a predefined rule-based parsing approach. Domains included airway management (delayed or overnight intubation, higher-acuity monitoring), swallowing-related symptoms and associated management, and other postoperative clinical events. Dysphagia severity was classified as mild, clinically significant, or severe based on documented clincal impact and dysphagia-related dietary or nutritional interventions.

RESULTS: A total of 236 patients were included. Delayed or overnight intubation occurred in 37.3% of patients, and higher-acuity postoperative monitoring in 24.6%. Dysphagia was documented in 21.6% of patients; among these, 70.6% were classified as mild, 27.5% as clinically significant, and 2.0% as severe. Odynophagia and dysphonia/hoarseness were documented in 5.5% and 1.7%, respectively. Perioperative corticosteroid administration was documented in 32.2%. Other clinical events were infrequent, including acute blood loss anemia (8.5%; transfusion 1.7%), neck hematoma or swelling (1.3%), postoperative neurological findings (3.8%), and intraoperative dural tear (0.8%).

CONCLUSIONS: In primary four-level ACDF, early inpatient airway management strategies and swallowing-related events are common, yet clinically significant complications are infrequent. Most documented dysphagia was mild and did not require dysphagia-related dietary modification, while severe dysphagia requiring enteral feeding was rare. These findings suggest that the early postoperative course is defined more by clinical monitoring and risk-adapted management than by clinically significant complications, providing a more nuanced assessment of postoperative morbidity beyond traditional reporting.