National Trends and Risk Factors for Dysphagia After Anterior Cervical Discectomy and Fusion

BACKGROUND: Dysphagia remains one of the most common complications following anterior cervical discectomy and fusion (ACDF), yet recent national trends and risk factors across surgical indications have not been fully characterized. OBJECTIVE: To evaluate national trends in ACDF and dysphagia rates and to identify patient, surgical, and indication-specific risk factors for postoperative dysphagia. METHODS: A retrospective analysis of the Nationwide Inpatient Sample identified adult patients undergoing elective ACDF from 2016 to 2022. Multivariable logistic regression was used to determine independent risk factors for dysphagia and develop a predictive nomogram. Separate models were also constructed for single- and multilevel ACDF. RESULTS: Among 496,425 hospitalizations, dysphagia occurred in 7.7% of patients. Despite a 57.3% decline in ACDF, the odds of dysphagia increased at an estimated 11.4% annually (OR: 1.11, 95% CI: 1.09-1.13; p < 0.001). Cervical diffuse idiopathic skeletal hyperostosis (OR: 5.41; 95% CI: 3.81-7.67), cervical spine fracture (OR: 1.73; 95% CI: 1.31-2.30), and pseudoarthrosis (OR: 1.36; 95% CI: 1.15-1.61) were strong independent predictors of dysphagia. Additional risk factors included racial minority status, higher comorbidity burden, and care at urban teaching hospitals. Risk factors differed between single- and multilevel ACDF. Dysphagia was associated with higher rates of complications, including aspiration pneumonia, percutaneous endoscopic gastrostomy placement, and tracheostomy (all p < 0.001). CONCLUSIONS: These findings represent the first national analysis to demonstrate a decline in inpatient ACDF volumes yet rising postoperative dysphagia rates. Selective surgical indications emerged as key predictors, informing the development of a nomogram for risk stratification and preoperative optimization in ACDF patients.