Esophageal Perforation due to Anterior Cervical Spine Hardware Placement: Case Series

Abstract

Context. This case series discusses surgical management of esophageal perforations that occurred following cervical spine hardware placement. Purpose. (1) Determine presenting symptoms of esophageal perforation after anterior cervical spine hardware placement. (2) Discuss surgical management of these resulting esophageal perforation complications. Design/Setting. Case series of six patients at a tertiary-care, academic medical center. Patient Sample. Six patients with pharyngoesophageal perforations following anterior cervical spine surgery (ACSS). Outcome Measures. Date of ACSS, indication for ACSS, level of hardware, location of esophageal or pharyngeal injury, symptoms at presentation, surgical intervention, type of reconstruction flap, wound culture flora, and antibiotic choice. Methods. A retrospective review of patients with an esophageal or hypopharyngeal injury in the setting of prior ACSS managed by the otolaryngology service at a tertiary, academic center between January 2015 and January 2019. Results. Six patients who experienced pharyngoesophageal perforation following ACSS are included in this study. Range of presentation was two weeks to eight years following initial hardware placement. Five patients presented with an abscess and all had evidence of perforation on initial CT or esophagram. All patients underwent repair with a sternocleidomastoid flap with two patients eventually requiring an additional pectoralis myofascial flap for a persistent esophageal leak. Five patients eventually attained ability to tolerate oral nutrition. An algorithm detailing surgical reconstructive management is proposed. Conclusions. Esophageal perforations in the setting of prior ACSS are challenging clinical problems faced by otolaryngologists. Consideration should be given to early drainage of abscesses and spine surgery evaluation. Spinal hardware removal is recommended whenever possible. Utilization of a pedicled muscle flap reinforces primary closure and allows coverage of the vertebral bony defect. Nutrition, thyroid repletion, and culture-directed IV antibiotics are necessary to optimize esophageal perforation repair.

Esophageal Fistula following Anterior Cervical Discectomy and Fusion in Traumatic Cervical Injury Cases: A Review

“…Esophageal perforation may manifest itself, intraoperatively with recognized injury or anytime from the early postoperative period to years later, with varied clinical presentation. [1][2][3][4][7][8][9] Most commonly patients presented with dysphagia and odynophagia in a literature review by Halani et al 2 Postoperatively, any patient presenting with neck swelling, persistent neck or throat pain, crepitus in the neck, wound leak, cervical abscess, fever, septicemia, mediastinitis, or unexplained fevers should alert the clinician to the possibility of esophageal perforation. 10,11 As dysphagia is the most common presenting symptom, any patient with difficulty in swallowing after an anterior surgical intervention to the cervical spine, even years later, should undergo a thorough workup for a possible esophageal perforation.…”

“…There is a dilemma in the literature, whether these injuries needs to be treated aggressively or a conservative approach is more optimal. [1][2][3][4][5][6][16][17][18] As morbidity and mortality associated with esophageal perforation is high, timely diagnosis and early institution of appropriate treatment is of paramount importance for successful outcome.…”

“…Therefore more and more studies are favoring early surgical intervention for the management of esophageal fistulas. [1][2][3][4][5][6]…”

“…Most of these complications are transient and self-limited, but in some unfortunate instances, they may lead to significant morbidity and mortality. [1][2][3][4][5] Esophageal perforation is one such devastating iatrogenic complication. Reported incidence in the literature varies from 0.04 to 0.25%.…”

“…Patient may be asymptomatic or may present with dysphagia, odynophagia, local soft tissue infection, deep infection with hardware failure, osteomyelitis, pseudo arthrosis, and can be fatal at times with sepsis/infectious mediastinitis. [1][2][3][4][7][8][9] As morbidity and mortality from this complication is high early diagnosis and prompt institution of therapy is essential for successful outcome. In this review article, we will discuss the management dilemmas in patients with esophageal perforation along with an illustrative case.…”