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Ann Thorac Surg 2005;80:349
© 2005 The Society of Thoracic Surgeons

Images in cardiothoracic surgery

Delayed Esophageal Perforation: A Complication of Anterior Cervical Spine Fixation

Anastasios K. Konstantakos, MD, R. Thomas Temes, MD*

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation at MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio

* Address reprint requests to Dr Temes, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation at MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH44109 (Email: temest{at}ccf.org).

A 58-year-old human was involved in a motor vehicle accident and sustained a cervical spine fracture resulting in tetraplegia. One month after initial treatment with a halo vest, open reduction of a C5–6 subluxation, corpectomy of C6, fusion of C5–7 with iliac crest bone, and anterior plating were performed. Postoperatively, he required prolonged mechanical ventilation necessitating a tracheostomy. Mechanical ventilation was successfully discontinued and his tracheostomy was removed 9 weeks after insertion. A percutaneous gastrostomy was placed due to his persistent dysphagia; esophagoscopy during this procedure was normal.

Nine months after his accident, dislodgement of the anterior plate and resorption of the bone graft were identified. He underwent removal of the infected bone and plate, corpectomy with interbody fusion at C4-T1, and anterior autologous fibular strut bone grafting of C4-T1. A posterior cervical fusion of C4-T1 with autologous fibular bone graft and posterior axis plating was performed. Postoperatively, copious drainage from the anterior cervical incision developed. A fistula from the left piriform sinus to the prevertebral space was identified with contrast studies and direct laryngoscopy. Repeat esophagoscopy revealed a normal esophagus. The neck wound was managed with local wound care and ultimately healed.

Two years after the initial injury the patient’s dysphagia still persisted. In addition, he complained of globus and odynophagia. He was able to swallow his oral secretions but required tube feedings for nutrition. A computed tomographic scan of the neck showed air within the corpectomy defect and surrounding the fibular graft, with a small surrounding fluid collection and possible communication to the esophagus (Fig 1). Endoscopy revealed the fibular bone graft protruding into the proximal esophagus 17 cm from the incisors (Fig 2). Intraoperatively, the fibular graft was found to be solidly incorporated, but the proximal end was displaced from the spine and had penetrated into the esophagus. Thus, the fibular graft was removed and the esophageal opening drained. He did well and was discharged 1 week postoperatively. He was doing well at 14-month follow-up, without esophageal complaints.



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  		Fig 1.
 


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  		Fig 2.
 
Patients who sustain flexion injury to the cervical spine with fracture and(or) dislocation of cervical vertebrae often require spinal stabilization. Definitive surgical intervention typically involves an anterior approach to expose the vertebral bodies. The fusion of cervical vertebrae is usually performed by using allografted bone. Pharyngoesophageal injury after anterior spinal fusion procedures has been described since the development of the procedure. The cause of esophageal peroration in this setting is not clearly understood, but the dislocation of a solid bone graft caused by nonunion from infection is one likely explanation. Other possibilities may include direct injury by a fractured vertebra, overstretching during an accident, trauma during endotracheal or nasogastric intubation, or an intraoperative injury caused by a retractor blade.

The treatment for such esophageal perforations is controversial. Conservative treatment with local drainage, administration of parenteral antibiotics, external orthotic support, and tube feedings may be possible when a foreign body is not present in the esophagus. However, as in this case, early surgical closure, debridement, and removal of the foreign body are required.




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N. Rueth, D. Shaw, S. Groth, S. Stranberg, J. D'Cunha, J. Sembrano, M. Maddaus, and R. Andrade
Management of Cervical Esophageal Injury After Spinal Surgery
Ann. Thorac. Surg., October 1, 2010; 90(4): 1128 - 1133.
[Abstract] [Full Text] [PDF]

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