Clinical Neurology and Neurosurgery 115 (2013) 1842–1844
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Esophageal perforation more than 10 years after anterior cervical spine plating J. Lucas, E. Smith, M. Eskander ∗ , J. McPhee, A. Lapinsky Department of Orthopedics, University of Massachusetts Memorial Medical Center, 119 Belmont St., Worcester, MA 01605, USA
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Article history: Received 17 July 2012 Received in revised form 27 December 2012 Accepted 20 January 2013 Available online 5 March 2013 Keywords: Delayed esophageal perforation Delayed esophageal erosion Cervical plating
1. Introduction Esophageal perforation is a relatively rare but serious complication of anterior cervical discectomy and fusion. Most cases present as early within weeks of the initial surgery, but some cases can present years later due to a variety of mechanisms. This report details a case of esophageal perforation discovered 10 years after initial cervical surgery. 2. Case report This is a case report of an 85-year-old man with a delayed esophageal perforation after anterior cervical plating. After suffering an unwitnessed fall, our patient was admitted to the nearest hospital where he received a complete workup. A chest plain radiograph revealed air in the pericardium (Fig. 1). The patient’s history was signiﬁcant for anterior cervical fusion from C3 to C7 for multilevel spondylotic radiculopathy and myelopathy with allograft over 10 years prior. The patient appeared cachectic and stated that he had lost 100 pounds (from 211 to 111 lbs) within the last year. He had no complaints of fever, chills or sweats. He also complained of dysphagia and increasing intolerance for solid foods for the past 2–3 years. Direct laryngoscopy and direct rigid cervical esophagoscopy evidenced an exposed metal plate in
∗ Corresponding author at: Christiana Spine Center LLC, 4735 Ogletown-Stanton Road, Map 2, Suite 3302, Newark, DE 19713, USA. Tel.: +1 302 623 4144; fax: +1 302 623 4147. E-mail address: [email protected]
(M. Eskander). 0303-8467/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.clineuro.2013.01.016
thehypopharyngeal esophageal lumen at the approximate level of the cricoid cartilage and extending slightly below. Axial computed tomography (CT) at the cervical level revealed communication of the esophagus and the plate (Fig. 2). As a result of these ﬁndings, the patient was scheduled for surgery. To improve the postoperative prognosis, the surgeons placed a percuatenous endoscopic gastrostomy (PEG) tube before initiating cervical spine hardware removal. A left-sided approach was taken. After isolation and retraction of the carotid sheath laterally and the esophagus and trachea medially, the border of the cervical plate could be palpated. The esophageal defect was continuous with the plate and preveretebral space. The plate and screws were removed intact, revealing a diverticulum composed of excess esophageal tissue protruding into the lumen. The esophageal defect was closed using a patch of AlloDerm dermal matrix and running sutures. The tissue was sealed with ﬁbrin glue and a drain was left in place. Cultures of the removed cervical plate demonstrated growth of both candida albicans and oral ﬂora including beta hemolytic streptococcus. The patient was given comfort measures only status 18 days post-op due to respiratory failure secondary to pneumonia.
3. Discussion Based on a review of previous literature, there is no consensus for the optimal management of delayed esophageal perforation. One of the unique features of our case is the long (>10 years) asymptomatic period between his anterior cervical discectomy and fusion and development of a delayed esophageal erosion. Prior to this, the longest documented case of delayed esophageal erosion was
J. Lucas et al. / Clinical Neurology and Neurosurgery 115 (2013) 1842–1844
Fig. 1. AP plain radiograph showing pneumomediastinum.
9 years after the initial surgery . With the exception of dysphagia after cervical surgery, our patient was asymptomatic until 7–8 years after the anterior cervical plating. At this point he began experiencing increasing intolerance to solid food. Unlike many other reported cases presenting with delayed esophageal erosion after anterior cervical surgery, there were no signs of hardware failure, or graft dislodgement. The use of anterior cervical spine fusion and stabilization as a means of treating cervical spondylitic disease, cervical myelopathy/radiculopathy and cervical spine trauma has become commonplace due to reported fusion rates upwards of 98% . However some reported complications include esophageal erosion to deep neck space infection, mediastinitis, airway obstruction, etc.
Fig. 2. Axial computed tomography (CT) revealing communication of the esophagus and the plate.
. Esophageal perforation, while relatively uncommon with an incidence of 0.002–1.49% is a serious complication with a mortality rate of 12–20%. After esophageal erosion the clinical picture can include local infection, subsequent osteomyelitis, mediastinitis, and death [2,4]. Review of the literiatrogenic injury during surgery (this includes acute and delayed injuries) . Common causes of esophageal injury include: trauma from surgical instrumentation; traumatic intubation; pressure from long term artiﬁcial ventilation via tracheostoma; compression of the esophagus between a retractor and nasogastric tube; suboptimal placement of the graft and/or hardware; and migration of the graft and/or hardware due to failure or dislodgement; the latter two instances causing chronic friction with the posterior esophagus. Sharp instruments or retractor blades most frequently cause acute injuries, and thus contribute to early presentation. Delayed injuries, however, are most frequently caused by erosion of the posterior wall of the esophagus by the graft or instrumentation; the risk of which can be reduced through cervical plating . Some authors suggest that plating may result in early mobilization and reduced complications, especially in multi-level fusions . Compared to acute esophageal perforations commonly presenting with pain, dysphagia, cough aspiration, and vocal changes, delayed esophageal erosions may require a high level of suspicion to diagnose, as many may progress for extended periods of time without showing any signs or symptoms . A deﬁnitive diagnosis of esophageal erosion is made using imaging, endoscopic studies, or surgical exploration. Plain X-rays may demonstrate subcutaneous emphysema, widening of the retropharyngeal space, or loosening of the hardware. It should be noted that there is a false-negative rate of 10–46% associated with this method. Likewise, both CT scans and esophagoscopy can be useful in demonstrating graft displacement, abscess formation and hardware failure. However, in study of 44 patients by Gaudinez et al. imaging studies conﬁrmed esophageal perforations in only 72% of affected patients while esophagoscopy showed unequivocal diagnosis in only 64% highlighting a lack of sensitivity . Surgery was required for 18% of the patients in order to conﬁrm the diagnosis [4,5]. In the case of delayed esophageal erosion, basic treatment consists of surgery to remove hardware, drainage of the abscesses, closure of the perforation, parenteral nutrition and antibiotic therapy . While there is some controversy over the inﬂuence of time between injury and intervention on mortality it was shown in a study of 44 patients by Eroglu et al. that the mortality of patients treated within 24 h of injury was greatly reduced (3%) compared to those with delayed diagnosis and treatment (36.4%). In the case of delayed esophageal erosions, acute treatment is not an option. However, data presented by Eroglu et al. demonstrates the advantage of early detection. Repair methods for esophageal perforations include drainage, primary repair, muscle rotation ﬂap, feeding gastrostomy, and tracheostomy . Predicting the success of the procedure is multifactorial and should take into account the size of the defect, the timing of the recognition of the defect, and the status of cervical and esophageal stability post-fusion. The use of a muscle ﬂap has been shown to be effective in patients who are deemed to be at risk of a slow recovery from esophageal repair. The muscle ﬂap primarily serves two purposes: provided increased delivery of antibiotics to the site of repair and providing a cushion between the disrupted anterior spine and the damaged esophagus. The most common source for cervical repair is the sternocleidomastoid, but the sternothyroid, sternohyoid, and pectoralis major muscles have also been used. While the use of a muscle ﬂap has distinct advantages, it also carries its own inherent risks. Complications include reduction in cervical motion, cosmetic deformities, and disruption
J. Lucas et al. / Clinical Neurology and Neurosurgery 115 (2013) 1842–1844
of nearby nerves such as the spinal accessory nerve and sensory nerves to the ear and neck. For older, frail patients stenting and antibiotics may sufﬁce.
We are presenting this case in order to demonstrate the necessity of detailed long-term follow up as well as create awareness for the early detection and treatment of delayed esophageal erosion. This patient was treated with drainage, allograft, and antibiotics. Unfortunately, since he died from complications associated with pneumonia it is difﬁcult to gauge the success of our treatment. Early detection would most likely have been a beneﬁt for our patient. In high risk patients, such as older patients with extensive plating in the past, a high index of suspicion for symptoms such as dysphagia, odynophagia, inﬂammation and swelling of the neck, and the presence of air in the mediastinum and prevertebral space is recommended to increase early detection.
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None of the authors received ﬁnancial support for this study.