Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 51, Num. 4, 2003, pp. 534-536

Neurology India, Vol. 51, No. 4, October-December, 2003, pp. 534-536

Case Report

Delayed pharyngo-esophageal perforation: Rare complication of anterior cervical spine surgery - Case reports

Shenoy SN, Raja A

Department of Neurosurgery, Kasturba Medical College and Hospital, Manipal
Correspondence Address:Department of Neurosurgery, Kasturba Medical College and Hospital, Manipal - 576119. Udupi, shenoysn@yahoo.com

Code Number: ni03170

Abstract

An injury to the pharynx and esophagus is a known complication of anterior cervical spine surgery. Two cases of delayed pharyngo-esophageal perforation following anterior cervical spine surgery that resulted in fistula are presented. We postulate that graft displacement and dislodgement of implant with resulting esophageal erosion was responsible for this complication.

Introduction

Injuries to the pharynx and esophagus are known complications of anterior cervical spine surgery.[1] One-third of the reported cases of esophageal perforation occurred during surgery.[1] Very few cases of delayed pharyngo-esophageal perforation are reported in the literature.[1],[2],[3],[4],[5] Of the 260 cases of anterior cervical spine surgeries in the last 15 years, we had 2 cases of delayed esophageal fistulas. We report these cases of delayed pharyngo-esophageal perforation secondary to anterior cervical spine surgery.

Case Reports

Case 1
A 32-year-old gentleman underwent discectomy at C4-5 and C5-6 levels with single level bony fusion for cervical myelo-radiculopathy. A routine check X-ray of the cervical spine on the 5th postoperative day revealed partial extrusion of the bone graft [Figure:1a]. As the patient was asymptomatic, he was treated conservatively with cervical collar and discharged. He presented to us again at the end of 4 weeks with history of sudden bouts of purulent vomiting and a progressively increasing swelling at the operation site. On examination, he had a diffuse tender swelling at the operation site. Plain X-ray of the cervical spine revealed an air-fluid level in the prevertebral region with total extrusion of the bone graft [Figure:1b]. While he was waiting for drainage, the swelling ruptured discharging purulent material containing mucus and food particles. He underwent drainage of the pus and debridement including removal of the extruded bone graft. The culture of the pus showed growth of mixed organisms with sensitivity to multiple antibiotics. Hence he was started on Inj. Penicillin, Chloromycetin and Metronidazole. Postoperatively, he was continued on antibiotics and Ryle's tube feeding for 4 weeks. At 4-year follow-up, the patient was asymptomatic and X-ray of the cervical spine revealed bony fusion and no evidence of instability.

Case 2
An 18-year-old gentleman was referred to our department, with history of discharge from the neck. He underwent anterior cervical stabilization using plate and screw for fracture of the C4 vertebra [Figure:2a]. About 3 weeks later he developed a swelling at the operation site, which later ruptured discharging pus and food materials. On neurological examination, he was quadriplegic with grade 0/5 power below C6 level. The fistula was diagnosed after confirming the leakage of oral methylene blue from the operated site. The X-ray of the cervical spine showed loosened implant and screw with specks of air [Figure:2b]. He underwent drainage of the pus and debridement. The implant was found loose and eroding into the esophagus causing a large defect in the posterior esophageal wall. As the edges of the defect were edematous and friable, primary closure of the defect could not be done. Hence the sternocleidomastoid muscle flap was used to repair the esophageal defect. The pus culture showed growth of the Staph. Epidermidis sensitive to penicillin, quinolones, vancomycin and amino glycosides. Postoperatively, the patient was continued on Ryle's tube feeding and antibiotics (Penicillin and Gentamycin) for 8 weeks. Despite external healing of the fistula, esophagogram revealed persistent extravasation of contrast at the end of 3 weeks [Figure:2c]. Hence tube feeding was continued for one more month before starting oral feeding. At 6-month follow-up, in spite of complete healing of fistula, there was no change in his neurological state. The patient expired 2 months after the follow-up due to renal failure.

Discussion

Esophageal perforation following anterior cervical spine surgery is an uncommon but potentially devastating complication.[1],[2] This complication may occur during surgery, early in the postoperative period or months later.[2] Very few cases of delayed esophageal perforation are reported in the literature.[1],[2],[3],[4],[5] As it has happened in the present cases, the esophageal perforation is commonly associated with protruded or loosened hardware or dislodged bone graft.[1] Persistent dysphagia, especially associated with odynophagia following anterior cervical spine surgery should be evaluated for graft/implant-related complications.[6] The presence of air in the fascial planes of the neck and increasing soft tissue swelling in the postoperative X-ray suggest esophageal perforation.[6] The diagnosis can be confirmed by contrast esophagography with a high accuracy rate.[1],[5]

The treatment of esophageal perforation depends upon the severity of the problem, the patient's general condition and the presence of any complications. Asymptomatic extrusion of the graft in the gastrointestinal tract should be observed carefully for the development of any complications.[3],[4],[7] Patients presenting with external fistula and abscess formation require wound debridement and removal of the graft and internal fixation device as described in our patients.[2] Patients with a large esophageal defect require reinforcement using the sternocleidomastoid muscle flap.[8] It is better to delay oral feeding for at least 4-6 weeks after the healing is demonstrated radiologically.[5] We conclude that graft/implant dislodgement was responsible for the esophageal perforation, and early recognition and proper management of postoperative esophageal fistulas prevents further major complications.

References

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