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CASE REPORT Table of Contents   
Year : 2003  |  Volume : 37  |  Issue : 3  |  Page : 19
Pharyngoesophageal perforation following anterior cervical spine surgery - A Case Report


Sushrut Hospital, Research Centre & Post Graduate Institute of Orthopaedics, Nagpur, India

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How to cite this article:
Pande K C. Pharyngoesophageal perforation following anterior cervical spine surgery - A Case Report. Indian J Orthop 2003;37:19

How to cite this URL:
Pande K C. Pharyngoesophageal perforation following anterior cervical spine surgery - A Case Report. Indian J Orthop [serial online] 2003 [cited 2019 Dec 16];37:19. Available from: http://www.ijoonline.com/text.asp?2003/37/3/19/48561

   Introduction Top


Since its introduction, anterior cervical fusion has been an effective method of management of a variety of cervical disorders including disc degeneration, vertebral collapse resulting from metastatic disease and traumatic fracture dislocation. [1] Cloward presented an overview of complications of anterior cervical spine surgery .[2] Complications of anterior cervical spine surgery may occur from injury to arteries, veins, nerves, the pharynx, oesophagus, larynx and pleura as well as spinal cord and nerve roots. Perforation of the pharynx and oesophagus is one of the rare and an infrequent complication but a life­threatening problem because of the risk of sequlae from mediastinitis or infective spondylitis. [3] The diagnosis of this complication is often delayed making treatment difficult and resulting in significant patient morbidity and mortality.


   Case Report Top


A 59 year-old male was admitted following a driving accident. He was diagnosed to have quadriplegia due to complex fracture dislocation of C 5 -C 6 [Figure 1]. Closed reduction of the fracture dislocation with anterior fusion and stabilization was performed from C 5 - C 7 on the same day. A 6 hole Cervical Spine Locking Plate (CSLP) was used to stabilize the spine [Figure 2]. Post-operatively, the patient was transferred to Intensive Care Unit (ICU) for respiratory support and monitoring. The patient's stay in ICU over the next month was complicated by recurrent bacteraemia and chest infection which were managed by administration of intravenous antibiotics. A week after admission, percutaneous tracheostomy was performed under adequate antibiotic cover for continued respiratory support. Investigations were performed to identify the possible source of relapsing bacteraemia. There was purulent discharge from the anterior neck wound and around the drain site and a perforation of pharynx / oesophagus and / or a deep wound infection were suspected. Plain radiographs of the cervical spine showed evidence of loosening of the CSLP and a subsequent gastrograffin study revealed a possible pharyngoesophageal fistula communicating with the prevertebral space [Figure 3]. CT scan of the neck revealed gas in the soft tissues at C 5 -C 6 level on the left side confirming extravasation from the airway [Figure 4]. Streptococcus milleri was isolated on blood cultures. The white cell count at this stage was 15.7 x 10 9 / l (Normal 4 - 11 x 10 9 / l ) with a neutrophil count of 14.92 x 10 9 / l (Normal 2 - 7 x 10 9 / l ).

One month after admission, re-exploration of the neck was performed. The CSLP was removed with debridement of the operative site and a halo was applied to stabilize the cervical spine. The perforation of the pharynx and oesophagus was repaired by mucosal closure with a corrugated drain and a nasogastric tube was inserted. The immediate postoperative course was uneventful and enteral feeding via the nasogastric tube was started on the first postoperative day.

Two weeks after this procedure the patient had features of persistent pharyngeal fistula typified by a persistent discharge from the neck wound, drain site and the oral cavity. This was managed by insertion of a large size Atkinson tube per orally. This resulted in an improvement in the patient's general condition. There was no change in the neurological status. One week after insertion of Atkinson tube, there was a continued persistence of the purulent discharge from the neck wound. Pharyngoscopy was performed with removal of the Atkinson tube and a pharyngocutaneous stoma was fashioned to aid drainage and a feeding jejunostomy was placed to aid with nutritional support. Postoperatively the patient developed ischaemic brain damage, which was confirmed by a CT scan. The patient subsequently died 24 hours after his last surgery.


   Discussion Top


Perforation of the pharynx and oesophagus is a rare complication of anterior cervical spine surgery. The actual incidence of this complication is not known as a large number of reports in the literature have primarily focused on the neurological complications. Most of the reported instances have been in the form of case reports. [4],[5],[6],[7],[8],[9],[10],[11],[12] Flynn surveyed 704 neurosurgeons by questionnaire. [13] In this survey, of a total of 82,114 patients who had anterior cervical spine surgery, 5 succumbed to pharyngeal perforation. A review of 258 cases of anterior cervical spine surgery performed at the Centre for Spinal Studies & Surgery over 3 years revealed the present case to be the only instance of pharyngoesophageal perforation. The etiology of pharyngoesophageal perforation following anterior cervical spine surgery is not clearly understood. Most authors believe that it is due to pressure necrosis caused by retractor blade during surgery [2],[5],[14] , migration of screws [15] , direct injury by a fractured vertebra, overstretching during an accident [6] , injury during endotracheal or nasogastric intubation, migration of solid bone graft or perforation by prominent screw heads. [4],[16] The most likely cause of pharyngoesophageal perforation in the case reported here was pressure necrosis caused by retractor blade during surgery. There was no evidence of injury to the pharynx or oesophagus at the end of surgery. On the postoperative radiographs, the screw heads were not seen to be prominent, ruling this out as a possible cause. The likely sequence of events being pressure necrosis of the pharyngoesophageal wall leading to infection at the operative site, which resulted in the loosening of the CSLP.

Certain symptoms and clinical signs should alert clinicians to the possibility of an pharyngoesophageal perforation especially after internal fixation of the cervical spine. Usually no absolute pathognomonic signs exists. Neck pain, redness and swelling, unresponding pyrexia, tenderness and crepitus of the neck are indicative of an oesophageal injury associated with infection. Air in the cervical fascial spaces is an obvious indication of an njury to the upper aerodigestive system as was seen in this case. This case also illustrates the use of Gastrograffin study in the diagnosis of a suspected pharyngoesophageal perforation. The cervical spine in such a case needs stabilisation by alternative means after debridement and removal of implants. [12],[16]

There is considerable controversy regarding the best modality of management of pharyngoesophageal perforation following anterior cervical spine surgery. Conservative treatment consisting of intravenous antibiotics, elimination of oral intake and parenteral nutrition has been used in certain cases with success. [16],[17] The treatment of choice is surgical exploration, repair and drainage of the fistula / abscess. In cases of delayed diagnosis, treatment must be restricted to drainage of the associated abscess and diversion of the fistula. The insertion of a 'T' tube allows healing of small perforations of the oesophagus without the risk of leakage. After stabilisation, the pharyngoesophagocutaneous fistula tends to close spontaneously after which the tube can be removed. In large perforations, there remains the possibility of oesophagostomy with secondary reconstruction. [18] Sternocleidomastoid myoplasty has been used for the repair of chronic cervical pharyngoesophageal fistulae, where a localised muscle flap is turned down to provide vascularised coverage for the larger defects unsuitable for primary or advancement closure. [19] In the patient reported here, the pharyngoesophageal perforation was initially managed by mucosal closure. This possibly failed because of inadequate debridement and persistence of the infection. In the next stage, as suggested in the literature, an Atkinson tube was inserted, but this also failed to heal the persistent fistula.

The increased morbidity associated with pharyngoesophageal perforation is due to the difficulty in managing the unstable cervical spine in a quadriplegic patient along with management of vertebral osteomyelitis and chest infection which is common in such patients. The patients life is threatened by sepsis and mediastinitis. [3] High mortality may be associated with penetrating injuries of oesophagus which were initially missed. [20]

In conclusion, perforation of the pharynx or oesophagus following anterior cervical spine surgery is a rare complication. Prevention consists of the careful placement of retractor blades and gentle tissue handling during surgery. In the absence of any pathognomonic signs, a high index of suspicion is required for the early diagnosis of pharyngoesophageal perforation. Delay in diagnosis may occur because of lack of awareness of this complication and is associated with a high mortality.

 
   References Top

1.Robinson RA, Smith GW. Anterolateral cervical disc re-moval and interbody fusion for the cervical disc syndrome. Bull Johns Hopkins Hosp 1955;96:223-224.  Back to cited text no. 1    
2.Cloward RB. Complications of anterior cervical disc op­eration and their treatment. Surgery 1971;69:175-182.   Back to cited text no. 2  [PUBMED]  
3.Bohlman HH. Complications of treatment of fractures and dislocations of the cervical spine. In Complications in Or-thopaedic Surgery, Vol. 2. Philadelphia; JB Lippincott. 1986: 681-712.  Back to cited text no. 3    
4.Yee GKH, Terry AF. Esophageal penetration by an ante-rior cervical fixation device. Spine 1993;18(4):522­-527.  Back to cited text no. 4    
5.Newhouse KE et al. Oesophageal perforation following anterior cervical spine surgery. Spine 1989;14: 1051-1053.  Back to cited text no. 5    
6.Pollock RA, Pervis JM, Apple DF, Murray HH. Esoph-ageal hypopharyngeal injuries in patients with cervical spine trauma. Ann Otol Rhinol Laryngol 1981;90: 323-327.  Back to cited text no. 6    
7.Balmaseda MT, Pellioni DJ. Oesophagocutaneous fistula in spinal cord injury : A complication of the anterior cervi-cal fusion. Arch Phys Med Rehabil 1985;66:783-784.  Back to cited text no. 7    
8.Whitehill R, Sirna EC, Young DC, Cantrell RW. Late esophageal perforation from an autogenous bone graft: Re-port of a case. J Bone Joint Surg [Am] 1985;67: 644-645.  Back to cited text no. 8  [PUBMED]  
9.Lindhorst E, Encke A. Esophageal perforation. A rare complication after operation of degenerative and traumatic pathology of the cervical spine. Zentralbl Chir 1999;124:562-567.  Back to cited text no. 9    
10.Muller CA, Strohm PC, Pfister U. Esophageal perfora-tion by osteosynthesis material after ventral spondylodesis of the cervical spine. Unfallchirurg 2001;104: 549-552.  Back to cited text no. 10    
11.English GM, Hsu SF, Edgar R, Eccles MG. Esophageal trauma in patients with spinal cord injury. Paraplegia 1992;30:903-912.  Back to cited text no. 11    
12.Sharma RR, Sethu AU, Lad SD, Tural KE, Pawar SJ. Pharyngeal perforation and spontaneous extrusion of the cervical graft with its fixation device: a late complication of C2-C3 fusion via anterior approach. J Clin Neurosci 2001;8: 464-468.  Back to cited text no. 12    
13.Flynn TB. Neurological complications of anterior cervi-cal interbody fusion. Spine 1982;7: 536-539.   Back to cited text no. 13  [PUBMED]  
14.Tew JM Jr, Mayfield FH. Complications of surgery of the anterior cervical spine. Clin Neurosurg 1976;23:424- 434.  Back to cited text no. 14  [PUBMED]  
15.Smith MD, Bolesta MJ. Esophageal perforation after an-terior cervical plate fixation: a report of two cases. J Spinal Dis 1992;5(3): 357-362.  Back to cited text no. 15    
16.Hanci M, Toprak M, Sarioglu AC, Kaynar MY, Uzan M, Islak C. Oesophageal perforation subsequent to ante-rior cervical spine screw / plate fixation. Paraplegia 1995; 33(10): 606-609.  Back to cited text no. 16    
17.17. Skinner DB, Belsey RHR. Penetrating wounds, crush in-juries, foreign bodies and other cases of tracheoesophageal fistula. In Management of Esophageal Disease. Philadel-phia; WB Saunders.1988: 792-801.   Back to cited text no. 17    
18.Van Berge Henegouwen DP, Roukema JA, de Nie JC, vd Werken C. Esophageal perforation during surgery on the cervical spine. Neurosurgery 1991;29: 766-768.   Back to cited text no. 18  [PUBMED]  
19.Fuji T, Kuratsu S, Shirasaki N, Harada T, Tatsumi Y, Satani M, Kubo M, Hamada H. Oesophagocutaneous fis-tula after anterior cervical spine surgery and successful treat-ment using sternocleidomastoid muscle flap. Clin Orthop 1991; 267: 8-13.  Back to cited text no. 19    
20.Defore WW, Mattox KL, Hansen HA, Garcia­Rinaldi R, Beall AC, DeBeaky ME. Surgical management of pen-etrating injuries of the esophagus. Am J Surg 1977;134: 734-737.  Back to cited text no. 20    

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Correspondence Address:
K C Pande
Sushrut Hospital, Research Centre & Post Graduate Institute of Orthopaedics, Nagpur
India
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Source of Support: None, Conflict of Interest: None


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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