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.