An t e r i o r cervical spine surgery is one of the most. Management of delayed esophageal perforations after anterior cervical spinal surgery

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1 J Neurosurg Spine 11: , 11: , 2009 Management of delayed esophageal perforations after anterior cervical spinal surgery Clinical article El i a s Da k w a r, M.D., 1 Ju a n S. Ur i b e, M.D., 1 Ta pa n A. Pa d h ya, M.D., 2 a n d Fe r n a n d o L. Va l e, M.D. 1 Departments of 1 Neurological Surgery and 2 Otolaryngology, University of South Florida, Tampa, Florida Object. Delayed esophageal perforation is an uncommon but well-known complication after anterior cervical spine surgery. To the authors knowledge there is no consensus to the optimal management of these patients in the literature. Methods. The authors performed a retrospective review of 5 cases involving patients who were referred to their institution for the management of delayed esophageal perforations after undergoing anterior cervical spine surgery for a variety of reasons. Results. The primary presenting symptom in all 5 patients was dysphagia. All patients initially underwent primary closure of the perforation with a sternocleidomastoid muscle flap. One patient required multiple surgeries to correct the perforation and ultimately required a free flap. Conclusions. The authors recommend a multidisciplinary approach that involves otolaryngological surgeons as well as spine surgeons. They recommend removal of all anterior hardware and believe that it is essential to the treatment of esophageal perforations. If the patient does not have evidence of fusion at the time of presentation, then posterior cervical instrumentation is a viable alternative. (DOI: / SPINE08522) Ke y Wo r d s esophageal perforation anterior cervical spine surgery management An t e r i o r cervical spine surgery is one of the most commonly performed procedures in the US for degenerative disc disease with or without myelopathy, neoplasm, and trauma. The anterior approach to the cervical spine was initially described by Smith and Robinson, Bailey and Badgley, and Cloward. 2,7,9,10,25,26 These techniques have since been refined with the use of internal fixation with or without bone implants. Anterior plate and screw fixation has been advocated to ensure immediate stabilization, improve the union rate, decrease the need for external immobilization, prevent graft migration, and in certain instances avoid the need for posterior procedures. Esophageal perforation is a well-recognized complication of anterior cervical spine surgery. 8,16,21,27 It is a relatively uncommon complication, but can be highly morbid or even fatal. The incidence of esophageal perforation after anterior cervical spine surgery is estimated to be between 0.02 and 1.49%. 5,14,21,22,27 The mortality rate Abbreviations used in this paper: ACDF = anterior cervical discectomy and fusion; SCM = sternocleidomastoid. for cervical esophageal perforations is 6%. 4 Esophageal perforation may occur intraoperatively, perioperatively, or in a delayed fashion. Delayed esophageal perforations have been described occurring from weeks to years after anterior spinal surgery. The clinical presentation of patients with this condition is extremely variable; patients may have painful cervical swelling, fevers, dysphagia, odynophagia, or subcutaneous emphysema or be completely asymptomatic. 14 There have been several reports in the literature of delayed esophageal perforations including asymptomatic hardware extrusion. 24 A common theme proposed in the literature has been that early recognition and aggressive investigation and treatment are essential to ensure a good outcome. Nevertheless, the management has been extremely variable. The surgical plan must take 2 factors into consideration: 1) method of esophageal repair, and 2) the stability of the spine. A customized interdisciplinary surgical approach is essential for successful treatment. We describe the management strategies in a group of patients with delayed esophageal perforations treated at our institution. 320 J Neurosurg: Spine / Volume 11 / September 2009

2 Delayed esophageal perforation Methods This is a retrospective study of 5 cases of delayed esophageal perforation following anterior cervical spine surgery that were managed at our institution during In all 5 cases, the initial surgery was performed by physicians who were not at our institution, and all of the patients were subsequently referred to our institution for management of complications. The surgical plan addressed the status of spinal fusion and method of esophageal repair. The esophageal perforations were managed according to their morphological characteristics and the clinical condition of the patient. Perforations with healthy margins in a clinically stable patient were managed with primary repair. Patients with unhealthy margins or evidence of sepsis were treated with drains and diversions. The status of spinal fusion was assessed preoperatively by standard radiological techniques including CT scans and flexion-extension radiographs. Patients with documented spinal fusion did not undergo additional stabilization. Patients without evidence of spinal fusion underwent posterior cervical instrumentation and fusion for spinal stability. All patients were followed up for evidence of spinal instability. The clinical characteristics of all 5 cases are summarized in Table 1. Case 1 Summary of Cases History and Presentation. This 38-year-old man with a medical history significant for ankylosing spondylitis and Crohn disease had sustained a C6 7 fracture dislocation and incomplete spinal cord injury as a result of an assault and ground-level fall. He underwent a C6 7 ACDF with anterior plate placement and C5 T1 posterior instrumentation and fusion. His early postoperative course was uneventful, but 27 months postoperatively he presented with dysphagia and recurrent aspiration pneumonia. Examination Findings. He was found to have erosion of the esophagus, with the anterior cervical plate visible during esophagoscopy. Preoperative radiographs did not show any backing out, loosening, or displacement of the hardware. Preoperative CT demonstrated stability of the spine with good solid cervical fusion (Fig. 1). Operation and Postoperative Course. The patient underwent surgery for removal of the anterior hardware, and primary repair of the esophageal perforation with a SCM muscle flap. The surgery was performed by a neurosurgeon and an otolaryngological surgeon. Intraoperatively, the screws were found to still have good solid fixation and the anterior plate was not loose. Since the patient had evidence of fusion, no further stabilization was deemed necessary. The esophageal perforation healed and he did not require any further interventions. Case 2 History and Presentation. This 36-year-old man initially presented with a C5 6 fracture dislocation and complete spinal cord injury status after a motor vehicle crash. He underwent a C5 6 ACDF with anterior plate placement and C4 7 posterior instrumentation and fusion. He presented 24 months later with dysphagia and aspiration pneumonia. Examination Findings. A barium swallow demonstrated an esophageal diverticulum at the level of C5 6. Esophagoscopy revealed that the anterior cervical hardware was exposed into the lumen of the esophagus. Preoperative CT demonstrated successful stable fusion. Operation and Postoperative Course. The anterior hardware was removed and primary repair of the esophageal perforation was performed with a SCM muscle flap. The surgery was performed by a neurosurgeon and an otolaryngological surgeon. Intraoperatively no evidence of hardware failure was seen. The patient did not require any further stabilization and recovered with no recurrence. Case 3 History and Presentation. This 38-year-old woman had undergone C5 6 ACDF for degenerative disc disease approximately 2 years after being involved in a motor vehicle accident. Postoperatively, her symptoms did not improve. She underwent a C-5 corpectomy and C4 6 an- TABLE 1: Summary of clinical characteristics in 5 patients with delayed esophageal perforation* Patient No. Primary Pathology Clinical Presentation Time to Dx Length of FU 1 trauma dysphagia, pneumonia 27 mos 2 yrs primary, SCM flap 2 trauma dysphagia, pneumonia 24 mos 2 yrs primary, SCM flap Esophageal Repair 3 spondylosis dysphagia, fever, abscess 7 mos 4 yrs primary, pectoralis flap radial forearm free flap 4 trauma dysphagia, fever, abscess 6 wks 1 yrs primary, SCM flap 5 trauma dysphagia, pneumonia 6 yrs 3 yrs primary, SCM flap * FU = follow-up. J Neurosurg: Spine / Volume 11 / September

3 E. Dakwar et al. Fig. 1. Case 1. Sagittal reconstruction (left) and axial CT (right) demonstrating evidence of air near the inferior edge of the cervical hardware. terior fusion with plate placement approximately 1 year after her initial surgery. Seven months after the second procedure, she presented to our institution with symptoms of neck pain, swelling, fevers, and dysphagia. Examination Findings. A barium swallow study demonstrated an esophageal fistula and CT revealed an epidural abscess from C-4 to T-2. Direct esophagoscopy revealed an esophageal tear in the mucosa and exposed cervical hardware. First Operation and Postoperative Course. Surgical treatment was performed by a neurosurgeon and an otolaryngological surgeon. Intraoperatively the plate appeared to be well placed and fixed, but the cage was loose, suggesting pseudarthrosis of the cervical spine. Since there was no evidence of fusion, we believed instrumentation for anterior stability was necessary. The old cage and plate were removed and replaced with a new anterior cervical cage and anterior plate. The esophageal perforation was repaired primarily with the use of a pectoralis myocutaneous flap. Second Operation and Postoperative Course. Approximately 3 weeks later the patient returned to the hospital with purulent discharge from her neck wound. She underwent repeated surgery, performed by an otolaryngological surgeon, for neck exploration, debridement of the wound, closure of the esophageal fistula, and reinsertion of the pectoralis major myocutaneous flap. Three months later an esophagoscopy was performed to assess the integrity of her esophagus; the procedure demonstrated a small esophageal defect with exposed cervical hardware. Third Operation and Postoperative Course. Because the esophagus was not being completely healed, an additional procedure was performed, during which the anterior plate was removed without removing the interbody cage. Posterior instrumentation and fusion from C-4 through C-6 was performed at this time. Her esophagus was repaired with a radial forearm cutaneous free flap. Fourth Operation and Postoperative Course. Eight months later her fistula recurred once again and we removed the anterior cervical cage. At this point CT and dynamic cervical spine radiographs demonstrated cervical stability via posterior fusion, so no additional stabilization was necessary. The esophageal perforation healed with no recurrent fistulas. Case 4 History and Presentation. This 51-year-old man had undergone a C5 6 and C6 7 ACDF following a traumatic cervical spine injury. Approximately 6 weeks postoperatively, he presented with fevers, dysphagia, and odynophagia. Examination Findings. Cervical radiographs did not show any backing out, loosening, or displacement of the hardware. A barium swallow study demonstrated an esophageal perforation, and CT of the neck revealed an abscess. First Operation and Postoperative Course. Primary repair of the esophageal perforation was performed by an otolaryngological surgeon. The patient initially did well, but 18 months postoperatively he presented with worsening dysphagia, nausea, vomiting, and regurgitation of undigested food particles. A second barium swallow study demonstrated a small pseudodiverticulum of the posterior esophagus in the area of the instrumentation. Esophagoscopy demonstrated erosion of the posterior esophagus with exposed cervical hardware. Preoperative CT demonstrated stability of the spine with good solid cervical fusion. Second Operation and Postoperative Course. The patient underwent additional surgery, performed by a neurosurgeon and an otolaryngological surgeon, for removal of the cervical hardware and layered primary closure with a SCM muscle flap. The esophageal perforation healed and he did not require any further intervention. Case 5 History and Presentation. This 61-year-old woman had undergone a C5 7 ACDF with instrumentation following a motor vehicle accident. The patient presented approximately 6 years postoperatively with worsening dysphagia and recurrent pneumonias. 322 J Neurosurg: Spine / Volume 11 / September 2009

4 Delayed esophageal perforation Examination Findings. A barium swallow study demonstrated extravasation of contrast medium on the left (Fig. 2). Rigid esophagoscopy was performed and revealed a small area of exposed metallic hardware in the cervical esophagus. Preoperative CT demonstrated stability of the spine with good solid cervical fusion. Operation and Postoperative Course. The cervical hardware was removed and primary closure was performed with a SCM muscle flap. The surgery was performed by a neurosurgeon and an otolaryngological surgeon. Intraoperatively, we identified 1 loose screw but no evidence of hardware failure. The patient s postoperative course was uneventful, and no further intervention was required. Discussion The anterior approach for cervical spine surgery was described more than 50 years ago and since then has been refined, especially with the addition of anterior plate placement. The use of an anterior cervical plate is expected to reduce graft migration, maintain alignment, and improve the rate of fusion. 3,6,18 Internal fixation has expanded the number of cervical spine pathologies treatable using the anterior approach. Despite its usefulness, complications associated with the anterior approach are well known. Esophageal perforation is an uncommon but potentially devastating complication that may present anytime from the early postoperative period to years later. In our group of patients, the time from initial surgery to the time of diagnosis ranged from 1.5 to 72 months. The clinical presentation of patients can also be extremely variable, ranging from asymptomatic to severely septic. In our clinical series the main presenting symptom was dysphagia, and no patient was asymptomatic. All patients were followed regularly until adequate healing was demonstrated with conventional radiographic studies. The length of followup ranged from 1 to 4 years (mean 2.4 years). The literature and our experience indicate that certain symptoms should raise the suspicion of a possible esophageal perforation in patients who have undergone anterior cervical spine surgery. Persistent neck pain, difficulty swallowing, unexplained fevers, or crepitus in the neck should alert the physician to aggressively investigate for esophageal perforation. 20 The diagnosis can be made by esophagogram, esophagoscopy, or CT. Contrast swallowing studies can help locate the perforation or diverticulum. In our group, all patients underwent a barium swallow study, CT, and esophagoscopy. These available diagnostic techniques are not always accurate, so negative results should not decrease suspicion of an esophageal perforation. Gaudinez et al. 14 found that only 72% of patients with an esophageal perforation had positive findings on an imaging study, and the diagnosis was made by endoscopy in only 64% of cases. The addition of high-resolution MR imaging to the preoperative workup is useful for the diagnosis of cervical osteomyelitis with or without the presence of epidural abscesses. Magnetic resonance imaging with and without the administration of contrast medium represents the gold J Neurosurg: Spine / Volume 11 / September 2009 Fig. 2. Case 5. Radiograph demonstrating a moderate-sized esophageal diverticulum/fistula with retained food and contrast medium in this patient who had undergone cervical fusion. standard in the diagnosis of cervical osteomyelitis, with a sensitivity of 96% and a specificity of 93%. Contrastenhanced T1-weighted images are the most sensitive diagnostic images for osteomyelitis. 1 Various etiologies of esophageal perforations have been described, with the most common being surgery. Delayed injuries are the result of erosion of the posterior wall of the esophagus by the graft and/or the instrumentation affecting the posterior wall of the esophagus. 13,16,19,28 Hanci et al. 17 suggested that esophageal perforations were due to pressure sores caused by the metallic implant and its microtrauma effect on the esophagus. It has been re- 323

5 E. Dakwar et al. Fig. 3. Proposed algorithm for evaluation and treatment of delayed esophageal perforation. Flex/Ext = flexion-extension. ported with and without instrumentation failure. 29 There have been reported cases of orally or intestinally extruded screws. 12,15 It has been suggested in the literature that a predisposing factor is suboptimal placement of screws. 12 In our group we did not identify any evidence of hardware failure or screw pullout, but did identify 1 loose screw. The status of spinal fusion at the time of presentation in these patients may also vary. In our group, all patients underwent preoperative CT and flexion-extension radiographs to determine if fusion had taken place and to ascertain the status of spinal stability. We removed the anterior hardware without supplementation in all but 1 patient. The patient in Case 3 presented to our institution approximately 7 months after her initial surgery. At that time she did not show any evidence of fusion, so we did not completely remove the anterior hardware, but simply revised it. In this case the patient developed multiple recurrent fistulas that ultimately did not resolve until all anterior hardware was removed. It is our recommendation that all anterior cervical hardware should be removed for adequate healing of esophageal perforation. Posterior cervical supplementation can be used to achieve spinal instability, if necessary. There are several treatment options for the repair of esophageal perforations. Some authors have advocated conservative management for small contained defects consisting of extraoral feeding, antibiotic therapy, and close observation. 23 We recommend neck exploration and primary repair of the perforation reinforced by a muscle flap. The muscle functions as a buttress for the repair, provides a layer between the esophagus and the graft, and increases antibiotic delivery to the site. In our patient group we used the SCM muscle in 4 of 5 cases with great success. The SCM is a great candidate because it is pliable, has great blood supply, easy to harvest and has low donor-site morbidity. 11 Other flaps that have been used include pleura, sternohyoid muscle, sternothyroid muscle, pectoralis muscle, and omentum. 4 The muscle flap is harvested by exposing the entire lateral and medial surface of the SCM muscle. The dissection is carried around the muscle, with special attention to identifying and preserving the spinal accessory nerve. The nerve is then dissected as it courses through the muscle so as to free all the muscle below the nerve as an inferiorly pedicled flap. The distal end of the flap is then secured to the prevertebral tissue on the contralateral side to hold it in place during healing. Complications associated with the use of an SCM flap include functional loss of cervical motion, mild deformity in the neck, and disruption of sensory nerves to the ear and neck. 324 J Neurosurg: Spine / Volume 11 / September 2009

6 Delayed esophageal perforation Conclusions Delayed esophageal perforation is a rare but serious complication of anterior cervical spine surgery. In the setting of cervical spine surgery, delayed esophageal perforation most likely results from erosion of the esophageal wall against the instrumentation and not from an acute undiagnosed injury at the time of surgery. We recommend a multidisciplinary approach that includes both otolaryngological surgeons and spine surgeons. We advocate prompt recognition and aggressive management. Upon presentation, spinal stability must be investigated by means of CT and/or flexion-extension radiographs. We recommend removal of all anterior hardware and believe that this is essential to the treatment of esophageal perforations. If the patient does not have evidence of fusion at the time of presentation, then posterior cervical instrumentation may be required. An algorithm for the initial evaluation and management of these patients is proposed (Fig. 3). 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Report of a case. J Bone Joint Surg Am 67: , Witwer BP, Resnick DK: Delayed esophageal injury without instrumentation failure: complication of anterior cervical instrumentation. J Spinal Disord Tech 16: , 2003 Manuscript submitted August 13, Accepted March 31, Address correspondence to: Fernando L. Vale, M.D., 2A Columbia Drive, Suite 850, Tampa, Florida fvale@health. usf.edu. J Neurosurg: Spine / Volume 11 / September