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Successful repair of esophageal perforation after anterior cervical fusion for cervical spine fracture
Journal of Clinical Neuroscience 18 (2011) 1374–1380
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Operative Technique
Successful repair of esophageal perforation after anterior cervical fusion for cervical spine fracture Song-Ho Ahn, Sun-Ho Lee ⇑, Eun Sang Kim, Whan Eoh Department of Neurosurgery Samsung Medical Center, Sungkyunkwan University, School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
a r t i c l e
i n f o
Article history: Received 23 September 2010 Accepted 13 February 2011
Keywords: Anterior Cervical fusion Esophagus Perforation Sternocleidomastoid
a b s t r a c t Esophageal injury after anterior cervical discectomy and fusion (ACDF) is a rare complication that can be life threatening. The sternocleidomastoid (SCM) pedicled muscle flap has emerged as an effective and versatile tool for selected esophageal perforations. The authors report their surgical experience in three patients with an esophageal perforation after ACDF, and the steps taken to achieve successful repair using a SCM muscle flap. All three patients underwent ACDF at another hospital. Postoperatively, patients complained of severe dysphagia, neck swelling, fever, and alimentary fluid leakage. They were later referred to the author’s hospital for diagnostic evaluation and surgical treatment of an esophageal perforation. Esophageal perforation was diagnosed on esophagoscopy and esophagography, and treated by primary closure using an SCM muscle flap. Postoperatively, all patients had a good result. Surgery-related complications occurred in one patient with dysfunction of the recurrent laryngeal nerve. This study shows that esophagoscopic diagnosis and surgical treatment using a SCM muscle flap is highly effective in patients with an esophageal perforation related to ACDF. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction
2. Material and methods
Esophageal injury after anterior cervical discectomy and fusion (ACDF) is a rare complication that can be life threatening. To prevent a potentially devastating result, prompt diagnosis and treatment are required. As soon as an esophageal injury is clinically suspected, a diagnostic work-up should be immediately initiated to confirm the presence of a perforation, its morphologic aspects, and related lesions.1–4 Although optimal management remains controversial, most authors agree that esophageal perforations are best treated by primary surgical repair, especially if recognized early.5,6 The utilities of local, regionally pedicled, and even distant, free flaps have been well established as means of achieving and maintaining perforation closure. Of these, the sternocleidomastoid (SCM) pedicled muscle flap has emerged as an effective and versatile tool for treating selected esophageal perforations.2 This paper describes the technical nuances associated with the use of the SCM pedicled muscle flap and presents our experiences of three patients with an esophageal perforation after ACDF.
2.1. Preoperative evaluation Persistent neck pain, difficulty swallowing, unexplained fever, or crepitus in the neck should alert the physician to investigate the possibility of esophageal perforation in patients who have undergone anterior cervical spine surgery. Endoscopy, CT scan and esophagography with soluble contrast medium allow surgeons to assess perforation extent preoperatively, and contrast swallowing studies can help locate perforations or diverticula. Furthermore, the addition of high-resolution MRI to the preoperative work-up is likely to be useful for the diagnosis of cervical osteomyelitis with or without epidural abscesses. Normal radiographic findings may be present in some patients, and therefore, a negative radiographic work-up does not rule out the presence of an esophageal perforation. Furthermore, spinal stability should be assessed by cervical plain radiography and CT scan to determine the requirements for posterior stabilization prior to the mandatory removal of the anterior osteosynthetic material that has damaged esophageal structures.
2.2. Surgical procedures ⇑ Corresponding author. Tel.: +82 2 3410x3496; fax: +82 2 3410x0048. E-mail address: [email protected] (S.-H. Lee). 0967-5868/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2011.02.031
A nasogastric tube (NGT) is inserted before surgery. Esophageal lesions can be located easily by palpating or visualizing the NGT
S.-H. Ahn et al. / Journal of Clinical Neuroscience 18 (2011) 1374–1380
through a hole in the esophagus (Fig. 1A). Surgical repair starts with a skin incision along the previous operative scar on the lesion side, a subplatysmal oblique incision along the anterior border of the SCM muscle, and by blunt dissection using the standard approach to the spine. In addition, intraoperative esophagoscopy may be performed to expose the esophageal rent. When the esophageal lesion is exposed, primary repair should be attempted whenever feasible by gently mobilizing and gaining as much esophageal
1375
mucosa as possible around the rent, while taking care not to extend the defect (Fig. 1B). Poorly viable or chronically inflamed margins should be carefully freshened to increase the likelihood of successful closure. Absorbable interrupted stitches should be used to suture the esophagus. The SCM muscle belly is then dissected superiorly and incised distally, while preserving the accessory nerve. The SCM muscle flap is elevated until a sufficient length (up to 8–10 cm if needed) is available for the tension-free coverage
Fig. 1. Intraoperative photographs showing: (A) after inserting a nasogastric tube (NGT) through the esophagus, the operator can easily locate the esophageal lesion by palpating the NGT (circle); (B) primary closure of the esophageal lesion (circle) using 3–0 prolene; (C) the sternocleidomastoid (SCM) muscle belly is dissected superiorly and incised distally, and a right superiorly pedicled SCM muscle flap is then elevated; (D) the SCM muscle flap interposed between the prevertebral plane and the esophagus to protect the esophageal wall; and (E) the anterior border of the SCM muscle flap fixed by suturing it to platysma muscle.
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of the esophageal defect. A right superiorly pedicled SCM muscle flap is then elevated (Fig. 1C), medially rotated, and then interposed between the prevertebral plane and the esophagus to protect the esophageal wall (Fig. 1D). Finally, the anterior border of the SCM muscle flap is fixed by suturing it to the platysma muscle (Fig. 1E). Cervical drainage is placed and the separated layers are then closed.
2.3. Postoperative management Postoperatively, patients are treated with broad-spectrum antibiotics. The non per oral (NPO) period is usually 7 days and total parenteral nutrition (TPN) is started immediately; enteral feeding follows via a nasogastric tube after TPN for 1 week. The cervical drain is removed 1 week after surgery. Within 3 weeks of operation, consecutive esophagography and flexible endoscopy are performed. If they reveal no abnormalities, the NGT is removed and oral intake begins from liquids. During the postoperative period, special attention is paid to restoring adequate nutritional status by one of these routes.
3. Illustrative patients 3.1. Patient 1 A 43-year-old man presented with fever at another hospital. The patient became quadriparetic after a motor vehicle accident 9 years before presentation. He underwent C6–7 ACDF at an another institution. Two months later, the patient underwent C7 corpectomy with autologous iliac fusion, anterior cervical plating from C6 to T1, and a posterior C6–7 fusion with a titanium cable because of instability diagnosed during follow-up. Nine years after the second operation, he complained of sudden neck swelling and a febrile sensation. Under suspicion of an esophageal injury, he was transferred to our hospital. Plain radiography and a CT scan of the cervical spine revealed prevertebral air, neck swelling, and anterior migration of the screws and plate (Fig. 2A and B). Esophagography suggested esophageal perforation of the right inferolateral wall, and esophagoscopy revealed a blood clot; the esophageal wall fissure was visualized after removing this clot (Fig. 2C). Because of the solid arthrodesis, we removed the hardware and conducted primary repair of the esophageal perforation with a SCM muscle flap (Fig. 2D and E). His postoperative course was favorable except for postoperative hoarseness due to dysfunction of the right recurrent laryngeal nerve.
3.2. Patient 2 A 39-year-old man had suffered a C6 burst fracture and quadriparesis after diving. He underwent C5–7 ACDF at another hospital, and 1 week later complained of neck swelling, dysphagia, and fever. Suspecting a wound infection, he was treated by wound irrigation and revision at another hospital. Despite conservative management including gastrostomy and enteral feeding, his symptoms did not improve. He was transferred to our hospital for further management. A diagnostic work-up, including barium swallow esophagography (Fig. 3A), contrast CT scan of the neck (Fig. 3B), and esophagoscopy, was performed. During esophagoscopy, the anterior cervical plate was observed outside a thinned esophageal wall (Fig. 3C). We removed the anterior cervical plate and performed primary closure of the esophageal wall using a SCM flap and a C5–7 posterior lateral mass screw fixation (Fig. 3D).
3.3. Patient 3 A 28-year-old man was transferred to our institute with wound dehiscence after cervical surgery. He had sustained a C5–6 fracture dislocation with complete spinal cord injury after a motor vehicle accident. The patient underwent C5–6 ACDF and posterior fixation from C2 to T1 at another hospital (Fig. 4A). Two weeks after surgery, he complained of neck swelling, wound dehiscence with alimentary fluid leakage, and fever. Under suspicion of esophageal injury, wound irrigation and drainage were performed twice. However, his symptoms did not improve and he was transferred to our institute for evaluation and further surgical management. He was diagnosed by esophagography and esophagoscopy as having an esophageal perforation (Fig. 4B). The plate was removed and primary closure of the esophageal wall was performed using a SCM flap (Fig. 4C). After surgical treatment of the perforation, his symptoms were relieved without complication (Fig. 4D). 4. Results Three patients were treated for esophageal injuries associated with ACDF. All patients underwent ACDF after cervical traumatic injury. Postoperatively, the mean NPO period was 6.7 days (range: 6–7 days) and the mean time to effective resumption of oral feeding was 22.3 days (range: 17–27 days). No cervical motion impairment or neck deformity related to SCM muscle dissection was reported by patients or clinicians at last follow-up visits. One fixation device failure (patient 1) was noted during radiologic examination, and the plate concerned was removed. Although no fixation failure was observed in the other two patients, we removed the plate in both because the perforated esophageal walls were compressed by plate edges. Surgery-related complications occurred in one patient with dysfunction of the right recurrent laryngeal nerve. 5. Discussion Esophageal perforation related to ACDF is a rare but potentially catastrophic complication. A review of the literature regarding esophageal injury after ACDF revealed an esophageal perforation rate of 0% to 1.62%.7,8 The Cervical Spine Research Society (CSRS) survey reported an overall rate of esophageal injury after cervical spine surgery of 0.25%.4 However, we cannot determine the incidence of this complication at our unit, because all three patients underwent ACDF at a different hospital, and we have had no experience of esophageal perforation after ACDF at our institution for over 10 years. The etiologies of esophageal perforation after ACDF vary widely. Most reports of esophageal complications have been attributed to graft dislodgement or instrumentation,1,4,9 whereas others have cited trauma with hyperextension injury or fracture.10 The CSRS survey conducted on the topic revealed that esophageal retraction and direct injury during esophageal manipulation are the most common causes (25%), and that hardware failure was the third most common cause of esophageal injury related to ACDF.8 Unfortunately, we are not in a position to attribute causality precisely because all patients underwent initial surgery elsewhere. Nevertheless, some causes of esophageal perforation can be speculated. First, blunt trauma to the esophagus may have occurred at the time of cervical injury. Second, the original graft may have protruded beyond the margin of the vertebral body and its sharp edges may have eroded the esophagus. Third, direct esophageal trauma may have been caused by the retractor during surgery. In patient 3, esophageal diverticulum at the operated site was found on esophagography. In the other two patients, esophagi were kinked by
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Fig. 2. Patient 1. (A) Preoperative lateral cervical radiograph and (B) axial CT scan showing air bubbles at the prevertebral space, neck swelling, and a prevertebral abscess. (C) Esophagoscopic finding showing blood clots and an esophageal fissure. (D) Intraoperative photograph showing esophageal wall laceration with mucosal swelling (arrow), and (E) follow-up lateral radiograph taken at 6 months after surgery showing repair of the esophageal perforation with a sternocleidomastoid muscle flap.
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Fig. 3. Patient 2. (A) Esophagography showing contrast leakage (arrow) through an esophageal fistula. (B) A contrast axial neck CT scan showing a gas-containing collection anterior to the cervical plate, which raised concerns regarding esophageal perforation. (C) Esophagoscopic finding showing the anterior cervical plate outside a thinned esophageal wall. (D) Follow-up lateral radiograph after anterior exploration with removal of the anterior cervical plate followed by primary closure of the esophageal wall using a sternocleidomastoid flap and a C5–7 posterior lateral mass screw fixation. This figure is available in colour at www.sciencedirect.com.
plates in esophagoscopic view. Furthermore, all three patients had experienced cervical trauma and not degenerative cervical disease. The incidence of esophageal perforation associated with anterior cervical surgery for cervical trauma is higher than that associated with anterior cervical surgery for a degenerative cervical disorder.11 Presenting symptoms and signs, such as dysphagia, neck pain and swelling, hoarseness, cough, aspiration, and fever can be overlooked or suggest diagnoses of other more common local or systemic conditions. However, diagnostic or treatment delays significantly increase the risks of morbidity and mortality.12 Bernazzo
et al. claimed that if an esophageal injury is clinically suspected, diagnostic work-up should be undertaken immediately to confirm the presence of a perforation.13 Plain radiographs and neck CT scans can be useful for detecting air around the graft, screw, and plate sites. However, imaging studies are not always successful and should be used as adjuvant investigatory tools, because endoscopy and swallowing studies can locate perforations and fistulae more accurately.2,7 In particular, radiographic findings may be normal in some patients, and therefore, it should be remembered that a negative radiographic work up does not rule out the possibility of an esophageal perforation.14 Further advanced imaging
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Fig. 4. Patient 3. (A) Preoperative cervical lateral radiograph. (B) Esophagography showing barium contrast leakage (black arrow) through an esophageal fistula. (C) Intraoperative photograph showing an esophageal wall defect and a nasogastric tube (white arrow) just anterior to the cervical plate. (D) Follow-up lateral radiograph taken 3 months after surgery. This figure is available in colour at www.sciencedirect.com.
modalities, such as endoscopy or esophagography, should be used to confirm the presence of an esophageal perforation. In our patients, a barium swallow study and contrast CT scan were used to assess the integrity of esophageal walls, and after obtaining
positive imaging, flexible endoscopy was performed to confirm the diagnosis. Treatment of esophageal perforation and its sequelae should be conducted on a multidisciplinary basis and tailored for indi-
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vidual patients, and the involvement of specialist spinal, neck, and thoracic surgeons, intensive care unit physicians, and gastroenterologists should be considered.15 Conservative treatment may be effective when perforations are small and early with a well-contained leak and without signs of septicemia. Conservative treatment includes NPO, the institution of parenteral or enteral nutrition by NGT, jejunostomy or percutaneous endoscopic gastrostomy, prolonged intravenous wide spectrum antibiotic coverage, and close observation.16 However, some authors recommend that esophageal injuries should be treated aggressively, because those conservatively addressed have an abscess rate of 25% to 45%.2,4–7 For larger, more symptomatic rents, which present greater risks of mediastinitis and sepsis, surgical treatment including primary closure with reinforced tissue closure using a longus coli, SCM, or latissimus dorsi muscle, or an omental free flap, or exclusion and diversion by end-cervical esophagostomy and gastrostomy are mandatory.17 Primary repair has the advantages of faster recovery and shorter inpatient care duration, and the time required for fasting and parenteral alimentation is usually as short as 5 days to 7 days. For patients with recognized lacerations intraoperatively, primary repair with or without tissue reinforcement, followed by short-term esophageal rest via NGT placement and intravenous antibiotic therapy is preferable. The choice of soft tissue reinforcement includes an omental free flap, a pectoralis muscle, a longus coli muscle, or an SCM muscle flap.6,17–19 Proper flap selection is important to avoid flap strain and to provide sufficient coverage of the perforation. Primary closure with an SCM muscle flap is considered the standard surgical treatment for esophageal perforation, because the SCM is close to the cervical esophagus, is easy mobilized, and is sufficient to cover most esophageal defects. Benazzo et al. reported successful surgical repair using this flap.13 In the present study, we encountered no complication after reparative surgery using this flap, and all patients experienced an uneventful postoperative course. Sometimes, a pectoralis myocutaneous flap is used to close a cervical esophageal defect during head and neck cancer procedures, but it presents the risk of loss of pectoralis functions. Rees et al. used seven pectoralis flaps when closing chronic esophageal fistulas after tumor resections in cancer patients.19 In their series of 16 patients, fistula closure was performed at a mean 37 days after the procedure. Furthermore, Collins reported good results for a longus colli muscle reconstructive flap in 16 patients with defects of the lateral pharyngeal wall or pyriform.18 This flap is easily transferred from its anatomical location and preserves SCM muscle function, but it introduces the risk of injury to the cervical sympathetic trunk.18 Moreover, although Reid et al. claimed that the omental free flap provides more successful outcomes than the pedicle flap for the closure of esophageal fistula after spinal surgery,20 this flap presents greater risks of microvascular thrombosis and total flap loss.
6. Conclusion In this report, we describe primary repair of esophageal perforation after anterior cervical fusion using an SCM flap. The surgical technique of primary repair using an SCM muscle flap is a highly effective treatment in patients with esophageal perforation related to ACDF. Finally, we stress that when esophageal perforation after ACDF is suspected, early diagnosis and prompt surgical treatment are mandatory. References 1. Cloward RB. Complications of anterior cervical disk operation and their treatment. Surgery 1971;69:175–82. 2. Fuji T, Kuratsu S, Shirasaki N, et al. Esophagocutaneous fistula after anterior cervical spine surgery and successful treatment using sternocleidomastoid muscle flap. Clin Orthop Relat Res 1991;267:8–13. 3. Graham JJ. Complications of cervical spine surgery – a five year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine 1989;14:1046–50. 4. Kelly MF, Rizzo KA, Spiegel J, et al. Delayed pharyngoesophageal perforation: a complication of anterior spine surgery. Ann Otol Rhinol Laryngol 1991;100:201–5. 5. Gupta NM, Kaman L. Personal management of 57 consecutive patients with esophageal perforation. Am J Surg 2004;187:58–63. 6. Navarro R, Javahery R, Eismont F, et al. The role of the sternocleidomastoid muscle flap for esophageal fistula repair in anterior cervical spine surgery. Spine 2005;30:E617–22. 7. Van Berge Henegouwen DP, Roukema JA, de Nie JC, et al. Esophageal perforation during surgery on the cervical spine. Neurosurgery 1991;29:766–8. 8. Newhouse KE, Lindsey RW, Clark CR, et al. Esophageal perforation following anterior cervical spine surgery. Spine 1989;14:1051–3. 9. Smith MD, Bolesta MJ. Esophageal perforation after anterior cervical plate fixation: a report of two cases. J Spinal Disord 1992;5:357–62. 10. Morrison A. Hyperextension injury to the cervical spine with rupture of the esophagus. J Bone Joint Surg 1960;42:356–7. 11. Gaudinez RF, English GM, Gebhard JS, et al. Esophageal perforations after anterior cervical surgery. J Spinal Disord 2000;13:77–84. 12. Eroglu A, Can Kürkçüogu I, Karaoganogu N, et al. Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus 2004;17:91–4. 13. Benazzo M, Spasiano R, Bertino G, et al. Sternocleidomastoid muscle flap in esophageal perforation repair after cervical spine surgery: concepts, techniques, and personal experience. J Spinal Disord Tech 2008;21:597–605. 14. Han SY, McElvein RB, Aldrete JS, et al. Perforation of the esophagus: correlation of site and cause with plain film findings. AJR Am J Roentgenol 1985;145:537–40. 15. Von Rahden BH, Stein HJ, Scherer MA. Late hypopharyngoesophageal perforation after cervical spine surgery: proposal of a therapeutic strategy. Eur J Spine 2005;14:880–6. 16. Michel L, Grillo HC, Malt RA. Operative and nonoperative management of esophageal perforations. Ann Surg 1981;194:57–63. 17. McCullen GM, Garfin SR. Cervical spine internal fixation using screw and screw-plate construct. Spine 2000;25:643–52. 18. Collins SL. The longus colli muscle flap for reconstruction of the lateral pharyngeal wall. Head Neck 1997;19:297–308. 19. Rees R, Cary A, Shack B, et al. Pharyngocutaneous fistulas in advanced cancer: closure with musculocutaneous or muscle flaps. Am J Surg 1987;154:381–3. 20. Reid RR, Dutra J, Conley DB, et al. Improved repair of cervical esophageal fistula complicating anterior spinal fusion: free omental flap compared with pectoralis major flap. J Neurosurg 2004;100:66–70.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Operative Technique
Successful repair of esophageal perforation after anterior cervical fusion for cervical spine fracture Song-Ho Ahn, Sun-Ho Lee ⇑, Eun Sang Kim, Whan Eoh Department of Neurosurgery Samsung Medical Center, Sungkyunkwan University, School of Medicine, 50 Ilwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea
a r t i c l e
i n f o
Article history: Received 23 September 2010 Accepted 13 February 2011
Keywords: Anterior Cervical fusion Esophagus Perforation Sternocleidomastoid
a b s t r a c t Esophageal injury after anterior cervical discectomy and fusion (ACDF) is a rare complication that can be life threatening. The sternocleidomastoid (SCM) pedicled muscle flap has emerged as an effective and versatile tool for selected esophageal perforations. The authors report their surgical experience in three patients with an esophageal perforation after ACDF, and the steps taken to achieve successful repair using a SCM muscle flap. All three patients underwent ACDF at another hospital. Postoperatively, patients complained of severe dysphagia, neck swelling, fever, and alimentary fluid leakage. They were later referred to the author’s hospital for diagnostic evaluation and surgical treatment of an esophageal perforation. Esophageal perforation was diagnosed on esophagoscopy and esophagography, and treated by primary closure using an SCM muscle flap. Postoperatively, all patients had a good result. Surgery-related complications occurred in one patient with dysfunction of the recurrent laryngeal nerve. This study shows that esophagoscopic diagnosis and surgical treatment using a SCM muscle flap is highly effective in patients with an esophageal perforation related to ACDF. Ó 2011 Elsevier Ltd. All rights reserved.
1. Introduction
2. Material and methods
Esophageal injury after anterior cervical discectomy and fusion (ACDF) is a rare complication that can be life threatening. To prevent a potentially devastating result, prompt diagnosis and treatment are required. As soon as an esophageal injury is clinically suspected, a diagnostic work-up should be immediately initiated to confirm the presence of a perforation, its morphologic aspects, and related lesions.1–4 Although optimal management remains controversial, most authors agree that esophageal perforations are best treated by primary surgical repair, especially if recognized early.5,6 The utilities of local, regionally pedicled, and even distant, free flaps have been well established as means of achieving and maintaining perforation closure. Of these, the sternocleidomastoid (SCM) pedicled muscle flap has emerged as an effective and versatile tool for treating selected esophageal perforations.2 This paper describes the technical nuances associated with the use of the SCM pedicled muscle flap and presents our experiences of three patients with an esophageal perforation after ACDF.
2.1. Preoperative evaluation Persistent neck pain, difficulty swallowing, unexplained fever, or crepitus in the neck should alert the physician to investigate the possibility of esophageal perforation in patients who have undergone anterior cervical spine surgery. Endoscopy, CT scan and esophagography with soluble contrast medium allow surgeons to assess perforation extent preoperatively, and contrast swallowing studies can help locate perforations or diverticula. Furthermore, the addition of high-resolution MRI to the preoperative work-up is likely to be useful for the diagnosis of cervical osteomyelitis with or without epidural abscesses. Normal radiographic findings may be present in some patients, and therefore, a negative radiographic work-up does not rule out the presence of an esophageal perforation. Furthermore, spinal stability should be assessed by cervical plain radiography and CT scan to determine the requirements for posterior stabilization prior to the mandatory removal of the anterior osteosynthetic material that has damaged esophageal structures.
2.2. Surgical procedures ⇑ Corresponding author. Tel.: +82 2 3410x3496; fax: +82 2 3410x0048. E-mail address: [email protected] (S.-H. Lee). 0967-5868/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2011.02.031
A nasogastric tube (NGT) is inserted before surgery. Esophageal lesions can be located easily by palpating or visualizing the NGT
S.-H. Ahn et al. / Journal of Clinical Neuroscience 18 (2011) 1374–1380
through a hole in the esophagus (Fig. 1A). Surgical repair starts with a skin incision along the previous operative scar on the lesion side, a subplatysmal oblique incision along the anterior border of the SCM muscle, and by blunt dissection using the standard approach to the spine. In addition, intraoperative esophagoscopy may be performed to expose the esophageal rent. When the esophageal lesion is exposed, primary repair should be attempted whenever feasible by gently mobilizing and gaining as much esophageal
1375
mucosa as possible around the rent, while taking care not to extend the defect (Fig. 1B). Poorly viable or chronically inflamed margins should be carefully freshened to increase the likelihood of successful closure. Absorbable interrupted stitches should be used to suture the esophagus. The SCM muscle belly is then dissected superiorly and incised distally, while preserving the accessory nerve. The SCM muscle flap is elevated until a sufficient length (up to 8–10 cm if needed) is available for the tension-free coverage
Fig. 1. Intraoperative photographs showing: (A) after inserting a nasogastric tube (NGT) through the esophagus, the operator can easily locate the esophageal lesion by palpating the NGT (circle); (B) primary closure of the esophageal lesion (circle) using 3–0 prolene; (C) the sternocleidomastoid (SCM) muscle belly is dissected superiorly and incised distally, and a right superiorly pedicled SCM muscle flap is then elevated; (D) the SCM muscle flap interposed between the prevertebral plane and the esophagus to protect the esophageal wall; and (E) the anterior border of the SCM muscle flap fixed by suturing it to platysma muscle.
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of the esophageal defect. A right superiorly pedicled SCM muscle flap is then elevated (Fig. 1C), medially rotated, and then interposed between the prevertebral plane and the esophagus to protect the esophageal wall (Fig. 1D). Finally, the anterior border of the SCM muscle flap is fixed by suturing it to the platysma muscle (Fig. 1E). Cervical drainage is placed and the separated layers are then closed.
2.3. Postoperative management Postoperatively, patients are treated with broad-spectrum antibiotics. The non per oral (NPO) period is usually 7 days and total parenteral nutrition (TPN) is started immediately; enteral feeding follows via a nasogastric tube after TPN for 1 week. The cervical drain is removed 1 week after surgery. Within 3 weeks of operation, consecutive esophagography and flexible endoscopy are performed. If they reveal no abnormalities, the NGT is removed and oral intake begins from liquids. During the postoperative period, special attention is paid to restoring adequate nutritional status by one of these routes.
3. Illustrative patients 3.1. Patient 1 A 43-year-old man presented with fever at another hospital. The patient became quadriparetic after a motor vehicle accident 9 years before presentation. He underwent C6–7 ACDF at an another institution. Two months later, the patient underwent C7 corpectomy with autologous iliac fusion, anterior cervical plating from C6 to T1, and a posterior C6–7 fusion with a titanium cable because of instability diagnosed during follow-up. Nine years after the second operation, he complained of sudden neck swelling and a febrile sensation. Under suspicion of an esophageal injury, he was transferred to our hospital. Plain radiography and a CT scan of the cervical spine revealed prevertebral air, neck swelling, and anterior migration of the screws and plate (Fig. 2A and B). Esophagography suggested esophageal perforation of the right inferolateral wall, and esophagoscopy revealed a blood clot; the esophageal wall fissure was visualized after removing this clot (Fig. 2C). Because of the solid arthrodesis, we removed the hardware and conducted primary repair of the esophageal perforation with a SCM muscle flap (Fig. 2D and E). His postoperative course was favorable except for postoperative hoarseness due to dysfunction of the right recurrent laryngeal nerve.
3.2. Patient 2 A 39-year-old man had suffered a C6 burst fracture and quadriparesis after diving. He underwent C5–7 ACDF at another hospital, and 1 week later complained of neck swelling, dysphagia, and fever. Suspecting a wound infection, he was treated by wound irrigation and revision at another hospital. Despite conservative management including gastrostomy and enteral feeding, his symptoms did not improve. He was transferred to our hospital for further management. A diagnostic work-up, including barium swallow esophagography (Fig. 3A), contrast CT scan of the neck (Fig. 3B), and esophagoscopy, was performed. During esophagoscopy, the anterior cervical plate was observed outside a thinned esophageal wall (Fig. 3C). We removed the anterior cervical plate and performed primary closure of the esophageal wall using a SCM flap and a C5–7 posterior lateral mass screw fixation (Fig. 3D).
3.3. Patient 3 A 28-year-old man was transferred to our institute with wound dehiscence after cervical surgery. He had sustained a C5–6 fracture dislocation with complete spinal cord injury after a motor vehicle accident. The patient underwent C5–6 ACDF and posterior fixation from C2 to T1 at another hospital (Fig. 4A). Two weeks after surgery, he complained of neck swelling, wound dehiscence with alimentary fluid leakage, and fever. Under suspicion of esophageal injury, wound irrigation and drainage were performed twice. However, his symptoms did not improve and he was transferred to our institute for evaluation and further surgical management. He was diagnosed by esophagography and esophagoscopy as having an esophageal perforation (Fig. 4B). The plate was removed and primary closure of the esophageal wall was performed using a SCM flap (Fig. 4C). After surgical treatment of the perforation, his symptoms were relieved without complication (Fig. 4D). 4. Results Three patients were treated for esophageal injuries associated with ACDF. All patients underwent ACDF after cervical traumatic injury. Postoperatively, the mean NPO period was 6.7 days (range: 6–7 days) and the mean time to effective resumption of oral feeding was 22.3 days (range: 17–27 days). No cervical motion impairment or neck deformity related to SCM muscle dissection was reported by patients or clinicians at last follow-up visits. One fixation device failure (patient 1) was noted during radiologic examination, and the plate concerned was removed. Although no fixation failure was observed in the other two patients, we removed the plate in both because the perforated esophageal walls were compressed by plate edges. Surgery-related complications occurred in one patient with dysfunction of the right recurrent laryngeal nerve. 5. Discussion Esophageal perforation related to ACDF is a rare but potentially catastrophic complication. A review of the literature regarding esophageal injury after ACDF revealed an esophageal perforation rate of 0% to 1.62%.7,8 The Cervical Spine Research Society (CSRS) survey reported an overall rate of esophageal injury after cervical spine surgery of 0.25%.4 However, we cannot determine the incidence of this complication at our unit, because all three patients underwent ACDF at a different hospital, and we have had no experience of esophageal perforation after ACDF at our institution for over 10 years. The etiologies of esophageal perforation after ACDF vary widely. Most reports of esophageal complications have been attributed to graft dislodgement or instrumentation,1,4,9 whereas others have cited trauma with hyperextension injury or fracture.10 The CSRS survey conducted on the topic revealed that esophageal retraction and direct injury during esophageal manipulation are the most common causes (25%), and that hardware failure was the third most common cause of esophageal injury related to ACDF.8 Unfortunately, we are not in a position to attribute causality precisely because all patients underwent initial surgery elsewhere. Nevertheless, some causes of esophageal perforation can be speculated. First, blunt trauma to the esophagus may have occurred at the time of cervical injury. Second, the original graft may have protruded beyond the margin of the vertebral body and its sharp edges may have eroded the esophagus. Third, direct esophageal trauma may have been caused by the retractor during surgery. In patient 3, esophageal diverticulum at the operated site was found on esophagography. In the other two patients, esophagi were kinked by
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Fig. 2. Patient 1. (A) Preoperative lateral cervical radiograph and (B) axial CT scan showing air bubbles at the prevertebral space, neck swelling, and a prevertebral abscess. (C) Esophagoscopic finding showing blood clots and an esophageal fissure. (D) Intraoperative photograph showing esophageal wall laceration with mucosal swelling (arrow), and (E) follow-up lateral radiograph taken at 6 months after surgery showing repair of the esophageal perforation with a sternocleidomastoid muscle flap.
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Fig. 3. Patient 2. (A) Esophagography showing contrast leakage (arrow) through an esophageal fistula. (B) A contrast axial neck CT scan showing a gas-containing collection anterior to the cervical plate, which raised concerns regarding esophageal perforation. (C) Esophagoscopic finding showing the anterior cervical plate outside a thinned esophageal wall. (D) Follow-up lateral radiograph after anterior exploration with removal of the anterior cervical plate followed by primary closure of the esophageal wall using a sternocleidomastoid flap and a C5–7 posterior lateral mass screw fixation. This figure is available in colour at www.sciencedirect.com.
plates in esophagoscopic view. Furthermore, all three patients had experienced cervical trauma and not degenerative cervical disease. The incidence of esophageal perforation associated with anterior cervical surgery for cervical trauma is higher than that associated with anterior cervical surgery for a degenerative cervical disorder.11 Presenting symptoms and signs, such as dysphagia, neck pain and swelling, hoarseness, cough, aspiration, and fever can be overlooked or suggest diagnoses of other more common local or systemic conditions. However, diagnostic or treatment delays significantly increase the risks of morbidity and mortality.12 Bernazzo
et al. claimed that if an esophageal injury is clinically suspected, diagnostic work-up should be undertaken immediately to confirm the presence of a perforation.13 Plain radiographs and neck CT scans can be useful for detecting air around the graft, screw, and plate sites. However, imaging studies are not always successful and should be used as adjuvant investigatory tools, because endoscopy and swallowing studies can locate perforations and fistulae more accurately.2,7 In particular, radiographic findings may be normal in some patients, and therefore, it should be remembered that a negative radiographic work up does not rule out the possibility of an esophageal perforation.14 Further advanced imaging
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Fig. 4. Patient 3. (A) Preoperative cervical lateral radiograph. (B) Esophagography showing barium contrast leakage (black arrow) through an esophageal fistula. (C) Intraoperative photograph showing an esophageal wall defect and a nasogastric tube (white arrow) just anterior to the cervical plate. (D) Follow-up lateral radiograph taken 3 months after surgery. This figure is available in colour at www.sciencedirect.com.
modalities, such as endoscopy or esophagography, should be used to confirm the presence of an esophageal perforation. In our patients, a barium swallow study and contrast CT scan were used to assess the integrity of esophageal walls, and after obtaining
positive imaging, flexible endoscopy was performed to confirm the diagnosis. Treatment of esophageal perforation and its sequelae should be conducted on a multidisciplinary basis and tailored for indi-
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vidual patients, and the involvement of specialist spinal, neck, and thoracic surgeons, intensive care unit physicians, and gastroenterologists should be considered.15 Conservative treatment may be effective when perforations are small and early with a well-contained leak and without signs of septicemia. Conservative treatment includes NPO, the institution of parenteral or enteral nutrition by NGT, jejunostomy or percutaneous endoscopic gastrostomy, prolonged intravenous wide spectrum antibiotic coverage, and close observation.16 However, some authors recommend that esophageal injuries should be treated aggressively, because those conservatively addressed have an abscess rate of 25% to 45%.2,4–7 For larger, more symptomatic rents, which present greater risks of mediastinitis and sepsis, surgical treatment including primary closure with reinforced tissue closure using a longus coli, SCM, or latissimus dorsi muscle, or an omental free flap, or exclusion and diversion by end-cervical esophagostomy and gastrostomy are mandatory.17 Primary repair has the advantages of faster recovery and shorter inpatient care duration, and the time required for fasting and parenteral alimentation is usually as short as 5 days to 7 days. For patients with recognized lacerations intraoperatively, primary repair with or without tissue reinforcement, followed by short-term esophageal rest via NGT placement and intravenous antibiotic therapy is preferable. The choice of soft tissue reinforcement includes an omental free flap, a pectoralis muscle, a longus coli muscle, or an SCM muscle flap.6,17–19 Proper flap selection is important to avoid flap strain and to provide sufficient coverage of the perforation. Primary closure with an SCM muscle flap is considered the standard surgical treatment for esophageal perforation, because the SCM is close to the cervical esophagus, is easy mobilized, and is sufficient to cover most esophageal defects. Benazzo et al. reported successful surgical repair using this flap.13 In the present study, we encountered no complication after reparative surgery using this flap, and all patients experienced an uneventful postoperative course. Sometimes, a pectoralis myocutaneous flap is used to close a cervical esophageal defect during head and neck cancer procedures, but it presents the risk of loss of pectoralis functions. Rees et al. used seven pectoralis flaps when closing chronic esophageal fistulas after tumor resections in cancer patients.19 In their series of 16 patients, fistula closure was performed at a mean 37 days after the procedure. Furthermore, Collins reported good results for a longus colli muscle reconstructive flap in 16 patients with defects of the lateral pharyngeal wall or pyriform.18 This flap is easily transferred from its anatomical location and preserves SCM muscle function, but it introduces the risk of injury to the cervical sympathetic trunk.18 Moreover, although Reid et al. claimed that the omental free flap provides more successful outcomes than the pedicle flap for the closure of esophageal fistula after spinal surgery,20 this flap presents greater risks of microvascular thrombosis and total flap loss.
6. Conclusion In this report, we describe primary repair of esophageal perforation after anterior cervical fusion using an SCM flap. The surgical technique of primary repair using an SCM muscle flap is a highly effective treatment in patients with esophageal perforation related to ACDF. Finally, we stress that when esophageal perforation after ACDF is suspected, early diagnosis and prompt surgical treatment are mandatory. References 1. Cloward RB. Complications of anterior cervical disk operation and their treatment. Surgery 1971;69:175–82. 2. Fuji T, Kuratsu S, Shirasaki N, et al. Esophagocutaneous fistula after anterior cervical spine surgery and successful treatment using sternocleidomastoid muscle flap. Clin Orthop Relat Res 1991;267:8–13. 3. Graham JJ. Complications of cervical spine surgery – a five year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine 1989;14:1046–50. 4. Kelly MF, Rizzo KA, Spiegel J, et al. Delayed pharyngoesophageal perforation: a complication of anterior spine surgery. Ann Otol Rhinol Laryngol 1991;100:201–5. 5. Gupta NM, Kaman L. Personal management of 57 consecutive patients with esophageal perforation. Am J Surg 2004;187:58–63. 6. Navarro R, Javahery R, Eismont F, et al. The role of the sternocleidomastoid muscle flap for esophageal fistula repair in anterior cervical spine surgery. Spine 2005;30:E617–22. 7. Van Berge Henegouwen DP, Roukema JA, de Nie JC, et al. Esophageal perforation during surgery on the cervical spine. Neurosurgery 1991;29:766–8. 8. Newhouse KE, Lindsey RW, Clark CR, et al. Esophageal perforation following anterior cervical spine surgery. Spine 1989;14:1051–3. 9. Smith MD, Bolesta MJ. Esophageal perforation after anterior cervical plate fixation: a report of two cases. J Spinal Disord 1992;5:357–62. 10. Morrison A. Hyperextension injury to the cervical spine with rupture of the esophagus. J Bone Joint Surg 1960;42:356–7. 11. Gaudinez RF, English GM, Gebhard JS, et al. Esophageal perforations after anterior cervical surgery. J Spinal Disord 2000;13:77–84. 12. Eroglu A, Can Kürkçüogu I, Karaoganogu N, et al. Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus 2004;17:91–4. 13. Benazzo M, Spasiano R, Bertino G, et al. Sternocleidomastoid muscle flap in esophageal perforation repair after cervical spine surgery: concepts, techniques, and personal experience. J Spinal Disord Tech 2008;21:597–605. 14. Han SY, McElvein RB, Aldrete JS, et al. Perforation of the esophagus: correlation of site and cause with plain film findings. AJR Am J Roentgenol 1985;145:537–40. 15. Von Rahden BH, Stein HJ, Scherer MA. Late hypopharyngoesophageal perforation after cervical spine surgery: proposal of a therapeutic strategy. Eur J Spine 2005;14:880–6. 16. Michel L, Grillo HC, Malt RA. Operative and nonoperative management of esophageal perforations. Ann Surg 1981;194:57–63. 17. McCullen GM, Garfin SR. Cervical spine internal fixation using screw and screw-plate construct. Spine 2000;25:643–52. 18. Collins SL. The longus colli muscle flap for reconstruction of the lateral pharyngeal wall. Head Neck 1997;19:297–308. 19. Rees R, Cary A, Shack B, et al. Pharyngocutaneous fistulas in advanced cancer: closure with musculocutaneous or muscle flaps. Am J Surg 1987;154:381–3. 20. Reid RR, Dutra J, Conley DB, et al. Improved repair of cervical esophageal fistula complicating anterior spinal fusion: free omental flap compared with pectoralis major flap. J Neurosurg 2004;100:66–70.