Delayed esophageal perforation 17 years after anterior cervical fusion surgery with plating

Pharyngoesophageal Damage from Hardware Extrusion at an Average of 7.5 Years After Anterior Cervical Diskectomy and Fusion: A Case Series, Discussion of Risk Factors, and Guide for Management

OBJECTIVE

We present a single-institution case series of patients who experienced pharyngoesophageal damage, specifically from extruded hardware occurring at an average of 7.5 years after anterior cervical diskectomy and fusion (ACDF).

METHODS

A retrospective chart review was conducted of patients who had undergone ACDF with subsequent delayed pharyngoesophageal perforation or erosion from extruded hardware ≥1 year after surgery. A discussion of the literature surrounding this complication, including risk factors and management, is also presented.

RESULTS

Nine patients were identified (average age 58 years, 66.7% male) among a total of 4122 ACDF patients (incidence: 0.22%). Average time to injury was 7.5 years. Indications for initial ACDF were degenerative cervical disease (n = 7), ankylosing spondylitis (n = 1), and cervical fracture (n = 1). Eight patients had prior multilevel ACDF spanning 2 (n = 4), 3 (n = 1), or 4 levels (n = 2). Fusion levels for prior ACDF included C5-C7 (n = 3), C3-C7 (n = 2), C4-C7 (n = 1), C4-C6 (n = 1), C2-C5 (n = 1), and C6-C7 (n = 1). Pharyngoesophageal injuries included esophageal perforation (n = 3), pharyngeal perforation (n = 2), esophageal erosion (n = 3), and pharyngoesophageal erosion (n = 1). In most (n = 6) cases, the cause of pharyngoesophageal damage was due to ≥1 extruded screws. Dysphagia (n = 8) was the most common presenting symptom. For perforations (n = 5), 2 repairs used a rotational flap to reinforce a primary closure; the other 3 cases were repaired via primary closure.

CONCLUSIONS

Pharyngoesophageal damage caused by extruded hardware may occur several years after ACDF. These delayed complications are difficult to predict. Proper screw placement may be the most important factor for minimizing the chances of this potentially devastating complication, particularly with multilevel constructs.

Algorithmic Approach to Reconstruction of Esophageal/Hypopharyngeal Injuries After Anterior Cervical Spinal Fusion

BACKGROUND

Anterior cervical disk fusion (ACDF) is a common surgical approach for the treatment of cervical spine pathology. Esophageal perforations, though uncommon, are a devastating complication of this surgery. The objective of this paper is to assess the success of different treatment approaches for the management of esophageal/pharyngeal injury after ACDF.

METHODS

Given the absence of prospective trials, the review includes institutional case reports and case series from 1985-2020 in the English language literature. Only cases of esophageal/pharyngeal injury in the setting of anterior cervical hardware were considered for study inclusion. For purposes of this study, treatment success is defined as resumption of oral intake.

RESULTS

The database review identified 76 distinct series that meet criteria for study inclusion, with 173 patients available for analysis. A heterogeneous array of treatments was used for the management of pharyngoesophageal injuries after ACDF ranging from observation to complex free tissue reconstruction, with varying degrees of treatment success reported. We identified a number of factors, specifically duration of injury from initial ACDF procedure, which may impact the complexity of treatment required to maximize likelihood of treatment success.

CONCLUSIONS

Pharyngoesophageal injuries, albeit rare, are a serious and often complex complication after ACDF procedures. We propose a detailed algorithmic approach to guide decision making if faced with this clinical challenge. The huge variability in how these patients are treated emphasizes the potential utility of future multiinstitutional studies.