Esophageal, pharyngeal and hemorrhagic complications occurring in anterior cervical surgery: Three illustrative cases

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.

Comparison of Perioperative Complications in Anterior Decompression With Fusion and Posterior Decompression With Fusion for Cervical Spondylotic Myelopathy: Propensity Score Matching Analysis Using a Nationwide Inpatient Database

STUDY DESIGN

A retrospective cohort study with a national inpatient database.

OBJECTIVE

This study aimed to research the perioperative complication rates of cervical spondylotic myelopathy (CSM) patients who underwent anterior decompression with fusion (ADF) and posterior decompression with fusion (PDF) using a large national inpatient database and propensity score matching (PSM) analysis.

SUMMARY OF BACKGROUND DATA

There are several ways to successfully achieve surgical spinal decompression in CSM patients; however, evidence of the systemic complications and reoperation rates in ADF and PDF is lacking.

MATERIALS AND METHODS

We identified patients who were hospitalized for CSM and underwent either ADF or PDF from 2010 to 2016 using the Japanese Diagnosis Procedure Combination database. In the ADF and PDF groups, we compared postoperative complications (systemic and local), medical costs during hospitalization, and mortality before and after PSM. In addition, multivariate regression analysis was performed to identify risk factors for perioperative systemic complications.

RESULTS

A total of 1013 matched pairs were made after PSM. More perioperative systemic complications were detected in the ADF group than in the PDF group (at least 1 complication: ADF vs. PDF: 15.2% vs. 12.0%, P=0.038), especially for respiratory failure (1.4% vs. 0.4%, P=0.018), pneumonia (1.9% vs. 0.5%, P=0.004), and dysphagia (3.0% vs. 1.1%, P=0.003). The costs were ~$8000 higher (P<0.001) and the length of hospital stay was almost 5 days longer (P<0.001) in the PDF group. The risk factors for perioperative systemic complications in ADF were high age, low body mass index, and preoperative respiratory disease, and the factors in PDF were high body mass index and preoperative renal disease.

CONCLUSION

More systemic complications, especially respiratory events, were more frequently observed in the ADF group, while the medical costs were higher and the hospital stay was longer in the PDF group.

LEVEL OF EVIDENCE

Level III.

Esophageal Fistula following Anterior Cervical Discectomy and Fusion in Traumatic Cervical Injury Cases: A Review

Background Esophageal fistula is a very rare complication associated with anterior approaches to the cervical spine. Timely diagnosis and early intervention are associated with favorable outcomes. There is a dilemma in the literature for its optimal management. In this review article, we will discuss the management dilemmas in patients with esophageal perforation along with an illustrative case.

Material and Methods A 24-year-old male patient operated for C5–6 fracture dislocation, presented with esophageal fistula 1 month after surgery. Investigations were done to localize the site of fistula but definitive site of leak could not be identified. Patient was counselled regarding possible surgical intervention; however, patient was opted for conservative treatment.

Conclusion Esophageal fistula is a very rare occurrence. Because of varied clinical presentation and frequent delay in diagnosis, a very high index of suspicion should always be kept in mind while evaluating a patient postoperatively for dysphagia. Timely diagnosis and early intervention are key to a successful outcome.

Surgical Landmark of Mandible Angle in the Identification of Cervical Spinal Level

Mandible angle is considered to be a consistently palpable external landmark for the identification of cervical spinal level by a radiographic study. But this anatomical study aimed to determine the positional relationship between mandible angle and cervical spinal level in cadavers. In this study, the cervical spine of 10 adult cadavers with intact head and neck structure, including 6 males and 4 females, was dissected, and the position of mandible angle (MA) relative to the corresponding cervical spinal level was measured when the head was fixed in the flexion, anatomy position, and extension. The difference between the genders and the sides was analyzed. On the basis of the study of the corpse samples, the reference level of cervical spine was approximated to C2/3 intervertebral disc. The result has confirmed MA as a consistent and convenient landmark in the identification of cervical spinal level. Given some external landmarks do not consistently correspond to the exact level of the cervical spine, MA provides the relatively consistent reference point: C2/3 intervertebral disc. The authors hold that MA is a superior external landmark, which can help surgeons to localize the skin incision before anterior cervical spine surgery.

Iatrogenic Vertebral Artery Injury During Anterior Cervical Spine Surgery: A Systematic Review

BACKGROUND

Iatrogenic vertebral artery injury (VAI) during anterior cervical surgery is rare but potentially catastrophic.

METHODS

Causes, presentation, diagnosis, management, prognosis, and prevention of VAI were reviewed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. English language studies and case reports published from 1980 to 2017 were retrieved. Data on diagnosis, surgical procedures and approach, site and cause of VAI, management, outcomes, and vertebral artery (VA) status were extracted.

RESULTS

In 25 articles including 54 patients, VAI was diagnosed during or after surgery commonly indicated for cervical degenerative diseases (64%), tumors (14%), and trauma (9%). The incidence of VAI for each side was similar regardless of approach. Common presentations were unexpected copious surgical bleeding, delayed hemorrhage of pseudoaneurysm with neck swelling, dyspnea, hypotension, and cervical bruits caused by arteriovenous fistula. Causes included drilling (61%), instrumentation (16%), and soft tissue retraction (8%). Direct exposure or angiography confirmed VAI. Ten patients had VA anomalies; collateral status was verified in 9 before definitive treatment. Tamponade was adopted for urgent hemostasis in most cases but with a high incidence of pseudoaneurysm (48%). Unknown VA status increased occlusion risk and neurologic sequelae (41%). VA repair and stent placement had excellent outcomes.

CONCLUSIONS

Extensive lateral decompression, loss of landmarks, and anatomic variations or pathologic status of VA increased VAI risk. Evaluation of collateral vessels before definitive treatment helped determine appropriate management and avoid neurologic sequelae. Tamponade was not recommended as definitive treatment. Meticulous preoperative evaluation, cautious intraoperative manipulation, and real-time radiographic guidance reduced VAI risk.

[Results to 4-year follow-up of the treatment of the cervical stenosis by corpectomy, titanium mesh cage and anterior plate fixation]

BACKGROUND

Cervical spondylotic myelopathy is caused by cervical stenosis. Several techniques have been described for the treatment of multilevel disease, such as the anterior corpectomy with titanium mesh cage and anterior cervical plate placement, which has the advantage of performing a wider decompression and using the same bone as graft. However, it has caused controversy since the collapse of the mesh cage continues being a major limitation of this procedure.

MATERIAL AND METHOD

A prospective 4-year follow-up study was conducted in 7 patients diagnosed with cervical stenosis, who were treated surgically by one level corpectomy with titanium mesh cage and anterior cervical plate placement, evaluating them by radiographs and clinical scales.

RESULTS

7 patients, 5 women and 2 males were studied. The most common level was C5 corpectomy (n=4). The Neck Disability Index (NDI) preoperative average was 30.01±24.32 and 4-year postoperative 16.90±32.05, with p=0.801. The preoperative and 4-year postoperative Nürick was 3.28± 48 and 3.14±1.21 respectively, with p=0.766. Preoperative lordosis was 14.42±8.03 and 4-year postoperative 17±11.67 degrees, with p=0.660. The immediate postoperative and 4-year postoperative subsidence was 2.69±2.8 and 6.11±1.61 millimeters respectively, with p=0.0001.

CONCLUSIONS

Despite the small sample, the subsidence of the mesh cage is common in this procedure. No statistically significant changes were observed in the lordosis or Nürick scale and NDI.