Pharyngocutaneous fistula after anterior cervical spine surgery

Abstract

Pharyngocutaneous fistulae are rare complications of anterior spine surgery occurring in less than 0.1% of all anterior surgery cases. We report a case of a 19 year old female who sustained a C6 burst fracture with complete quadriplegia. She was treated urgently with a C6 corpectomy with anterior cage and plating followed by posterior cervical stabilization at another institution. Post operatively she developed a pharyngocutaneous fistula that failed to heal despite several attempts of closure and esophageal exclusion with a Jpeg tube. The patient was eventually successfully treated with a three-stage procedure consisting of firstly a posterior approach to reinforce the posterior stabilization of the cervical spine that was felt to be inadequate, secondly an anterior approach with removal of all the anterior instrumentation followed by iliac crest bone graft and thirdly a superior based sternocleidomastoid flap that was interposed between the esophagus and the anterior cervical spine. The patient's fistula healed successfully. However, yet asymptomatic, the anterior iliac crest bone graft resorbed almost completely at 16 months follow up. In light of this complication, we discuss the surgical options for the treatment of pharyngocutaneous fistulae and the closure of this fistula using a superiorly based sternocleidomastoid muscle flap.

Fig. 1

a Note severe burst fracture of C6, with evidence of spinal cord injury prior to surgery at outside facility. b Construct from outside facility after anterior corpectomy and posterior fixation

Fig. 2

a Note opening of pharyngocutaneous fistula. b Axial CT of spine at level of fistula. Note the presence of air deep to the skin surface as well as adjacent to the hardware (white arrows)

Fig. 3

Note the cervical plate seen from the laryngoscope, hence demonstrating defect in pharyngeal wall

Fig. 4

a Hemostat is inserted into the esophageal wall defect. b After removal of the plate and cage, iliac crest bone was inserted in the corpectomy defect (black arrow)

Fig. 5

Note the mobilized sternocleidomastoid muscle and associated flap that has been attached to the pharyngeal defect (white arrow)

Fig. 6

Two months postoperative X-rays seem to show incorporation of the iliac crest bone graft

Fig. 7

Note resorption of iliac crest bone graft at 16 months follow up (white arrow)