Esophageal perforation associated with fracture of the upper thoracic spine from blunt trauma: a case report

Abstract

We report the successful conservative management of an unusual case of esophageal perforation associated with an upper thoracic spinal fracture from blunt trauma in Minamata, Kumamoto, Japan. A 69-year-old man became paraplegic secondary to an L1 burst fracture caused by a boating accident and underwent posterior fixation on the day of admission. The patient also had a minimally displaced T4 vertebral fracture. Fever, dyspnea and elevated inflammatory markers all persisted postoperatively. Computed tomography showed free mediastinal air at the T4 level, and an esophagram showed contrast medium leakage, which helped diagnose esophageal perforation. The esophageal perforation healed with conservative treatment without life-threatening complications. The possibility of esophageal injury should always be considered when treating upper thoracic spinal injuries due to blunt trauma.

Keywords: Neurosurgery; Trauma.

Figure 1

Initial computed tomography (CT) revealed a T4 vertebral body fracture with minimal displacement, fractured thoracic spinous processes 5–7 (a), an L1 burst fracture with T12 anterior subluxation (b) and ankylosing spinal hyperostosis.

Figure 2

On day 12, follow-up CT demonstrated free air in the mediastinum at the T4 level (a). Re-evaluation of the initial CT revealed that small air inclusions had been present in the extra-esophageal soft tissues slightly cephalad to the fractured vertebra (b). Esophagography revealed contrast medium leakage at the T3–4 levels (c). On day 34, closure of the esophageal perforation was confirmed by esophagography (d). Magnetic resonance imaging (MRI) showed T4 vertebral body destruction and wide-range epidural abscess formation that was complicated with pyogenic spondylitis, which was secondary to the esophageal perforation (e). On day 106, MRI showed healing of the pyogenic spondylitis (f).