Two Cases of Esophageal Injury Following Anterior Cervical Discectomy and Fusion: One Overt and One Covert

Abstract

Esophageal perforation is a dreaded complication of anterior cervical spinal surgery. A 52-year-old diabetic man had undergone a surgery for a C6-C7 disc prolapse and developed spiking fever with chills and rigor on the 7th postoperative day. No cause could be found out but a CT scan of thorax done in the course of investigations revealed pneumomediastimum. The patient succumbed on the 10th day after surgery. Autopsy revealed the cause of death to be mediastinitis following iatrogenic esophageal perforation. A second patient, 53 years of age, following surgery for C5-C6 disc prolapse and developed intractable dysphagia. Later, fever and purulent discharge from the wound prompted an MRI showing prevertebral collection extending to the superior mediastinum. Presuming only wound infection, debridement and implant removal was done. However persistent serous discharge from the wound revealed an esophageal injury. Late diagnosis precluded primary repair. With conservative treatment, the fistula finally closed after 42 days. Postoperative dysphagia, a common complaint following surgery, may not always be present in cases of esophageal injury. A high index of suspicion is required for diagnosing and initiating treatment for esophageal perforation before complications set in.

Keywords: Anterior cervical spinal discectomy; Cervical osteomyelitis; Dysphagia; Esophageal injury; Esophagography; Mediastinitis.

Fig. 1

Sagittal T2 (a) and axial MRI sequence (b) showing C5-C6 left sided disc prolapse; clinical photograph (c) showing pus discharge from the lateral side of the incision.

Fig. 2

a Chest X-ray showing bilateral lower zone haziness suggestive of aspiration pneumonitis; b sagittal T2 MRI sequence showing implants in situ and large prevertebral collection extending upto D3 vertebral body level.

Fig. 3

a Esophagography with gastrograffin showing hold up of dye in the esophagus with periesophageal spillage; b CT scan showing large abscess cavity filled with air abutting the carotid sheath and crossing the midline precluding placement of a sternomastoid flap for fear of blocking the drainage of dependant segment.

Fig. 4

a Clinical photograph showing fistulous site healed by secondary intention (green arrows) and medial part of the wound healed by primary intention (blue arrows); b lateral X-ray cervical spine showing bony fusion at C5 and C6.