Esophageal perforation following cervical spine surgery: A review with considerations in airway management
A 24-year-old man presented to an outside hospital following a motor vehicle accident with cervical spine fractures of C5 - C7, anterolisthesis of C6 and associated spinal cord transection with resulting quadriplegia. The patient was taken to the operating room and underwent anterior cervical decompression and fusion (ACDF) of C5-7, C6 corpectomy with polyetheretherketone (PEEK) cage and C4 - T1 posterior fusion []. Postoperatively the patient did well and was discharged to a rehabilitation center at our institution.\nApproximately four months following his surgeries the patient began to develop increased sputum production, cough and fever. Chest X-ray revealed bilateral infiltrates consistent with aspiration pneumonia. At this time, the aspiration was thought to be due to the patient's poor pulmonary clearance from his immobility and quadriplegia. While on antibiotic therapy for aspiration pneumonia the patient developed acute dysphagia. Computed tomography (CT) scan demonstrated air surrounding the implant at C6 as well as the anterior fusion plate []. Upper endoscopy and bronchoscopy did not demonstrate any esophageal or airway defects. Barium swallow revealed an esophageal defect with contrast tracking down the prevertebral space to the level of T1 anterior to the cervical fusion plate as well as a tracheo-esophageal fistula [].\nThe patient underwent removal of the anterior plate, which was visualized in the pharyngoesophagus during intraoperative video-assisted laryngoscopy,[] removal of PEEK cage and placement of antibiotic impregnated bone cement, primary repair in conjunction with a sternocleidomastoid muscle flap being placed on the esophageal defect []. Although the barium swallow study revealed a tracheoesophageal fistula, none was seen intraoperatively. A nasogastric tube (NGT) was placed under direct endoscopic visualization as well. Postoperatively, the patient remained intubated with the NGT to remain in place for one week. The patient was extubated over a soft 22-french exchange catheter without incident and repeat barium swallow study demonstrated resolution of the esophageal perforation [].