Ann Otol Rhinal Laryngol100: 1991

DELAYED PHARYNGOESOPHAGEAL PERFORATION: A COMPLICATION OF ANTERIOR SPINE SURGERY MD DAVID ZWILLENBERG, MD

F. KELLY, MD KAREN A. RIZZO, MD

JOSEPH SPIEGEL,

MARK

PHILADELPHIA, PENNSYLVANIA

Stabilization of the cervical spine is often accomplished via an anterior cervical approach. Bone grafts and lor plates and screws are used to achieve stabilization. Injuries to the pharynx and esophagus are known complications in anterior exposure of the cervical spine. These injuries are manifest in the early postoperative period. Reports of late perforations are very rare. We present four cases of delayed injury to the pharynx and esophagus that resulted in abscess or fistula. We postulate that graft displacement with resulting erosion was responsible for these serious complications. Postoperative odynophagia in patients who undergo anterior cervical fusion warrants evaluation of the bone graft location. Early surgical intervention and repair may decrease prolonged morbidity in these patients. KEY WORDS - anterior fusion, cervical fusion. cervical spine, pharyngoesophageal perforation.

onstrated. A few small pieces of bone that had been displaced from the fusion site and were bathed in the fistula were removed. A Penrose drain was placed and postoperatively he took nothing by mouth (was kept NPO) and had a nasogastric tube in place for feeding. He was treated with intravenous cefoxitin sodium for 14 days on the basis of operating room cultures that grew anaerobes and gram-negative bacteria. He continued to have a salivary fistula that remained stable. Over the next few months he had continued but decreased drainage from the fistula. On November 5, 1985, he was returned to the operating room for drainage of an abscess in the retropharyngeal area. Endoscopy at that time revealed a posterior pharyngeal wall perforation just above the level of the cricopharyngeus muscle. The area appeared to be granulating well and no bone fragments were identified. Over the next 6 weeks, the fistula spontaneously closed. He underwent barium swallow evaluation that confirmed resolution of the fistula in mid-December 1985. He then began oral feeding and experienced no difficulties. A cervical spine computed tomography (CT) scan revealed fibrous fusion and significant resorption of allograft bone. His cervical tongs were removed and he experienced no further difficulties. He currently has had no sequelae from the fistula and remains an incomplete C-6 quadriplegic.

INTRODUCTION

Patients who sustain flexion injury to the cervical spine with fracture and/or dislocation of cervical vertebrae often require stabilization to prevent further injury of the cervical spinal cord. Definitive surgical intervention most commonly involves an anterior approach to expose the vertebral bodies. Fusion of cervical vertebrae is accomplished by using allograft bone from the iliac crest, which is fashioned into a pocket created in the cervical vertebral bodies. The aim is to reconstruct stable and viable support of the cervical cord. At Thomas Jefferson University Hospital, a regional spinal cord trauma center, 680 cervical cord injuries were treated between 1979 and 1989. Approximately 60% of these patients underwent surgical stabilization of the spine with anterior fusion. During this time, we have encountered four cases of delayed pharyngocutaneous fistulas. None of these patients sustained perioperative pharyngeal trauma. Our experience with these rare and hazardous complications is presented. CASE REPORTS

Case 1. This 38-year-old man sustained a C-5 flexion fracture in a diving accident on July 4, 1985. He had an incomplete C-6 spinal cord injury. Cervical tongs were placed, and on July 5, 1985, he underwent anterior cervical fusion from C-4 to C-7 with allograft iliac crest. Sixteen days postoperatively, he developed new-onset odynophagia. Results of a barium swallow study were normal at this time. On July 27, 1985, he developed neck swelling and high fevers. A repeat barium swallow study revealed a pharyngeal fistula present. He underwent immediate neck exploration via the cervical fusion incision and a left paraspinal abscess was drained. The site of pharyngeal perforation could not be dem-

Case 2. This 34-year-old man with a history of insulin-dependent diabetes was involved in a motor vehicle accident September 6, 1984. He sustained a left clavicular fracture, multiple left rib fractures, and a compression fracture at C-7 with incomplete C-7 spinal cord injury. He was stabilized in cervical tongs and transferred to Thomas Jefferson University Hospital. He underwent anterior corpectomy and C-6 to C-7 anterior cervical fusion using allograft iliac crest on October 1, 1984. He had an un-

From the Department of Otolaryngology, Jefferson Medical College at Thomas Jefferson University. Philadelphia, Pennsylvania. Presented at the meeting of the American Broncho-Esophagological Association, Palm Beach, Florida, May 2-3, 1990. REPRINTS - Mark F. Kelly, MD, Dept of Otolaryngology, Jefferson Medical College at Thomas Jefferson University, Philadelphia, PA 19107.

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Fig 1. (Case 3) Computed tomographic sagittal reconstruction of cervical spine reveals anteriorly displaced bone fragment (arrowhead) impinging on posterior pharyngeal wall.

eventful early postoperative recovery. In early November 1984 he developed mild odynophagia. Within several days he developed elevated temperatures and white blood cell counts. The left side of his neck became swollen and painful to palpation. A bone scan performed at this time revealed no osteomyelitis in the cervical spine. A gallium scan revealed increased uptake in the soft tissues of the neck. On November 17, 1984, he underwent neck exploration, and an abscess with salivary fistula was discovered in the C-7 area. The perforation was oversewn and drains were placed in the area. He was prescribed intravenous antibiotics on the basis of operating room cultures. He continued to have salivary drainage without cellulitis or abscess in the fistula. He was maintained on gastrostomy feedings and was transferred to the rehabilitation unit in December 1984. The fistula failed to spontaneously close. Follow-up examinations revealed granulation tissue around the fistula site. Barium swallow examinations demonstrated an unchanging fistula tract. Computed tomography scans of the cervical spine revealed failed fusion with resorption of the iliac crest allograft. However, fibrous union was present and he had his cervical halo removed in June 1985. This management continued until July 1985, when he developed elevated temperatures. Workup included a bone scan that revealed possible osteomyelitis of the cervical spine. On July 29, 1985, reexploration of the neck, biopsy of the cervical bone, and debridement of the fistula with oversewing of the esophagus were performed. Bone cultures revealed Enterobacter and anaerobic bacteria. He was again placed in cervical traction. He continued to have a draining salivary fistula. On October 4, 1985, he required another neck exploration for drainage of an abscess. Later that month, he underwent a posterior cervical fusion for cervical spine stabilization. He was again maintained on gastrostomy feedings and continued to have drainage until May 1986. The fistula then spontaneously closed and a barium swallow study revealed no leak. He was begun on oral feedings and developed no problems related to the fistula thereafter. Case 3. This 40-year-old man sustained a C-6 burst fracture that was treated with posterior cer-

vical wiring and anterior cervical fusion November 26, 1986. Postoperatively, he had good recovery until early January 1987, when he developed dysphagia and then right-sided neck swelling with drainage. He had local incision and drainage of the right side of the neck and thereafter was fed with a nasogastric tube and kept NPO. He was given intravenous antibiotics as dictated by cultures for 14 days. The drainage cleared and he developed a noninfected salivary fistula. He had a percutaneous gastrostomy placed and was kept NPO. Fiberoptic laryngoscopy revealed a dysfunction of the right superior laryngeal nerve. He was maintained in cervical halo traction over the next few months and had a persistent cervical fistula without abscess or cellulitis. Barium swallow evaluation on repeated occasions failed to reveal esophageal leakage, but there was preferential filling of the left pyriform sinus. However, he required two additional cervical drainage procedures for abscess, in March and April 1987. A CT evaluation of his cervical spine revealed fibrous union of his spine, and halo traction was removed in April 1987. He continued to have cervical drainage. He was readmitted on October 27, 1987, and had a CT of the neck and cervical spine, revealing significant resorption of iliac crest bone with a bony fragment displaced anteriorly at the inferior site (Fig I). He underwent direct laryngoscopy on November 2, 1987, and a large amount of granulation tissue was found in the right pyriform sinus. There appeared to be a small punctate rent in the apex of the right pyriform sinus mucosa. The neck was explored along the fistula tract and a sequestrum of osteomyelitic bone was found and removed. The cervical drainage stopped after operation and results of a follow-up barium swallow study on November 11, 1987, were reported to be normal. The patient was begun on oral feeding and has developed no complications since that time. Case 4. This 68-year-old man saw a neurosurgeon for complaints of upper extremity paresthesia and weakness. Evaluation and CT revealed severe cervical spondylosis with anterior compression. He underwent anterior cervical fusion from C-3 to C-7 on October 19, 1988. Postoperatively he did well and was discharged home in cervical tongs. He pre-

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oped some salivary drainage in his suction drains. He had compression dressings placed and was kept NPO. He was maintained on intravenous penicillin on the basis of operating room cultures that grew a-hemolytic streptococci. The drainage spontaneously stopped by December 23, 1988. A repeat barium swallow study on December 28, 1988, revealed no fistula, but a small posterior pharyngeal irregularity. Fiberoptic pharyngoscopy failed to reveal any abnormalities. He was maintained on gastrostomy tube feedings until January 16, 1989. He underwent a repeat barium swallow study; the findings were normal. He underwent a posterior approach to the cervical spine and had a successful cervical fusion on February 11, 1989. His cervical tongs were removed 6 weeks later and he now is in good condition with no further complications. DISCUSSION

Fig 2. (Case 4) Lateral cervical tomogram reveals anteriorinferior displacement of iliac crest allograft.

sented to the Thomas Jefferson University Hospital emergency room complaining of difficulty swallowing and fever on November 29, 1988. Lateral cervical spine x-ray films revealed anterior displacement of the spinal fusion graft (Fig 2); a barium swallow study done at this time showed no leak. He was brought to the operating room December 1, 1988, and some purulent material was found in the area of the anteriorly displaced graft. The area was irrigated after cultures were taken and the wound was closed. The patient continued to have fever and developed salivary drainage on the first postoperative day. Methylene blue was given orally and confirmed the presence of a pharyngocutaneous fistula. A gastrograffin swallow study confirmed the fistula, but the exact level of the fistula could not be determined. He was returned to the operating room December 5, 1988, and upon exploration of the neck was found to have a l-cm posterior esophageal perforation at the C-7 level, at which the inferior portion of the iliac crest allograft was anteriorly displaced. The tissues around the perforation were markedly inflamed and edematous. A two-layer closure of the perforation was attempted. The iliac crest bone graft was removed. Two large suction drains were placed and the skin was loosely approximated. He was maintained in cervical tongs for spine stabilization. A feeding gastrostomy was placed. On the third postoperative day, he devel-

Pharyngoesophageal injury after anterior spinal fusion procedures has been described since the development of the procedure. Almost all reports involve fistulas developing in the early postoperative period. Delayed fistulas are rare and most likely have a different cause. In each of the previously described cases, patients developed cervical fistulas several weeks to months after anterior spinal fusion. All had recovered from the early postoperative period and were tolerating solid diets without pharyngeal complaints. Pharyngeal complications after cervical spine injury have been reported. Morrison! described a case in which a posterior esophageal tear appeared to be caused by the exposed C-7 vertebral body in a patient with C6-7 subluxation and an anterior longitudinal ligament tear. Tomaszek and Rosner" reported two cases involving fracture dislocations in the C6-7 region with esophageal injury. One patient developed neck abscess, the other mediastinitis and empyema. These reports demonstrate pharyngoesophageal injury with isolated cervical spine trauma. Other reports of esophageal injury in blunt trauma are related to increased intraesophageal pressure with rupture in the cricopharyngeus region. Intraoperative injury to the pharynx during anterior spinal fusion is rare. Experience with the procedure since the 1950s has produced a safer operative technique. Gentle dissection and retraction of the pharynx and esophagus avoids direct trauma. Corpectomy and graft placement as described by Rothman and Simeone" and Bohlman and Eismont" eliminates foreign materials, such as wires, that have produced esophageal injuries. The technique involves creation of a pocket to accept an appropriately fashioned iliac crest allograft while the spine is in extended traction. Small fragments of allograft bone are placed to fill the corpectomy site. Care is taken not to leave rough surfaces along the anterior

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Fig 3. Artist's depiction of sagittal view of anteriorinferior graft displacement with impingement on posterior pharyngeal wall. Iliac crest allograft has been resorbed, allowing for anterior displacement.

surface of the fusion site. Neither Cloward" nor Tew and Mayfield" reported any cases of intraoperative pharyngoesophageal injury in several hundred an . . terior spinal fusions. At Jefferson, we have seen no early pharyngeal perforations from intraoperative trauma in about 350 cases. Delayed injury to the pharynx and esophagus after anterior spine surgery has been reported. Whitehill et al" and Kuriloff et al" each reported a case of delayed fistula after cervical spine fusion occurring 6 to 10 weeks after operation. In one case, anterior displacement of an iliac crest graft was demonstrated on radiographs. In our series of patients, all developed odynophagia as the first symptom. In three of the four cases, fever and neck swelling occurred more than 24 hours after the swallowing difficulty. The fourth patient presented to the emergency room with odynophagia of 2 days' duration and new-onset fever. These findings suggest that the patients sensed the displacement of the iliac crest graft or surrounding bone fragments just prior to perforation. One patient underwent lateral cervical spine radiographs and tomograms demonstrating the graft displacement (case 4). Dysphagia after anterior spine surgery has been reported" and may be related to perioperative swelling or hematoma. However, odynophagia after spinal fusion is rare and probably warrants evaluation of the fusion site. Contrast pharyngoesophagrams were diagnostic after perforation occurred. However, in cases 1 and 4, barium swallow studies performed at the presentation of odynophagia did not reveal perforations. Once these patients developed neck swelling, however, all contrast studies were positive. Contrast swallowing studies are recommended to aid in determining location of the perforation and possible extension of extravasation. However, negative results should not decrease suspicion of impending or

developing perforation. Computed tomography scans were performed in three patients. These scans may help delineate the extent of abscess and possible extension along the prevertebral space and therefore should be performed if possible. Evaluation of the iliac crest allograft position in the sagittal plane is most easily accomplished with cervical tomography. In case 4, cervical tomograms clearly demonstrated graft displacement. Sagittal reconstruction of CT scans as in case 3 could also be useful in evaluating bone displacement or bony fragments impinging on the pharynx. Bone scans were performed in two patients. In one case, osteomyelitis was suspected. Bone scanning of cervical fusion sites will reveal increased uptake for about 9 months after operation. This is related to remodeling and osteointegration of the living iliac crest graft. Infection in a viable graft would display markedly increased uptake. Confusion may thus occur if portions of the allograft are nonviable and serve as infected foreign bodies. These areas will not show markedly increased activity. Operative considerations in these cases center upon adequate drainage of abscess and drain placement. If bony fragments or the iliac crest graft are exposed to infection, they must be removed. Dissection along the planes of previous exposure and/or along the fistula tract avoids spread of infected material in fresh tissue planes. In the first three cases, the iliac bone grafts did not appear to be directly involved in the abscess and were not removed. There appeared to be a fibrous barrier over the grafts. However, these patients had prolonged fistulas, most likely secondary to low-grade infection associated with the graft, which acted as a foreign body in the fistula area. In the fourth case, the graft was removed and the fistula closed quickly.

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Evaluations of the first three patients revealed failed graft fusions with major resorption of the iliac crest grafts. These patients developed secondary firm fibrosis in the corpectomy sites that provided adequate stabilization of the spine and allowed external stabilization to be discontinued. This process took months to over a year to occur. In the fourth case, the patient underwent a posterior approach and fusion and had external stabilization removed 4 months after he initially developed his fistula. At the time of his graft removal, 41 days after anterior spinal fusion, the graft had resorbed and was several millimeters smaller than the anterior lip of the corpectomy site (Fig 3). Closure of the pharynx or esophagus is recommended if possible, with consideration of reinforcement with muscle flap if necessary.:" The fate of iliac crest allografts in cervical fusion is not certain. Almost all grafts undergo some re-

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sorption after placement, although successful fusion is almost always accomplished. Some degree of anterior graft displacement is not rare, and fibrous union is considered acceptable. It appears that this anterior displacement of the iliac crest allograft with surrounding bone chips is responsible for these rare cases of delayed pharyngoesophageal perfora~ tion. CONCLUSION

Delayed pharyngoesophageal perforation after anterior spinal fusion is a rare complication. All patients presented with odynophagia. Perforations were located at the inferior portion of the fusion site. Anterior displacement of the graft with erosion into the esophagus was the most likely cause. Adequate drainage and removal of infected bone is essential in managing these potentially life-threatening complications.

REFERENCES 1. Morrison A. Hyperextension injury to the cervical spine with rupture of the esophagus. J Bone Joint Surg 1960;42:356-7.

6. Tew JM, Mayfield FH. Complications of surgery of the anterior cervical spine. Clin Neurosurg 1975;23:424-34.

2. Tomaszek D, Rosner MJ. Occult esophageal perforation associated with cervical spine fracture. Neurosurgery 1984;14: 492-4.

7. Whitehill R, Sierna EC, Young DC, Cantrell RW. Late esophageal perforation from an autogenous bone graft. J Bone Joint Surg [Am] 1985;67:644-5.

3. Rothman RH, Simeone FA. The spine. Vol 2. Philadelphia, Pa: WB Saunders, 1982:709-41. 4. Bohlman HH, Eismont FJ. Surgical techniques of anterior decompression and fusion for spinal cord injuries. Clin Orthop Relat Res 1981;154:57-67.

8. Kuriloff DB, Blaugrund S, Ryan J, O'Leary P. Delayed neck infection following anterior spine surgery. Laryngoscope 1987;97:1094-8. 9. Welsh LW, Welsh Jl, Chinnici Je. Dysphagia due to cervical spine surgery. Ann Otol Rhinol Laryngol 1987;96:112-5.

5. Cloward RB. New method of diagnosis and treatment of cervical disk disease. Clin Neurosurg 1962;8:93-132.

10. Rubin JS. Sternocleidomastoid myoplasty for the repair of chronic cervical esophageal fistulae. Laryngoscope 1986;96:834-6.

FIRST INTERNATIONAL LARYNGOTRACHEAL RECONSTRUCTION SYMPOSIUM The Cleveland Clinic Foundation is sponsoring a continuing education program entitled First International Laryngotracheal Reconstruction Symposium. The symposium will be held August 24-27, 1991, at Stouffer Tower City Plaza Hotel in Cleveland, Ohio. For further information, please contact The Cleveland Clinic Educational Foundation, Department of Continuing Education, 9500 Euclid Avenue, Rm TT-31, Cleveland, OH 44195-5241; 444-5696 (local) or (800) 762-8173.

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Delayed pharyngoesophageal perforation: a complication of anterior spine surgery.

Stabilization of the cervical spine is often accomplished via an anterior cervical approach. Bone grafts and/or plates and screws are used to achieve ...
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