A RARE CASE OF CERVICAL HARDWARE MIGRATION CAUSING ESOPHAGEAL PERFORATION

Abstract

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Esophageal perforation caused by migration of cervical hardware in the delayed setting is a rare but deadly complication of anterior cervical spine surgery (ACSS). Esophageal perforation is a known complication of ACSS, which accounts for more than 40% of documented cases. However only 0.2-1.5% of those cases happened in the delayed setting and the initial presentation can be atypical. The purpose of this report is to highlight the importance of promptly diagnosing these patients and moving forward with the appropriate management. CASE PRESENTATION: 32-year-old man with a PMH of C6 spinal cord injury 3 years prior with residual quadriplegia requiring anterior cervical discectomy and fusion (ACDF) of C6-T1 with C7 corpectomy and a tracheostomy. He presented with worsening abdominal pain. Imaging and colonoscopy were both normal so an EGD was performed which found an eroded foreign body in the lumen of the proximal esophagus. Neurosurgery was consulted and ordered CT imaging which confirmed our suspicion. A bronchoscopy was then done to evaluate his tracheostomy site which did not appear to have any effect on his airway nor were any fistulas observed. Despite the aforementioned findings the patient was clinically stable and denied any dysphagia, odynophagia, poor appetite, or irregular bowel movements. Patient is currently scheduled for cervical spine hardware revision. DISCUSSION: ACDF has been around since the 1950s, is well documented, and has an overall complication rate of 5%. That being said, surgical complications including perforation can be further subdivided into acute or delayed (>30 days post-op) and can range from local infection to mediastinitis and death. While most acute perforations during or after ACSS are iatrogenic, the majority of delayed perforations are from hardware failure (41%) which come from loosened or migrated screws/plates. Chronic erosion of hardware makes up 31% of cases and is thought to be caused by tissue ischemia from the prolonged pressure of cervical hardware, thus weakening the posterior esophageal wall leading to deadly complications. Esophageal perforation in this subset of patients can happen during ACSS or up to 11 years post-operatively in some studies. Obtaining a pertinent history is paramount in the settings of acute versus chronic esophageal perforations. An acute perforation would present with dysphagia and odynophagia (54%), fever (21%), and/or neck swelling (21%). Our case is atypical in that our patient was being worked up for something entirely different and denied any of the aforementioned signs and symptoms. CONCLUSIONS: Delayed esophageal erosions require a high level of suspicion as presenting signs and symptoms may be nonspecific. Operative interventions with revision of cervical spine surgery and myofascial repair are the standard of care for this condition with considerations being made for comorbidities and clinical circumstances. Reference #1: S. H. Halani, G. R. Baum, J. P. Riley et al., “Esophageal perforation after anterior cervical spine surgery: a systematic review of the literature,” Journal of Neurosurgery: Spine, vol. 25, no. 3, pp. 285–291, 2016. Reference #2: A. Marquez-Lara, S. V. Nandyala, H. Hassanzadeh, M. Noureldin, S. Sankaranarayanan, and K. Singh, “Sentinel events in cervical spine surgery,” The Spine Journal, vol. 39, no. 9, pp. 715–720, 2014. Reference #3: D. Yin, X. Yang, Q. Huang et al., “Pharyngoesophageal perforation 3 years after anterior cervical spine surgery: a rare case report and literature review,” European Archives of Oto-Rhino-Laryngology, vol. 272, no. 8, pp. 2077–2082, 2015. DISCLOSURES: No relevant relationships by Zaid Ansari, source=Web Response No relevant relationships by MAYKEL IRANDOST, source=Web Response No relevant relationships by Tyler Putnam, source=Web Response No relevant relationships by Ali Saeed, source=Web Response