Extruding Cervical Screw: A Rare Cause of Dysphagia

Abstract

Complications from instrumentation of the cervical spine may affect the esophagus, as it directly overlies the cervical vertebrae; there have been reported cases of perforation, abscess, stricture, and diverticulum formation. While orthopedic surgeons and neurosurgeons are aware of these rare complications, gastroenterologists may not be familiar with them and may not consider these diagnoses when evaluating patients with oropharyngeal issues. We present a case of cervical screw extrusion leading to dysphagia and hoarseness, that underscores the importance of careful endoscopic inspection of the retropharynx during endoscopy and the early use of imaging in evaluation of patients with a history of cervical instrumentation. A 49 year old woman presented with a 4 month history of increasing difficulty and pain swallowing (right side of the throat), and significant hoarseness. Past history was significant for a motor vehicle accident 17 years prior, with cervical spine injury leading to refractory radiculopathy. She subsequently underwent anterior cervical decompression, fusion, and insertion of an integrated cage and plate system. Upper endoscopy showed a normal esophagus. Careful inspection identified a prominent bulge in the right posterior oropharynx, proximal to the piriform sinus with a superficial mucosal erosion, but no perforation (Fig. 1). A follow-up cervical CT scan confirmed a screw extending from the C4-5 level into the posterior esophagus to the right of midline at the level of the piriform sinus (Fig. 2); there was also evidence of instrumented fusion at C4-5 and C4-6 using integrated cage and plate system. The patient was then referred to neurosurgery for urgent operative removal of the screws.1742_A Figure 1. Endoscopic examination identifying a prominent bulge in the right posterior oropharynx, proximal to the piriform sinus.1742_B Figure 2. CT scan confirming a screw extending from the C4-5 level into the posterior esophagus to the right of midline at the level of the piriform sinus.Esophageal complications related to cervical fusion hardware are rare, and may present in the immediate post-operative period or years later. Slow anterior migration of the screw or cage system over time may cause extrinsic compression of the pharyngoesophageal wall leading to pressure necrosis and ultimately erosion or perforation. Gastroenterologists should have a high index of suspicion for this diagnosis when evaluating patients with history of cervical instrumentation presenting with oropharyngeal dysphagia. Endoscopic exam should focus on careful inspection of the oropharynx, as the pertinent findings may be subtle. Follow-up imaging with CT or MRI should be considered in the appropriate setting to confirm the diagnosis.