Nerve Block Complication: A Rare Cause of Esophageal Perforation

Abstract

60 percent of esophageal perforations are iatrogenic, most of which occur during endoscopy. We describe a rare cause of iatrogenic esophageal perforation secondary to a nerve block procedure. A 57 year-old man with stage IV renal cell carcinoma, metastatic to his lungs and spine, presented after a cancer monitoring CT incidentally found a possible esophageal perforation. Importantly, two weeks prior, the patient underwent a nerve block procedure for a T5-T7 metastatic lesion that was causing neuropathic pain. The patient reported that after the procedure the back pain worsened. On presentation, he was afebrile and his labs were only significant for a leukocytosis. The esophagram did not identify a leak, however, CT chest showed a contained collection of extraluminal contrast in the mediastinum anterior to the thoracic spine related to a very small esophageal perforation. Broad spectrum antibiotics and antifungals were started. The endoscopy found a small defect that was the suspected perforation. The tear was sutured closed and a stent was placed. The patient's back pain initially improved, however, he had recurrence of his back pain 2 weeks later. Repeat CT showed extravasation of contrast tracking from the esophagus to the posterior spine making the nerve block the most likely cause of the perforation. Repeat endoscopy found the stent had dislodged and had to be replaced. While a paravertebral nerve block is considered a very safe procedure, it is important to note that esophageal perforation is a possible complication. A review of literature did not identify any other reported cases of esophageal perforation as a nerve block complication. As the medical community is looking toward non-opioid pain control methods, nerve blocks and advanced pain procedures are becoming more common. Interestingly, the initial esophagram did not identify the leak, however, esophagrams have a 10% false negative rate. This case also demonstrates that in stable patients who have a contained esophageal perforation, nonoperative management such as covered stent placement can be considered. While more robust data needs to be gathered, small case series have shown that in selected patients nonoperative management can have fewer complications.Figure: Initial CT chest with contrast showing a small contained collection posterior to the esophagus.Figure: Follow up CT after recurrence of the back pain showing collection in the posterior mediastinum and contrast tracking posterior to the spinal canal.