Esophageal perforation following anterior cervical discectomy and fusion

Abstract

Anterior cervical discectomy and fusion (ACDF) is one of the most common spinal surgeries performed in the US but is associated with various morbidities. Esophageal perforation is one of the rarest complications of ACDF, but it is potentially fatal, therefore requiring timely detection and treatment. We present three cases of esophageal perforation after ACDF.

Key Points

• Esophageal perforation is a rare but potentially fatal complication of anterior cervical discectomy and fusion (ACDF) that can be a result of iatrogenic injury or hardware erosion, among other causes.

• Symptoms of esophageal perforation can range from asymptomatic to dysphagia, neck/chest pain, and hoarseness. Many of these symptoms are also general complaints from patients following ACDF, so it is imperative to consider esophageal perforation in the differential to prevent delayed diagnosis of this serious complication.

• While there is no gold standard universal approach to treating esophageal perforation, primary surgical repair and hardware removal are mainstays of treatment for early and delayed cases.

CME

CME Information: https://ce.bswhealth.com/BUMC_Proceedings_CME_info

Credit Claim Process: To claim CME for this activity, read the entire article and go to ce.bswhealth.com/2025BUMC_Proceedings_Jan_ACDF. You will register for the course, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.

Dates for credit: January 1, 2025, to January 1, 2026. For questions about CME credit, visit our website ce.bswhealth.com/contact-us.

Case Summary

Case 1, early presentation (within 30 days)

A 46-year-old woman developed acute chest pain 1 week after C5-C7 anterior cervical discectomy and fusion (ACDF) indicated for cervical myelopathy. Neck and chest computed tomography (CT) scans revealed diffuse soft tissue emphysema, retroesophageal fluid collection at the thoracic inlet, adjacent pneumomediastinum with mediastinitis, and partial anterior migration of the C7 screws. An esophagram was performed due to concern for esophageal perforation, revealing contrast extravasation into the upper mediastinum due to a large perforation at the posterior lower pharynx and uppermost part of the esophagus. Esophagoscopy confirmed that the perforation was due to erosion by the C7 screws (Figure 1). A percutaneous endoscopic gastrostomy (PEG) tube was placed for enteral feeding access. The anterior plate and ventral body screws were removed during neck exploration followed by abscess drainage and wound vacuum-assisted closure (VAC). A follow-up esophagram 1 month after plate removal revealed improving esophageal perforation with resolution of contrast extravasation into the mediastinum. Fifty-five days after hardware removal, CT and magnetic resonance imaging (MRI) showed C4–C7 vertebral osteomyelitis resulting in an unstable cervical spine, requiring a C4–T1 posterior spinal fusion with C4–C5, C5–C6, and C6–C7 laminectomy and decompression. The patient was discharged with analgesics and followed up with physical therapy. A 2-month follow-up esophagram revealed no residual perforation or extravasation.

Figure 1.

Esophagoscopy demonstrating anterior migration of the C7 screws resulting in esophageal perforation.

Case 2, delayed presentation (after 30 days)

A 46-year-old woman presented as an outpatient 1 year following C5–C7 ACDF complaining of progressive dysphagia to solids and thick liquids. A neck CT scan revealed soft tissue inflammation around the cervical plates with no evidence of an abscess. Esophagram findings were equivocal for a diverticulum versus perforation, and so an esophagogastroduodenoscopy (EGD) was performed, showing mucosal disruption in the proximal esophagus due to cervical hardware plate erosion. The patient then underwent left neck exploration, where hardware was removed and the perforation was repaired followed by PEG tube placement. An esophagram 1 month later demonstrated a small residual contained leak, so the patient had an endosponge placed. This was removed 2 weeks later with an on-table esophagram demonstrating no clear leak. Two months later, the PEG tube was removed, and a small residual defect was repaired endoscopically with an X-tack device. A follow-up esophagram demonstrated a “Zenker diverticulum-like” outpouching along the posterior wall of the esophagus at the C6–C7 intervertebral disc (Figure 2). Because the patient did not complain of dysphagia and imaging remained stable with no communication to cervical hardware, this outpouching was managed conservatively.

Figure 2.

(a) Esophagram demonstrating extraluminal collection of contrast along the posterior wall of the esophagus at the level of C6-C7. (b) Esophagram demonstrating mid-cervical esophageal narrowing.

Case 3, delayed presentation (after 30 days)

A quadriplegic 66-year-old man (ASIA impairment grade C) had an ACDF 4 years prior at the C5–C7 levels due to C5 and C6 cervical compression fractures from an all-terrain vehicle crash. The patient became tracheostomy dependent following a respiratory setback and had a PEG tube placed. He was scheduled for an EGD due to bleeding from the PEG tube, but the procedure was aborted due to what appeared to be the tracheostomy tube obstructing the esophagus. A CT of the spine without contrast revealed that the anterior cervical fusion plate eroded into the upper esophagus at the C7 level. EGD confirmed this diagnosis. A cervical neck exploration was performed, and the posterior esophagus was mobilized off the anterior vertebral body of the cervical spine. The anterior cervical spinal plating system was removed, and the wound was left open for recovery by secondary intention utilizing negative pressure wound therapy (Figure 3). The patient was discharged 3 days postoperatively on intermittent tube feeds via PEG. Ultimately the negative pressure dressing was removed with complete healing of the cervical esophagus.

Figure 3.

Following mobilization of the esophagus and removal of the neck plate, the wound was left open due to concerns of leakage during recovery.

CME

Credit Claim Process: To claim CME for this activity, read the entire article and go to ce.bswhealth.com/2025BUMC_Proceedings_Jan_ACDF. You will register for the course, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.

Dates for credit: January 1, 2025, to January 1, 2026.

For questions about CME credit, visit our website ce.bswhealth.com/contact-us.

Clinical Questions

1. Which level of the spinal cord is the most common site of esophageal perforation following ACDF?

   1. C1–C2

   2. C3–C4

   3. C5–C6

   4. C7–T1

2. A-54-year old man with no pertinent past medical history presents to the emergency department with neck pain and difficulty swallowing. Upon questioning, he said he had a four-level ACDF completed 2 months ago to treat a multilevel cervical spinal cord compression. He denied any other symptoms. Vital signs were stable. Physical exam was unremarkable. A CT scan of his neck showed evidence of soft tissue inflammation around the cervical hardware. What is the appropriate next step in his management?

   1. Esophagram with contrast

   2. MRI of the neck

   3. Oral antibiotics with outpatient treatment

   4. An emergency neck exploration with removal of hardware

Answers are provided at the end of the article.

Discussion

The incidence of esophageal perforation following ACDF has been reported to be as low as 0.02% and as high as 1.15% in different studies.^1,2 Halani et al reviewed 153 patients across 65 articles and determined an average age of incidence of 44.7 years with 53.6% of cases occurring in men.³ This review determined an average time to diagnosis of 716.6 days, although this was heavily skewed due to some patients presenting with symptoms up to 18 years after surgery.³ The median time to diagnosis was 44.5 days, which is more consistent with the literature describing a time to diagnosis in the subacute postoperative period following ACDF.³

Esophageal perforation following ACDF has been previously categorized as early (<30 days) or delayed (>30 days).³ Early perforations are often iatrogenic, ranging from imprudent retraction to misuse of electrocautery or high-speed burr.^1–5 Delayed perforations are likely due to delayed hardware failure, often from repetitive microtrauma between the pharyngoesophageal complex and cervical hardware, leading to hardware contamination and loosening.^2,3,6,7 Overall, the most common cause of post-ACDF esophageal defects is migration or erosion by the hardware, which has a variable timeline (either early or delayed) until manifestation as seen in our cases.³

Esophageal perforation most commonly occurs at two sites of structural weakness: 1) Killian’s triangle usually lying anterior to the C5/C6 disc and 2) the lateral aspect at the level of the thyrohyoid membrane.² The most common symptom of esophageal perforation is dysphagia, which itself is a common complaint in up to 60% of patients following ACDF, so physicians may attribute this symptom to the surgery and overlook any underlying perforation.^3,8,9 Other symptoms of esophageal perforation include odynophagia, chest pain, dyspnea, neck pain/fullness, and cough.^2,4 Severe cases may result in sepsis and respiratory distress, especially if luminal contents enter the mediastinum. Other complications include prevertebral abscess formation and osteomyelitis. If esophageal perforation is suspected, we recommend a CT scan of the neck and chest with oral contrast (esophageal phase). If a perforation is unclear, we recommend obtaining a water-soluble esophagram and proceeding with esophagoscopy for confirmation of the diagnosis.

There is no gold standard universal approach to esophageal perforation therapy; however, surgical management is the mainstay. Sharma et al recommend a treatment algorithm stratifying perforation into early vs late injury with other considerations being location and size.¹⁰ This algorithm poses an iatrogenic, early injury repair approach consisting of primary surgical repair with or without local or regional flap reconstruction. Alternatively, a late hardware decay injury indicates primary surgical repair with hardware removal and a local or regional flap reconstruction reinforcing the primary closure. Enteral feeding access is mandatory, and intravenous antibiotic therapy should be continued until reassessment with an endoscopy or esophagram. Persistent leaks can be addressed with re-exploration, hardware removal, and flap reconstruction in early perforations or additional regional/free flap reconstruction in late perforations. One review noted that up to 25% of all esophageal perforations, particularly those without systemic symptoms, can be treated nonoperatively with fluid resuscitation, antibiotic therapy, and an NPO regimen.¹¹ However, nonoperative management is unlikely to succeed given the presence of the hardware foreign body. Our experience, along with that of others, suggests that drainage of the infection and healing by secondary intention with a closed negative suction dressing is an effective way to manage these perforations without the need for tissue flap reconstruction. Based on the patient’s spine stability, we recommend removing the titanium hardware to expedite infection control and promote granulation tissue formation and esophageal repair by secondary intention. This approach is especially important when a primary esophageal two-layer repair is not feasible, which is almost always the case.

In conclusion, successful treatment relies on clinical suspicion and timely diagnosis, enteral feeding access and systemic antibiotics, foreign body removal, and esophageal repair by primary or secondary intention.

Answers to Clinical Questions

Question 1, c. The most common site of esophageal perforation following ACDF is within Killian’s triangle between the thyropharyngeus and cricopharyngeus muscles, as the esophagus is not protected in this region by muscle and is only protected by a thin buccopharyngeal fascia. This region usually lies anterior to C5–C6, which has also been reported to be the most operated spinal level for ACDF.

Question 2, a. This patient had a history of ACDF and presented with dysphagia and neck pain, both of which are concerning symptoms for esophageal perforation. A CT scan showed soft tissue inflammation around the cervical hardware, further increasing clinical suspicion for esophageal perforation. Therefore, the best next step in management is to obtain an esophagram with contrast to determine if there is any extravasation of contrast, suggestive of an esophageal perforation. An MRI would be helpful in diagnosing any underlying osteomyelitis, but its role in esophageal perforation is not well defined. Oral antibiotics would be inappropriate in a patient with dysphagia. An emergency neck exploration would be inappropriate without first confirming with an esophagram or esophagoscopy the presence of a perforation.

Disclosure statement/Funding

No potential conflict of interest was reported by the author(s). The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patients consented to publication of this case report.