Abstract
Cervical bone graft erosion occurs in about 2% of patients as a late complication following cervical spine fusion surgery. The usual presentation in such patients is dysphagia. Stridor is a very rare late complication of such bone erosions. We report a 66-year-old gentleman who presented with stridor, describe the management thereof.
Keywords: Stridor, Bone graft erosion, Pharyngeal erosion, Cervical spine, Surgery
Introduction
Dysphagia is the most common complication after anterior cervical surgery. In contrast stridor is a rare, but a potentially lethal early post-operative complication. The most common cause for stridor is retropharngeal hematoma. Anterior displacement of a plate or a bone graft used for stabilisation is an uncommon complication, with a reported incidence of 2 to 6%. This presents with dysphagia because of compression or erosion of the pharynx or esophagus. Stridor secondary to anterior displacement of bone graft and erosion into the pharynx is rare.
Case Report
A 66-year-old gentleman presented to the emergency with difficulty in breathing and inspiratory stridor requiring intubation under bronchoscopic guidance. Bronchoscopy showed a normal vocal cords. He was shifted to the intensive care unit (ICU), stabilised and later extubated. Five years earlier he had undergone a surgery for degenerative disease of the cervical spine. A third and fourth cervical vertebrae discectomy, corpectomy and fibular bone graft was done by a right sided neck incision.
The patient was evaluated with X-ray neck lateral view, in both flexion and extension. Neck X-ray showed narrowed airways with bone destruction and a pre-vertebral swelling (Fig. 1a, b). An upper gastrointestinal endoscopy (UGIE) showed bulge in the posterior wall of hypo-pharynx and a normal oesophagus (Fig. 1c). Further, Magnetic Resonance Imaging (MRI) cervical spine showed erosion of the previously used fibular bone graft into hypo-pharynx (Fig. 1d). After extubation in the ICU, patient was managed with a hard cervical collar in slight extension.
Fig. 1.
a X-ray neck lateral view in flexion showing the narrowing of the airway (line arrow), bone destruction in C3–5 vertebrae also seen. b X-ray neck lateral view showing the narrowing (line arrow) clearly seen is the pre-verterbal swelling. c endoscopy image showing the bulge in the posterior wall (black arrow), vocal cords are seen to be normal (line arrow). d MRI cervical spine showing destruction of C4 vertebra (block arrow), narrowing of the airway (line arrow) secondary to anterior displacement of the bone graft and swelling in the pre-vertebral area
A multi-disciplinary team of neurosurgeon, pulmonologist, anaesthesiologist, gastroenterologist and a surgeon discussed the management options and offered surgical exploration and debridement. Patient was operated under general anesthesia, fibre-optic bronchoscope guided intubation was done with a 6.5F, flexo-metallic endotracheal tube. He was explored with a left collar incision. At surgery, anteriorly protruding bone graft had penetrated into the posterior pharyngeal wall for around 3 cm *3 cm (Fig. 2a). Further, there were no major fluid collections in the retropharyngeal space. The necrosed bone graft was debrided (Fig. 2c). The wound margins of the hypo-pharyngeal perforation were refreshened. Defect closed with vicryl 3-0 sutures (Fig. 2b). An on-table UGIE was done to check the patency of the lumen and confirm the air-tightness of the repair. Laparoscopic feeding jejunostomy was done. Neurosurgery opinion regarding the stabilisation of cervical spine sought and was advised no further management from their side.
Fig. 2.
a Intra operative photo of the infected bone graft which had perforated the hypo-pharynx. b Primary closure of the rent in the hypo-pharynx. c Extracted bone graft specimen
After the completion of the procedure, the patient was shifted to the post-operative ICU and electively ventilated for 24 h in view of the difficult airway. Patient was extubated on the first post-operative day after taking all the precautions for a possible re-intubation. He was started on FJ feeds on the first post-operative day. Computed Tomography (CT) neck and chest with oral contrast on seventh post-operative day showed no evidence of a leak from the suture line. At one and half year follow-up, patient has no complaints of dysphagia or stridor and on full oral diet.
Discussion
The most common complication after anterior cervical surgery is dysphagia. Stridor is a rare complication of anterior cervical spine surgery. Dysphagia could present both in the early post-operative period or as a delayed complication [1, 2]. Whereas stridor is a potentially lethal early post-operative complication. The most common cause for stridor is retropharngeal hematoma. Besides this, other causes include pharyngeal edema, CSF leak and rarely anterior displacement of a plate used for stabilisation. Its reported incidence ranges from 2 to 6% [3]. Risk factors for development of airway compromise include exposing three or more vertebral bodies at surgery, upper cervical vertebral surgeries, blood loss > 300 ml and operative time > 5 h [3].
The reported incidence of anterior graft dislocation is around 2% [2]. They present most commonly with dysphagia because of luminal compromise of the esophagus/hypo-pharynx. The delayed presentation with stridor after 5 years as in the present case is rare. There are no reports of stridor secondary to bone graft erosion presenting as a delayed complication.
Conclusion
In conclusion, stridor could be a delayed presentation of bone graft erosion of pharynx following anterior cervical surgery. MRI cervical spine confirms the diagnosis. Removal of the infected bone graft, primary closure of the perforation and a feeding access are the optimal management strategies.
Author Contributions
All authors are in agreement with the content of the manuscript. Conception: SG, MN. Drafting of the article: MN. Critical review: SG. Final approval: SG, MN. Accountability: MN, SG.
Funding
None.
Data Availability
All data is available with the authors.
Declarations
Conflict of interest
Authors have no conflicts of interest to declare.
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Not applicable.
Footnotes
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Contributor Information
Murugappan Nachiappan, Email: dr.murugappan.sge@gmail.com.
Srikanth Gadiyaram, Email: srikanthgastro@gmail.com.
References
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Data Availability Statement
All data is available with the authors.