Features and Management of Oesophageal Injury After Anterior Cervical Spine Injury
Oesophageal injury is a rare but potentially life-threatening complication of anterior cervical spine surgery that requires immediate surgical intervention with direct repair as the treatment of choice. 1, 2
Clinical Features and Presentation
- Dysphagia is the most common presenting symptom, followed by fever, neck swelling, and wound leakage 3
- Esophageal perforations can be categorized into three types based on timing of onset:
- The most common causes of esophageal perforation include:
- Hardware failure or migration
- Hardware erosion through the esophageal wall
- Direct intraoperative injury 3
- Physical examination and laboratory studies alone are not reliable for early diagnosis 5
Diagnostic Approach
- Contrast-enhanced CT and CT esophagography should be performed in hemodynamically stable patients with suspected esophageal injury (high sensitivity 95% and specificity 91%) 5
- Flexible endoscopy is recommended as an adjunct to CT, providing direct visualization of the injury site and can alter surgical management in up to 69% of patients 5
- In unstable patients requiring immediate surgery, intraoperative endoscopy can be employed to rule out esophageal perforation 5
- Triple endoscopy (esophagoscopy, laryngoscopy, and bronchoscopy) is indicated as injury to one structure should raise suspicion of damage to adjacent organs 5
Management Principles
Surgical Management (First-line Treatment)
- Operative repair is the treatment of choice for traumatic injuries of the esophagus 1, 2
- Key surgical principles include:
- Neck exploration with removal of hardware 4
- Debridement of non-viable tissue around the perforation 2
- Primary closure of the esophageal defect when feasible 2
- The mucosal defect is often longer than the muscular tear; longitudinal myotomy at both ends helps expose mucosal edges for appropriate repair 1
- Two-layer repair with separate suturing of the mucosa and muscle is traditionally recommended 1
- Buttressing the repair with vascularized tissue (muscle flap) decreases the risk of leakage 1, 2, 6
- Adequate drainage around the repair site 1
- Decompression of the esophagus and stomach via nasogastric tube 1
Non-Operative Management
- Can be considered only in highly selected patients with:
- Early presentation
- Contained esophageal disruption
- Minimal contamination of surrounding spaces 5
- Requires:
- Nil per os status
- Broad-spectrum antibiotic coverage
- Nasogastric tube placement
- Early nutritional support (enteral feeding or total parenteral nutrition)
- Intensive monitoring in an ICU setting 5
- Percutaneous radiological drainage of peri-esophageal collections and chest tube placement may be required 5
Complications and Outcomes
- Common complications include:
- Pneumonia
- Mediastinitis
- Osteomyelitis
- Sepsis
- Acute respiratory distress syndrome
- Recurrent laryngeal nerve damage 3
- Mortality rate ranges from 3.92% to 50% without appropriate management 2, 3
- Management is often prolonged and may require multiple procedures 4
- With proper treatment, most patients can resume oral intake (median time 66.5 days in one study) 4
Important Caveats
- Early diagnosis and immediate treatment are crucial for survival, as 92% of deaths occur within 24 hours 1
- Hardware removal is essential in cases of hardware-related perforation 4, 7
- Long-term follow-up is necessary for patients with anterior cervical spine plating to detect potential delayed perforations 6
- Treatment should be undertaken in specialized centers with multispecialty expertise (esophageal surgeons, interventional radiologists, endoscopists, intensive care specialists) 5
- Residual instability should be anticipated in patients with insufficient time for solid bony fusion 8