Esophageal Tear During Anterior Cervical Discectomy Procedure

This clinical otolaryngology case involves the complications and necessary follow-up surgeries sustained after an elective anterior cervical discectomy and fusion procedure. It was determined several weeks after the initial procedure that the patient suffered a perforated esophagus. The operative report does not mention any complications during surgery and does not make note of any signs of a tear or perforation. A few weeks following the discectomy, the patient began to complain of throat pain and difficulty swallowing. Approximately six to eight weeks after surgery, an infection was suspected and the patient underwent an imaging study that revealed subcutaneous air and crepitus. The patient was taken in for exploratory surgery to inspect and clean the infected area. This procedure was conducted without further complication, yet the tear in the esophagus was still unidentified. A second exploratory surgery was performed that finally indicated that a peri-esophageal infection and perforation was present and appeared to be related to the patient’s original cervical fusion surgery.

Question(s) For Expert Witness

1. What is the standard of care in diagnosing this complication and how should it have been treated?

Expert Witness Response E-004835

The Cervical Spine Research Society recently compiled a series of esophageal perforations cases following anterior cervical spine surgery. Out of the twenty-two cases that were assembled, six occurred at the time of surgery, six in the postoperative period, and ten occurred weeks or months after the surgery. Eight surgeries were because of fracture, and hardware was implicated in 25% of cases occurring after surgery. Diagnosis was confirmed most often by direct vision at reexploration or esophography. Treatment usually consisted of drainage, repair, and parenteral antibiotics. Two cases were successfully treated by enteral feeding and antibiotics alone. There was one fatality, and all patients required prolonged hospitalization. Cervical fracture and the use of hardware may be associated with this complication. Clinical suspicion and esophography are important diagnostic tools. Drainage and parenteral antibiotics are recommended treatments.