Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury

Abstract

Background context

Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected.

Purpose

Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation.

Study design

Case report.

Patient sample

A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level.

Methods

The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5–7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation.

Results

Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery.

Conclusions

To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.

Introduction

The esophagus perforation after anterior cervical spine surgery is a rare, but well-recognized complication [1], [2], [3], [4], [5], [6]. Development of this complication in the early postoperative period has been reported, as has delayed presentation, although this is even rarer [7]. The esophagus perforation has numerous causes, including blunt or penetrating trauma associated with cervical spine injury [8]. However, most esophagus perforations are caused by iatrogenic injury during the surgical approach; by inappropriate placement or dislodgement of retractors, excessive retraction, or chronic erosion secondary to migration of hardware or grafted bone [6], [7], [9]. Delayed or inappropriate treatment of the esophagus perforation may result in cervical abscess, mediastinitis, septic shock, and even death [6], [10], [11], [12]. The immediate and appropriate treatment of cervical esophagus perforation is, therefore, necessary [7], [10], [13]. However, as patients often present with nonspecific complaints and subtle physical findings, diagnosis is difficult and the problem frequently goes unrecognized until late in the clinical course [13], [14]. Furthermore, cervical esophagus perforation rarely heals spontaneously because of its biological and histological peculiarities [15]. Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair [4], [5], [14], [16]. However, the sternocleidomastoid has an important role as a powerful accessory respiratory muscle and neck stabilizer in patients with cervical spinal cord injury. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with the esophagus perforation. To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for the esophagus perforation after anterior cervical spine surgery.