Delayed esophageal perforation after anterior cervical fusion and retropharyngeal steroid use: A report of two cases

Background context Prevertebral soft-tissue swelling (PSTS) after anterior cervical spine surgery may result in postoperative catastrophic airway complications and persistent dysphagia. Systemic or local corticosteroids have been used to decrease complications related to PSTS. To date, studies using retropharyngeal steroid (RS) have not reported complications with local steroids such as infection, pseudarthrosis, and other systemic adverse effects. Purpose The aim was to report delayed esophageal perforation in two patients who underwent anterior cervical spine surgery and RS use. Study design/setting This was a case report with a review of literature. Methods We presented two cases of delayed esophageal perforation without obvious cause in two patients who underwent anterior cervical spine surgery and RS use. Results A 45-year-old woman underwent C5-C6 anterior cervical discectomy and fusion (ACDF) for radiculopathy. Just before closing the wound, one ampule of triamcinolone acetate was placed in the retropharyngeal space. Two months postoperatively, she presented to the emergency department with clinical symptoms of esophageal perforation. Radiographic studies demonstrated a retropharyngeal abscess. A 0.5×1.0-cm sized esophageal defect was identified during the emergency surgery. Complete healing of the esophageal defect was achieved by revision repair with reinforcement using local muscle flap. A 65-year-old man with a history of ankylosing spondylitis presented with severe dysphagia 1 year after C7 pedicle subtraction osteotomy, C2-T4 posterior instrumentation, and C6-C7 ACDF with a plate for a chin-on-chest deformity. Before closure, 1 cc of depomedrol had been placed into the wound. Eleven months postoperatively, he complained of new onset dysphagia. The endoscopic examination demonstrated an esophageal tear with visualization of the anterior cervical plate through the tear. Successful healing was possible with primary repair. Conclusions Retropharyngeal steroids have been shown to decrease PSTS and dysphagia after anterior cervical spine surgery. We believe that it would be prudent to consider avoiding the RS use in patients with a history of chronic corticosteroid use and/or soft-tissue vulnerability or only to use them with caution. Any history of dysphagia that occurs weeks, months, or even years later should be investigated for the possibility of esophageal perforation.