Name:
FOCUS25824video4
Description:
FOCUS25824video4
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Duration:
T00H06M13S
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https://cadmoreoriginalmedia.blob.core.windows.net/b3dd9456-8ef2-418f-8517-d117103d0bfe/4. 25-16.mp4?sv=2019-02-02&sr=c&sig=BFALt9Y7Wfpi2uVU0HlNB2AQijIRp3B7L%2FCU5tIPNqU%3D&st=2026-05-13T19%3A52%3A43Z&se=2026-05-13T21%3A57%3A43Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: Significant esophageal injury during anterior cervical
SPEAKER: spine surgery. This is a case of a 51-year-old woman who was transferred from an outside emergency room with progressive myelopathy. Our rationale for treatment for this patient was her progressive myelopathy and construct failure. We planned to approach this anteriorly with the help of ENT or otolaryngology for the approach.
SPEAKER: The plan was to remove her prior plate, the bone graft, and attempt to reconstruct this anteriorly, with the possibility of also posterior surgery for further stabilization after we finished the anterior portion. We anticipated some difficulty ahead of time with the exposure. The top screws at C6 were removed, and then the plate came out with the bottom screws intact, as well as the bone graft as one piece. There was significant soft tissue in this area, which was also sent for microbiology due to the excessive scarring and inflammation in this region.
SPEAKER: But it was clear after this was removed that the T1 vertebral body could not be readily visualized, and there would be significant difficulty with placing a interbody graft safely and even considering instrumentation at this time. An attempt was made to further dissect or further expose. And during further working in this region, a fairly macerated and complex tear in the esophagus was encountered due to the ability to see the blue bougie over approximately 2 cm within the wound.
SPEAKER: Our ENT colleague was quickly called back and confirmed this was a large esophageal injury, and we then had two difficulties on hand at this moment. One, how do we repair the esophagus? And two, how can we reconstruct the anterior spine in a situation where we could not readily visualize our inferior endplate? So how could a graft be placed safely in this manner? It was decided that we could try to use the Whitecloud- LaRocca strut for this.
SPEAKER: This is a type of strut graft that can be placed in a mortised fashion, and the endplate can be somewhat mortised such that a graft at the end looks somewhat like an "H" on each end, such that you could mortise the endplate of C6, the endplate of T1. Because it's just the endplate and somewhat anterior, it could be done somewhat blindly. When you look at esophageal injuries, there's acute injury.
SPEAKER: This is often due to things like retractor placement, injury during dissection or a drill, or trauma. And there's also chronic injuries, and this is often due to hardware failure, like screw back-out or plate migration. But we also have to consider things like erosion or ischemia. The tissue was very macerated. So we placed a feeding tube across the injury and used a few viscous sutures to essentially reapproximate the esophagus.
SPEAKER: A primary repair was not possible. It was decided, in our case, to use a sternocleidomastoid muscle flap because we could rotate it along the defect. This provides vascular tissue between the graft and the esophagus for repair. But it also protects the graft and the carotid from saliva, which is a benefit here as well. We had already placed the feeding tube under direct visualization, and we fixated it to the nasal septum.
SPEAKER: We placed a wound drain and then we closed the wound. Here's a sagittal CT scan showing our construct. On postoperative day 4, though, in the step-down unit, the patient was in severe pain. They were tachycardic. No new neurological symptoms or signs, but due to the severe pain and the severe tachycardia, the patient was taken for a CT scan somewhat urgently. So we called our ENT colleague.
SPEAKER: We went back to the operating room. We opened up the same incision, and we were able to get back to the window that we had. We used traction and replaced the graft into T1 the best we could. Again, this was somewhat of a blinded mortising of the T1 vertebral body. Limited on imaging, we fashioned the graft back the best we could into place. We put a few more sutures in the esophagus as well.
SPEAKER: We placed new drains and then flipped the patient over and immediately performed a cervical to upper thoracic instrumented fusion. The patient then recovered after our second surgery. Seven days after our second surgery, we discharged the patient to rehab because they were somewhat debilitated from their myelopathy. And here's our radiographic outcome, showing our posterior construct in place from approximately C4 down to T3, and the graft in place healing quite well.
SPEAKER: So when we look at this complication, opportunities for improvement, we probably should expected more difficulty from our anterior approach. One, she had three prior anterior surgeries. She had some swallowing difficulty afterward. Could this already have had some infection? Maybe that's why the construct failed. We could have suspected that ahead of time as well. We could have decided that we may want to approach this differently— treat for potential infection or approach from an opposite side.
SPEAKER: We could have obtained better imaging, like MRI, just to assess things to a greater extent. This may have given us some hint that we could have been dealing with something more than just a construct failure. I think when we approached the spine from the left side and found that we could not expose it adequately, we could have also stopped and perhaps considered maybe even going from the opposite side, and that both of her vocal cords were working, and perhaps we would have had better exposure from the opposite side and not continued to try to move on at this point.
SPEAKER: We did feel that the Whitecloud-LaRocca technique provided an excellent strut here for stabilization. But obviously, in retrospect, not knowing adequately where T1 was and being able to visualize that, we could have done posterior instrumentation somewhat immediately and stabilized at that point, regardless of the worry about infection. And that may have prevented the second revision surgery that we put her through.
SPEAKER: And we think, looking at how we repaired the esophagus, this worked quite well. We were able to get this closed, we got the feeding out, and she gained weight back after this point.
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