1703 Hematemesis: A Turn of the Screw

Abstract

INTRODUCTION: Anterior cervical discectomy and fusion (ACDF) in combination with locking plates is considered the standard treatment for cervical spinal trauma, tumors and degenerative disc disease. We present a case of upper gastrointestinal bleed resulting from delayed pharyngoesophageal perforation due to loosened screw in the presence of normally positioned hardware. CASE DESCRIPTION/METHODS: A 43-year-old male with hypertension, bradycardia status post pacemaker, cervical stenosis status post C3 -C6 fusion 1 year prior came to the ER with chief complaint of throat and chest pain followed by one episode of hematemesis noticing a 2 cm screw in vomitus. Initial vitals showed T 36.4, HR 78, BP 139/94, RR 18, and SpO2 96% on RA. Cervical spine x-ray showed intact plate of cervical spine with missing screw. Patient was admitted to the ICU and gastroenterology was consulted. Gastrografin swallow study did not show extravasation of contrast and subsequent endoscopy showed extensive soft tissue swelling in the left hypopharynx without purulent exudate. Bedside fiberoptic laryngoscopy showed left pharyngeal posterior wall prominence extending from inferior to tonsil to tip of epiglottis with intact overlying mucosa. Head and neck surgeon recommended non-operative intervention, so the patient was started on broad spectrum antibiotics through the PICC line. He was started on clear liquid diet and advanced to full liquids. His blood count remained stable and he had no further hematemesis. Outpatient follow up showed satisfactory recovery. DISCUSSION: Pharyngoesophageal injuries following ACDF are rare with an incidence of <2%. Most perforations are identified in immediate or early postoperative period and result from iatrogenic injury during the procedure and carry high mortality rates. Early local symptoms include neck swelling, dysphagia, fever and subcutaneous emphysema leading to mediastinitis. Fistula formation, microcytic anemia and neck mass are the most common late presentations. Xray of the neck, contrast swallow studies and flexible endoscopy can help locate perforation. When conservative treatment fails or there is systemic involvement, this requires hardware removal, debridement and suture closure of the defect with or without sternocleidomastoid muscle, superior omohyoid muscle, or pertoralis major flap enforcement to reduce the risk of failure. Patients presenting with upper GI bleed, signs of neck infection, and history of cervical spine plating should be evaluated for hardware-related complications.