Extension injury of the thoracic spine with rupture of the oesophagus and successful conservative therapy of concomitant mediastinitis

Abstract

The case of an upper oesophageal perforation as a concomitant injury of an isolated fracture of the upper thoracic spine without neurological compromise has not been described so far. A Case report and review of the literature is presented here. Concomitant oesophageal perforations carry a high risk of being missed initially. CT alone can visualize the subtle indirect signs like peri-oesophageal air. The literature revealed that only peri-oesophageal air might be a valid indicator of oesophageal injury. There are no systematic data on thoracic spine fractures with concomitant oesophageal perforations. Mediastinitis secondary to oesophageal perforation might be treated conservatively with endoscopic stent placement rather than surgically. As the radiological signs of concomitant soft tissue injury, like oesophageal perforations, in fractures of the upper thoracic spine are subtle and easily missed initially only anticipation of concomitant injuries by the treating physician based on the trauma mechanism ensures a timely diagnosis.

Esophageal injury in fatal rear-impact collisions

“…During frontal collisions the anterior neck organs are exposed to the potential for direct contact with a steering wheel, dashboard, deploying airbag, or even windshield. Additionally, there is also the compression of the thorax resulting from loading of a shoulder belt, adding to the forces compressing the esophagus against the anterior aspect of the cervicothoracic spine [16]. It can be reasonably hypothesized that because of a greater risk of vertebral fracture as well as incidence of anterior vertebral body osteophytosis elderly occupants are at a higher risk of esophageal injury than are younger occupants.…”

“…A total of four articles were retrieved for further review [13][14][15][16]. Additionally the presented case added to a total of five articles eligible for review (Table 1).…”

Esophageal perforation associated with fracture of the upper thoracic spine from blunt trauma: a case report

“…Despite a delayed diagnosis and the complications of sepsis and pyogenic spondylitis, we were able to successfully treat this esophageal perforation with conservative therapy because the patient's condition was relatively well maintained when finally diagnosed. 2 This suggests that a small perforation of the upper thoracic esophagus can be resolved with conservative treatment, 3,4,6,8,9 even in the event of delayed diagnosis, because of the low potential for the infection to spread to the mediastinum and thoracic cavity. However, delayed diagnosis can increase the difficulty of treatment Abbreviation: EP, Esophageal perforation.…”

“…[3][4][5][6][7][8][9] Such esophageal perforations have been previously reported to occur at the upper thoracic level (Table 1). [3][4][5][6][7][8][9] Nakai et al 7 suggested that, because the esophagus runs close to the spinal 1 column between C5 and T4, esophageal perforation is possible with hyperextension injuries of the thoracic spine. Regarding the mechanism of the spinal injury in the present case, it is likely that shear stress was concentrated on the cervicothoracic and thoracolumbar junctions because of decreased flexibility of the thoracic spine due to ankylosing spinal hyperostosis.…”

“…Ischemic esophageal perforation with a delayed appearance on CT is unlikely because CT demonstrated free air in the mediastinum on the day of the injury. 1,9 Thoracic esophageal perforation causes mediastinitis and sepsis more easily than cervical esophageal perforation. 1,2 In addition, a treatment delay of 424 h has been associated with higher complication and mortality rates in patients with esophageal perforation.…”