Esophageal perforation due to screw migration: A complication following C6–C7 anterior cervical fusion

INTRODUCTION

Anterior cervical corpectomy and fusion (ACCF) is a widely accepted standard procedure for cervical radiculopathy and myelopathy, which generally result in good outcomes.^[1,2] Complications related to implants such as screw loosening or migration, are reported to occur only in 0.1–1.2% of cases.^[1-3] Severe migration may extend into the mediastinum, injuring visceral organs.^[2-5] Esophageal perforation is a critical complication and is associated with a high rate of morbidity and mortality.^[3,4] We report a rare case of cervical screw migration causing esophageal perforation, which was successfully managed conservatively with a rigid cervical brace, emphysema debridement, and antibiotics.

CASE REPORT

A 50-year-old man complained of progressive weakness and numbness in all extremities. Neurological and supporting examination revealed motor strength 3/5 in lower limbs and 4/5 in upper limbs, consistent with cervical myelopathy. After 1 year of physiotherapy, his right arm strength deteriorated to 1/5, prompting C6–C7 ACCF with anterior screws. [Figure 1].

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Figure 1:

50-year-old male with cervical myelopathy. (A) Pre-operative magnetic resonance imaging shows cervical stenosis at the C6–C7 level (solid arrow), correlating with neurological deficits. (B) Post-operative chest X-ray after anterior cervical corpectomy and fusion demonstrates proper implant placement (solid arrow). (C) Cervical computed tomography (CT) scan reveals extensive emphysema at the C5 level (full arrow), migrated screw at the T3 level (dotted arrow), and implant in place (dashed arrow). (D) Reconstructed cervical CT scan confirms screw migration to the T3 vertebral level.

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DISCUSSION

This case highlights the possibility of a rare, critical complication of ACCF. Migration of a screw from C5 to T3 is unusually distant.^[2-4] Screw loosening is reported to occur months to years after surgery.^[2-4] But in our case, it developed within days, likely due to premature transition to a soft collar. Early post-operative immobilization with a rigid cervical collar is generally advised to restrict movement and support fusion stability.^[3-5] Soft collars do not effectively control rotational movement, which may allow very small movements at screw fixation that lead to loosening. The patient’s perceived “click” sound likely marked implant failure, underscoring the need for immediate radiological evaluation even in the absence of pain.

The screw migrated far from its origin, injuring the esophagus at T1 rather than C5. We propose that the absence of major vascular injury, despite the distant migration from C5 to T3, is likely due to the screw’s moving within the potential retropharyngeal space which lacks of vascular structures. Buccopharyngeal fascia nature was insufficient to withstand the mechanical stress elicited by esophageal motility combined with incomplete healing of prevertebral tissue and shearing forces from the migrating implant. Consequently, the esophagus was compressed and perforated, allowing the screw to descend through this space easily without injuring the vascular. Perforation of the esophagus represents a critical complication that typically necessitates surgical repair.^[3,4] Our patient refused surgery, demanding a conservative management instead. Broad-spectrum antibiotics, fasting, and drainage were employed. Spontaneous closure was presumed after endoscopic evaluation showed no perforation.

Despite of complications including repeated hypoalbuminemia, pleural effusion, fever, leukocytosis, and thrombocytosis, the infection was able to be controlled. The patient required 33 days of hospitalization and was discharged with a functional motor recovery level 3.^[6] This case demonstrates that, in select case, non-surgical management of esophageal perforation may succeed, although surgical repair remains the gold standard.

CONCLUSION

We report an uncommon case of anterior cervical screw distant migration complicated by esophageal perforation, which was successfully managed conservatively. This emphasizes patient education on post-operative compliance, awareness of early signs of complication, the importance of rigid immobilization during early fusion healing, and as a signal that future implants must meet clinical needs.