Expert’s comment concerning Grand Rounds case entitled ‘‘Postoperative pharyngocutaneous fistula: treated with sternocleidomastoid flap repair and cricopharyngeus myotomy’’ (by V.A. Iyoob)

Great care should be taken to minimise damage to the pharynx and upper oesophagus during an anterior approach to the cervical spine. If noticed at the time of surgery primary repair should be carried out; if noticed in the postoperative period, thorough cleaning and placement of a pharyngocutaneous drain will result in spontaneous healing of the majority of fistula. For persistent fistula secondary repair is required using well-vascularised tissue.     

Posterolateral cervical transpedicular corpectomy for the surgical management of metastatic tumor

Open image in new window Management of metastatic spinal disease in the upper cervical spine can be particularly challenging. Depending on the level of the lesion and the patient’s anatomy, multiple anterior approaches have been described for resection of the cancer, followed by posterior fixation and instrumentation. Although a single-stage posterolateral approach is now well established for thoracic pathology, less is known about the applicability of these principles when applied as an approach to the cervical spine. The authors present here a case using a posterolateral transpedicular approach for corpectomy and graft placement for circumferential reconstruction as a treatment of metastatic disease in the cervical spine to illustrate the feasibility of this technique, especially in the setting where the patient’s anatomy or pathology may impede an anterior or combined circumferential approach.     

Repair of cervical esophageal perforation using longus colli muscle flap: a case report of a patient with cervical spinal cord injury

BACKGROUND CONTEXT: Perforation of the esophagus after anterior cervical spine surgery is a rare, but well-recognized complication. The management of esophageal perforation is controversial, and either nonoperative or operative treatment can be selected. PURPOSE: Several reports have described the use of a sternocleidomastoid muscle flap for esophageal repair. In this case report, we describe a longus colli muscle flap as a substitute for a sternocleidomastoid flap in a patient with an esophageal perforation. STUDY DESIGN: Case report. PATIENT SAMPLE: A 20-year-old man sustained cervical spinal cord injury, on diving and hitting his head against the bottom of a pool. A C6 burst fracture was observed with posterior displacement of a bone fragment into the spinal canal. The patient exhibited complete paralysis below the C8 spinal segment level. METHODS: The patient underwent subtotal corpectomy of the sixth cervical vertebra with the iliac bone graft and augmented posterior spinal fixation (C5-7) with pedicle screws. After the primary operation, the patient showed signs of infection such as throat pain, a high fever, and osteolytic change of the grafted bone by cervical radiograph. A second operation was performed to replace the graft bone using fibula. On the day after the operation, food residue was confirmed in the suction drainage tube, suggesting esophagus perforation. A third operation was immediately performed to confirm and treat esophagus perforation, although apparent esophageal perforation could not be detected at the second operation. Because the erosion around the perforation of the esophageal posterior wall was extensive, a longus colli muscle flap transposition was accordingly performed into the interspace between the esophageal posterior wall and the grafted bone in addition to simple suturing of the perforation. RESULTS: Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery. CONCLUSIONS: To the best of our knowledge, this is the first report concerning the use of a longus colli muscle flap for esophageal perforation after anterior cervical spine surgery.     

Esophagocutaneous fistula after anterior cervical spine surgery and successful treatment using a sternocleidomastoid muscle flap. A case report

An esophagocutaneous fistula following anterior cervical fusion is rare. A 61-year-old man had cervical myelopathy because of ossification of the posterior longitudinal ligament of the cervical spine. Anterior decompression of the cervical spine and anterior fusion with strut bone grafting were performed. A second anterior fusion was done because the graft was dislodged after the patient fell out of bed one month after surgery. An esophagocutaneous fistula occurred three months after the second anterior surgery. One of the causes of this esophagocutaneous fistula was considered to be a pressure necrosis of the esophagus because of to projection of the bone graft. Conservative treatment, which consisted of wound drainage and intravenous administration of antibiotics, was tried but was unsuccessful. A good result was achieved by cancellous bone grafting, closure of the esophageal fistula, and transposition of a sternocleidomastoid muscle flap to the interspace between the esophagus and the cervical spine.     

Smart flap of sternocleidomastoid muscle in anterior cervical spine surgery: Surgical anatomical dissection technique

The use of sternocleidomastoid muscle flap has firstly been described in 1909. In spine surgery, it is usually reserved in the cases of revision after anterior cervical spine procedures. The aim of this article is to introduce its usage as prophylactic measure in cases at high risk of iatrogenic fistula formation. The procedure consists of three main steps: sternocleidomastoid isolation, flap design and harvesting, and flap fixation. The use of a surgical anchor allows a better adherence to the plate preventing hematoma formation. The use of SCM smart flap in primary anterior cervical spine surgery as a prophylactic method could be considered a safe and feasible procedure in patients with a high risk of iatrogenic fistulas.