Disclosures: Christopher G. Ng, MD, MBA: No financial relationships or conflicts of interest

Case Diagnosis: Dysphagia Secondary to Erosion of Cervical Hardware

Case Description or Program Description: An 83-year-old male with a history of C4 American Spinal Cord Injury Impairment Scale D spinal cord injury (SCI) and anterior cervical spinal decompression and fusion (ACDF) presented to a gastroenterologist for evaluation of dysphagia for four years. An esophagogastroduodenoscopy (EGD) revealed erosion of cervical hardware into the proximal esophagus. He was referred for outpatient orthopedic evaluation who recommended transfer to the emergency department (ED). He was seen by otolaryngology who admitted him for surgical management. Neck exploration revealed a sizeable defect in the hypopharynx and esophagus; this was repaired with a sternocleidomastoid muscle flap. A nasogastric tube was placed, and he was made nothing by mouth. He transferred to an SCI unit post-operatively and infectious disease was consulted. Esophagram one-month post-operatively revealed a small esophageal diverticulum without leak. The nasogastric tube was removed. He was started on a thin liquid/pureed diet after a swallow study.

Setting: SCI Unit

Assessment/Results: He was advanced to a thin liquid/regular diet after a three-month follow-up swallow study.

Discussion (relevance): Based on available literature, prevalence of dysphagia after ACDF ranges between 28%-57%. Most cases resolve within two years. Esophageal erosion of cervical hardware is a rare but life-threatening phenomenon with an incidence of 0.02%-.52% and mortality rates as high as 19%. Previous case reports document this occurrence up to 9 years post-ACDF. It is important to consider esophageal perforation secondary to hardware failure in patients presenting with chronic dysphagia and a history of ACDF. Standard of care consists of direct visualization (EGD) to confirm findings and early surgical management, such as a muscle flap, for durable coverage of the defect.

Conclusions: Esophageal erosion of cervical hardware should be considered on the differential of chronic dysphagia following ACDF in an SCI patient. Prompt workup and early surgical intervention portends a favorable prognosis.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/dysphagia-secondary-to-erosion-of-cervical-hardware-in-a-quadriplegic-patient-a-case-report/