Scholarly article on topic 'Oesophageal perforation after thoracic vertebral fracture in an ankylosed spine: Case report and review of the literature'

Oesophageal perforation after thoracic vertebral fracture in an ankylosed spine: Case report and review of the literature Academic research paper on "Clinical medicine"

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{"Oesophageal perforation" / "Thoracic oesophageal injuries" / "Thoracic vertebral fracture" / "Ankylosed spine" / "Conservative management"}

Abstract of research paper on Clinical medicine, author of scientific article — Johanne Summers, Craig Timms, Tony Goldschlager

Summary We present the case of a 74 year-old male with delayed diagnosis of post-traumatic thoracic oesophageal perforation that occurred secondary to thoracic vertebral fracture in an ankylosed spine. The injury resulted after a fall from chair secondary to an unconscious collapse due to ventricular fibrillation (VF). At 8 days after the injury, the patient was diagnosed with oesophageal perforation, secondary to fourth thoracic vertebral fracture without neurological deficit. The oesophageal laceration was complicated by sepsis with bacteraemia, pleural empyema and mediastinal abscess. Non-surgical management for the oesophageal perforation, chest complications and thoracic spine fracture resulted in complete recovery. A case report and review of the literature is presented. We report the first case of post-traumatic thoracic oesophageal perforation secondary to thoracic T4 vertebral fracture, in a patient with an ankylosed spine that survived neurologically intact after successful conservative management.

Academic research paper on topic "Oesophageal perforation after thoracic vertebral fracture in an ankylosed spine: Case report and review of the literature"

Injury Extra xxx (2014) xxx-xxx

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Case report

Oesophageal perforation after thoracic vertebral fracture in an ankylosed spine: Case report and review of the literature

Johanne Summers a *, Craig Timms a, Tony Goldschlager a,b

a Department of Neurosurgery, Monash Medical Centre, 3168 Victoria, Australia b Department of Surgery, Monash University, 3800 Victoria, Australia

ARTICLE INFO

SUMMARY

Article history: Accepted 22 March 2014

Keywords:

Oesophageal perforation Thoracic oesophageal injuries Thoracic vertebral fracture Ankylosed spine Conservative management

We present the case of a 74 year-old male with delayed diagnosis of post-traumatic thoracic oesophageal perforation that occurred secondary to thoracic vertebral fracture in an ankylosed spine. The injury resulted after a fall from chair secondary to an unconscious collapse due to ventricular fibrillation (VF). At 8 days after the injury, the patient was diagnosed with oesophageal perforation, secondary to fourth thoracic vertebral fracture without neurological deficit. The oesophageal laceration was complicated by sepsis with bacteraemia, pleural empyema and mediastinal abscess. Non-surgical management for the oesophageal perforation, chest complications and thoracic spine fracture resulted in complete recovery. A case report and review of the literature is presented. We report the first case of post-traumatic thoracic oesophageal perforation secondary to thoracic T4 vertebral fracture, in a patient with an ankylosed spine that survived neurologically intact after successful conservative management.

© 2014 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/3.0/).

1. Introduction

Oesophageal perforation is a life threatening injury, with serious complications such as sepsis and mediastinitis, and mortality rates 18-48% [1-6]. Mortality rates greater than 50% are reported with delayed diagnosis and treatment after 24 h [7-9]. Prevention of serious complications revolves around early diagnosis and treatment [4,5]. The causes of oesophageal injuries include iatrogenic, penetrating (20-25%) and blunt trauma (<10%). Blunt spinal injury as a cause of oesophageal perforation is uncommon, and most of the reported cases are due to cervical spine pathology [10-14]. Thoracic spinal fracture resulting in thoracic oesophageal perforation is extremely rare, with an incidence of less than 0.2% [15], and there are only a few reported cases in the literature [7,16-20]. It can occur when thoracic vertebral fracture causes posterior oesophageal wall laceration and typically results in death or severe morbidity [1 -3,6,8,21,22]. A case report and review of the literature is presented. We report the first case of post-traumatic thoracic oesophageal perforation secondary to thoracic T4 vertebral fracture after a low velocity fall, in a patient with an ankylosed spine that survived neurologically intact, successfully treated with conservative non-surgical management.

* Corresponding author at: Department of Neurosurgery, Monash Medical Centre, 3168 Victoria, Australia.

E-mail address: johannesummers@gmail.com (J. Summers).

2. Case report

A 74 year-old man, independent from home, was admitted to our hospital after a fall from a chair onto his back, following an episode of VF resulting in an unconscious collapse. After appropriate automatic internal cardiac defibrillator (AICD) discharge for VF (defibrillator activated, shocked back to paced rhythm), the patient awoke complaining of central chest pain radiating to his back. On arrival of the ambulance service, the patient had a Glasgow Comma Score of 15 and stable haemody-namics, he was neurologically intact and afebrile. On admission to the hospital emergency department, the patient was febrile at 40 °C, but remained stable without neurologic deficit, denied chest or spine tenderness, and there were no symptoms or signs indicating spinal cord compromise. The patient's past medical history consisted of atrial fibrillation on warfarin, dilated cardiomyopathy with an AICD, osteoarthritis, ankylosing spondy-litis, renal stent, hypertension, gout, peripheral vascular disease, glaucoma and a past smoking history.

Management and investigation were instigated for the initial diagnosis of unconscious collapse associated with the VF event, which was presumed secondary to sepsis. Initial thoracic spine imaging was not performed. The patient continued to have high fevers with chills and rigours. Blood cultures were positive for staph hominis, strep mitus, and strep milleri bacteraemia, treated with intravenous antibiotics, as directed by the infectious diseases unit. The initial source of the sepsis was presumed urinary tract

http://dx.doi.org/10.1016/j.injury.2014.03.015

1572-3461/© 2014 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativec0mm0ns.0rg/licenses/by-nc-nd/3.0/).

ARTICLE IN PRESS

J. Summers et al./Injury Extra xxx (2014) xxx-xxx

Fig. 1. Oblique fracture T4 vertebral body and free mediastinal gas at T4 level.

source, as the patient had a complicated renal stent insertion one month prior to admission. From the time of injury the patient complained of chest pain radiating to the inter-scapular region, but did not report swallowing problems. The patient was mobilized on day 3 with physiotherapy.

Despite antibiotic therapy the patient had persistent fever, raised inflammatory markers, and ongoing chest and back pain, prompting further investigation. On day 8 after injury, the patient underwent a chest computed tomography (CT) scan, which revealed thoracic oesophageal perforation secondary to fourth thoracic vertebral fracture, complicated by pleural empyema and mediastinal abscess. There was a moderate amount of free posterior mediastinal gas anterior to the thoracic spine and on the right side of the mediastinum, with a rind of soft tissue but no visible fluid. Oblique fracture of the T4 vertebral body extending from anterosuperior to posteroinferior with 4 mm of retrolisthesis, no involvement of the pedicles or posterior elements, and underlying ankylosed spine with extensive syndesmophyte [Fig. 1]. In addition, there was evidence of right lung middle and lower lobe consolidation with pleural effusion. Diagnostic imaging with MRI was contraindicated due to the patient's AICD. Gastrograffin swallow contrast oesophagography confirmed oesophageal laceration and ongoing leak at the level of the T4 vertebral body, with active contrast extravasation from the oesophagus to the right side of the mediastinum [Fig. 2].

The oesophageal perforation, sepsis, chest complications and thoracic spine fracture were successfully treated with non-surgical management. The Gastroenterologist advised conservative management for the traumatic oesophageal laceration and stenting was not employed due to the delayed diagnosis and

Fig. 2. Contrast extravasation at T4 level.

established infected pleural and mediastinal complications. Cardiothoracics instigated conservative management for the pleural empyema and mediastinal abscess, and the Infectious diseases unit directed intravenous antibiotic therapy. The patient was treated nil by mouth, with total parenteral nutrition, and followed with serial gastrograffin swallow studies. Non-surgical management was directed by neurosurgery for the thoracic vertebral body fracture. This decision was made as the patient had already been mobilized, and follow-up imaging showed no change in fracture alignment, as well as the patient's significant comorbidities in which precluded a general anaesthetic in the prone position. Initial orthotic spinal brace fitting was contra-indicated due to chest compromise.

The patient was nursed with spinal precautions and log roll pressure care, until the oesophageal leak and chest complications had resolved. The patient was managed in the intensive care unit for 4 days, and then nursed in a single room on the general ward. At day 42 after injury, gastrograffin swallow study showed the oesophageal laceration had resolved, with no evidence of extra-luminal contrast extravasation to suggest ongoing leak. A repeat chest CT scan revealed resolution of the chest collections/ empyema and mediastinal gas, and stable configuration of the T4 vertebral fracture with evidence of early bone healing. Diet was restarted without complications. The oesophageal laceration healed without further leak, and the patient tolerated oral intake without swallowing difficulties. The patient was mobilized in a Boston brace custom-made overlap ''clam shell'' design (anterior and posterior sections, side fastenings and shoulder straps), and discharged to a rehabilitation facility. The thoracic fracture remained stable on serial spine imaging and CT scan showed fracture union. The patient remained neurologically intact, and conservative non-surgical management resulted in complete recovery.

3. Discussion

Oesophageal perforation is rare and is associated with high morbidity and mortality [1-3,6,8,21,22]. It can be attributed to a number of aetiologies, including spontaneous rupture, iatrogenic injury, blunt or penetrating trauma [2]. In 15-20% of oesophageal perforations trauma is the cause, often due to penetrating neck or thorax injury, and more common with cervical spine trauma [1014]. Blunt trauma can occur in deceleration injury, with raised intraluminal pressure resulting in oesophageal wall tear [15]. Forced neck hyperextension can cause cervical oesophageal perforation, and shearing-distraction injuries can result in thoracic oesophageal perforation [16]. Delayed diagnosis and treatment can be due to lack of obvious symptoms or signs masked by other injuries, and result in serious complications such as sepsis, pleural empyema and mediastinitis [7,23]. Presentation can include a range of symptoms, dysphagia, odynophagia, dyspnoea, progressive sepsis, tachycardia, pyrexia, chest pain and surgical emphysema. Prompt diagnosis and management is important to prevent

J. Summers et al./lnjury Extra xxx (2014) xxx-xxx

Table 1

Cases of post-traumatic oesophageal perforation after thoracic spine fracture.

Case (reference) Level Contributing factors Delayed diagnosis [time] Management Neurologically intact Survived

1 (16) T3, T4 MA Yes [14 Days] E: [C] TS: [S] Ch: [S] Yes Yes

2(7) T3, T4 MA Yes [11 Days] E: [C] TS: [C] Ch:[C] Yes No

3(17) T3, T4 MA No E: [S] TS: [S] Ch: [S] No Yes

4(18) T3, T4 MVA Yes [6 Days] E: [S] TS: [S] Ch:[C] Yes Yes

5(19) T2 MVA Yes [5 Months] E: [C] TS: [C] Ch:[C] No Yes

6 (20) T3, T4 MVA No E: [S] TS: [S] Ch: [S] No Yes

7 (Current) T4 F, AS Yes [8 Days] E: [C] TS: [C] Ch:[C] Yes Yes

MA - motorcycle accident; MVA - motor vehicle accident; F - fall; AS - ankylosed spine; E - oesophagus; TS - thoracic spine; Ch - chest; C - conservative; S - surgery.

life threatening complications, with greater than 50% mortality rates reported for surgery more than 24 h after oesophageal perforation [7-9]. In certain cases, non-surgical management can be employed [2,3,24].

In the largest comprehensive review to date of thoracic oesophageal perforations there were no cases of thoracic spine fracture aetiology [25]. There are only six reported cases of post-traumatic thoracic oesophageal perforation due to thoracic spine fractures [Table 1] [7,16-20]. We present the first case not associated with a road traffic accident, in a patient with an ankylosed spine, with injury sustained after a low velocity fall. This is the only reported case of post-traumatic thoracic oesophageal perforation secondary to thoracic T4 vertebral fracture, in a patient with an ankylosed spine that survived neurologically intact after successful conservative management.

The spinal column is located close to the oesophagus between C5 and T4 [7], with the physiologically narrow oesophageal region close to the third and fourth thoracic vertebrae [8]. With hyperextension injury of the spine, forces can be transferred from the spine to the oesophagus is this area, resulting in oesophagus perforation [7]. Penetration of the oesophagus can result from a spinal fracture fragment [16]. Contrast oesophagography is the gold standard for localization and diagnosis of oesophageal perforation [2,3,15]. Extra-luminal peri-oesophageal air is reported as the most useful finding on chest CT [26]. Chest CT can also identify thickening of the oesophageal wall, oesophageal distortion or displacement at the cervico-thoracic junction, and para-oesophageal manifestations such as mediastinal abscess, and pleural collections or effusions [2,26-28].

The presented case highlights the importance of vigilance in all trauma cases involving patients with ankylosing spinal entheso-pathy, even after a low velocity mechanism. This report also serves to increase clinician awareness of possible thoracic oesophageal injury following upper thoracic spine fracture. Ankylosing Spondylitis (AS), also known as Marie-Striimpell disease, is a seronegative arthropathy, with peak incidence age 17-35 years. The primary skeletal site involved is the spine, usually progressing rostrally from the sacroiliac joints and lumbar spine. The spinal enthesopathy produces the ''bamboo spine'', square-appearing osteoporotic vertebral bodies with bridging syndesmophytes due to ossified ligaments and calcified intervertebral discs. The rigid spine of AS when fractured acts as a long lever, and fracture may occur following minimal trauma, these fractures are typically very

unstable and usually required surgical fixation. In this case it was fortunate that the fracture was stable and able to withstand early mobilization.

Oesophageal injuries can be managed with conservative management or operative intervention, with supportive measures to control sepsis and provide adequate nutrition [2,3]. Surgical options may include primary closure, drainage, diversion, or esophagectomy [2,3]. In selected cases, oesophageal perforations can heal with non-operative management consisting of broad-spectrum antibiotics, strict oral hygiene, nil orally and total parental nutrition [2,3]. The complex decision on treatment for the oesophageal perforation depends on the patient's clinical circumstances. Treatment selection should be based on patient condition and performance status, timing of diagnosis, resources available, oesophageal pathology, and presence/absence of complications, local phlegmon, and/or sepsis [25]. Prompt diagnosis and management of oesophageal perforation is of paramount importance to attempt to avoid serious complications. Our case report demonstrates that good outcome can be achieved with nonoperative management.

Conflict of interest statement

None of the authors have any potential conflict of interest. Nothing to disclose.

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