Diagnostic and Management Challenges of Esophageal Rupture with Concomitant Cervical Abscess in Chronic High Cervical Tetraplegia

TL;DR

A patient with a spinal cord injury and prior cervical surgery faced diagnostic challenges due to an esophageal rupture and abscess, highlighting the need for careful evaluation in similar cases.

Contribution

This case emphasizes the importance of considering esophageal rupture in chronic cervical surgery patients, even when symptoms are atypical.

Findings

Esophageal rupture was difficult to diagnose due to the absence of typical imaging signs and masked pain responses from tetraplegia.

Infection spread through cervical fascia from superficial to deep areas, complicating the clinical course.

Percutaneous endoscopic gastrostomy was a viable treatment option to prevent further infection recurrence.

Abstract

A 65-year-old with a history of spinal cord injury and previous cervical surgery presented with persistent fever despite antibiotic treatment. MRI scans revealed an abscess in the neck extending from C3 to C6, with associated osteomyelitis. After an initial discharge following antibiotic therapy, the patient was readmitted due to recurrent systemic infection symptoms and another abscess. A subsequent endoscopy showed esophageal rupture with protruding cervical fusion metal. Due to operative risks, a percutaneous endoscopic gastrostomy was performed without further infection recurrence. The absence of typical imaging signs of esophageal rupture made diagnosis difficult. The infection spread through the cervical fascia from superficial to deep cervical areas. Esophageal rupture, a rare complication of cervical surgery, presents with varying symptoms depending on its location and was particularly challenging to diagnose in this patient due to high cervical tetraplegia, which masked typical pain responses. Therefore, this case highlights the need to consider esophageal rupture in differential diagnoses for chronic ACDF patients, even when typical symptoms are absent.

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