anterior cervical spine fusion and stabilization is a well established procedure for cervical myelopathy , radiculopathy , neoplasms , and cervical trauma2 ) .
although injuries to the pharynx and esophagus are known complications of anterior cervical spine surgery , delayed pharyngeal or esophageal perforation is rare7,9,10 ) . here , we describe a rare but potentially life - threatening complication after anterior cervical spine fusion and plating .
the authors highlight this issue by presenting this case , which had no associated morbidity , and include a review of the relevant literature .
a 43-year - old man was admitted to our institute with a 3-month history of dysphagia and neck pain with swelling .
he was paraplegic due to a c6 - 7 fracture and dislocation and has been operated on 8 years previously .
initial surgical treatment included anterior corpectomy of c7 and anterior iliac crest graft placement using a plate and screws .
hematological studies including erythrocyte sedimentation rate ( esr ) and c - reactive protein ( crp ) were normal .
a simple lateral radiograph and a computed tomography scan showed partial anterior migration of the lower screw . a hydro - soluble contrast swallow image confirmed esophageal perforation ( fig .
the loose screw was removed and esophageal perforation was found during surgery and repaired directly by a cardiovascular team(fig .
the patient was fed using a nasogastric tube for 3 weeks and subsequently oral feeding was gradually resumed .
further progress was favorable , and a contrast study performed at 3 weeks postoperatively showed no evidence of fistula .
anterior cervical fusion and plate fixation is an effective procedure for the treatment of cervical myelopathy or radiculopathy and cervical spine trauma .
plating has been reported to achieve a fusion rate of up 98% , and to result in early mobilization , reduced graft - related complications ( especially for multilevel fusion ) , and to avoid late deterioration of the cervical spine alignment obtained at surgery1,4 ) .
the complication rate after anterior cervical plating is generally low and decreases with surgeon 's experience . according to zeidmann14 ) , the overall complication rate associated with anterior cervical spinal fusion is approximately 5% , and pharyngo - esophageal perforation is uncommon , but nevertheless of the utmost importance because of the possibility of graft infection leading to osteomyelitis , mediastinitis , sepsis , and death6 ) .
acute injury can be caused iatrogenically during surgical approach due to inappropriate placement or dislodgement of sharp - toothed retractor blades in the esophagus .
retraction is particularly dangerous when a nasogastric tube is positioned because the wall of the hypopharynx or esophagus may be " trapped " by a high - pressure claw between the retractor and the tube , causing ischemic injury and secondary perforation8 ) .
delayed esophageal injuries are due to chronic compression or contact and subsequent necrosis , abscess formation , and perforation due to graft dislodgement or screw migration with or without plate failure4,7 ) .
screw dislodgement often follows a benign course and is completely asymptomatic , due to the small diameters of the screws used and slow migration from the external to the internal mucosa , which permits spontaneous tissue repair of the defect caused
repetitive friction between the retropharyngo - esophageal wall and the plating system(normally positioned with adhesion ) , traction - type pseudodiverticulum , and perforation are other causes of delayed injury11 ) .
the complications of esophageal perforation range from asymptomatic with local infection to mediastinitis and death .
the clinical course depends on the etiology , location , and timing of the perforation .
asymptomatic perforation has as well been reported as incidental oral extrusion of screw even years after anterior cervical spine stabilization5 ) .
patients generally present with swallowing difficulty , regional swelling , neck pain , dysphagia , weight loss , dysphonia , subcutaneous emphysema , and fever ; our patient presented with dysphagia and neck pain with regional swelling12,13 ) .
conservative treatment may be preferred for small , contained defects of less than 1 cm , and consists of the elimination of oral feeding , tube feeding to restore fluid and nutritional balance , and intravenous antibiotics .
some cases need surgical repair , such as , perforation closure with a primary suture or sternocleidomastoid or pectoralis major flap repair13 ) .
we operated on our patient to remove the offending screw due to evident fistula confirmed by esophagography and esophagoscopy .
direct repair was effective in achieving a successful perforation repair of the esophageal perforation with an early return to oral feeding .
we report a rare case of delayed esophageal perforation caused by screw displacement after anterior cervical spine plating .
careful periodic follow - up is necessary , and when encountered , early surgical closure following removal of the offending screw is mandatory .
 although anterior approaches to the cervical spine are popular and safe , they cause some of complications . esophageal perforation after anterior spinal fusion is a rare but potentially life - threatening complication . 
 we present a rare case of delayed esophageal perforation caused by a cervical screw placed via the anterior approach . 
 a 43-year - old man , who had undergone surgery for complete cord injury at another orthopedic department 8 years previously , was admitted to our institute due to painful neck swelling and dysphagia . 
 radiological studies revealed a protruding screw and esophageal perforation . 
 the perforation was found during surgery and was successfully repaired . 
 this case emphasizes the need for careful long - term follow - up to check for delayed esophageal perforation in patients that have undergone anterior cervical spine plating . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION