Inomata Kazuhiro, Takasawa Eiji, Mieda Tokue, Iizuka Yoichi, Chikuda Hirotaka
Department of Orthopedic Surgery, Gunma University, Maebashi, JPN.
Cureus. 2023 Apr 19;15(4):e37831. doi: 10.7759/cureus.37831. eCollection 2023 Apr.
Systemic sclerosis (SSc) is a systemic, immune-mediated disease characterized by abnormal cutaneous and organ-based fibrosis that results in progressive organ dysfunction including the esophagus. We herein report our experience of a patient with SSc who underwent salvage anterior cervical spine surgery that led to late-onset esophageal perforation. A 57-year-old female had progressive cervical kyphosis after laminoplasty for cervical spondylotic myelopathy. We performed anterior cervical discectomy and fusion using a stand-alone cage. Despite prolonged use of a neck collar, migration of the anterior cage was noted three months after surgery. Rapid progression of kyphotic deformity prompted us to perform revision surgery of circumferential cervical correction. However, conventional posterior surgery was precluded due to the extremely poor condition of her neck, including severely sclerotic skin and atrophic muscles. To address this, she underwent a posterior fusion with the closed technique and C4-C5 corpectomy and bone grafting using a low-profile anterior plate. One year after the surgery, CT and routine upper gastrointestinal endoscopy (UGE) showed no evidence of esophagus injury. She remained asymptomatic thereafter. Over three years after her last surgery, however, follow-up CT incidentally revealed an abnormal air leak around the anterior plate. UGE demonstrated large esophagus perforation with the exposed metal plate. As she had already been on parenteral nutrition due to the disease progression of SSc, we decided not to remove the implant. Potential esophagus perforation after anterior cervical spine surgery, even years later, should be considered regardless of the patient's symptoms, such as chest pain and dysphagia. Spine surgeons need to be cognizant of the fragility of the esophagus, especially in patients with SSc. For patients with SSc, posterior reconstruction alone is recommended as a relatively safe option, even with a suboptimal skin condition.
系统性硬化症（SSc）是一种全身性、免疫介导的疾病，其特征是皮肤和器官出现异常纤维化，导致包括食管在内的器官功能进行性障碍。我们在此报告1例接受挽救性颈椎前路手术并导致迟发性食管穿孔的SSc患者的治疗经验。1例57岁女性因脊髓型颈椎病行椎板成形术后出现颈椎后凸畸形进展。我们使用独立椎间融合器进行了颈椎前路椎间盘切除融合术。尽管术后长时间佩戴颈托，但术后3个月仍发现前路椎间融合器移位。后凸畸形的快速进展促使我们进行颈椎环形矫正翻修手术。然而，由于其颈部状况极差，包括皮肤严重硬化和肌肉萎缩，无法进行传统的后路手术。为解决这一问题，她接受了后路闭合技术融合、C4-C5椎体次全切除及使用低轮廓前路钢板植骨。术后1年，CT和常规上消化道内镜检查（UGE）未发现食管损伤迹象。此后她一直无症状。然而，在她最后一次手术后3年多，随访CT偶然发现前路钢板周围有异常漏气。UGE显示食管有大的穿孔，钢板外露。由于SSc病情进展，她当时已接受肠外营养，我们决定不移除植入物。无论患者有无胸痛和吞咽困难等症状，都应考虑颈椎前路手术后甚至数年之后发生食管穿孔的可能性。脊柱外科医生需要认识到食管的脆弱性，尤其是在SSc患者中。对于SSc患者，即使皮肤状况欠佳，单独进行后路重建也被推荐为相对安全的选择。
