1Professor of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
2Resident of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran
Received Date: 07 Nov, 2019 ; Accepted Date: 21 Nov, 2019 ; Published Date: 26 Nov, 2019
Anterior Cervical Discectomy and Fusion (ACDF) is the most common cervical spinal surgeries. Rare side effects for this surgery are reported but it can become troubling. We are supposed to consider a case which is about a middle-aged woman that caused screw pull out and then outbreak of dysphagia, 20 years after the surgery of ACDF. Instrumentation of anterior cervical spine is so common and has very slight side effects, dangerous consequences may take place in case of side effects. Delayed Screw pullout is very rare in this type of patients and may cause deadly injuries for them.
Cervical Instrumentation; Side Effect; Screw Pull Out
Anterior Cervical Discectomy and Fusion (ACDF) is the most common cervical spinal surgeries. Recently, Trauma and spondylotic myelopathy are the most reasons for this procedure . Rare side effects for this surgery are reported but it can become troubling . Dura tearing, dysphagia, and hematoma after the surgery, Laryngeal recurrent nerve paralysis, Horner syndrome, and esophageal perforation are the most possible side effects which are reported in papers so far . A number of intensive side effects are reported which are caused by screw pull out and plate dislocation which are mentioned into previous reports . We are supposed to consider a case which is about a middle-aged woman that caused screw pull out and then outbreak of dysphagia, 20 years after the surgery of ACDF.
A 61 years old woman referred to us complaining about odynophagia and dysphagia. She had neck trauma background caused by car accident in 1998 and then she was operated - by the writer of this paper - for traumatic disk herniation of C4-C5 in Mashhad’s Ghaem hospital. The patient’s fusion was done by autologous iliac graft and she had no neurologic symptoms and discharged from hospital with no side effects of surgical operation. Moreover, follow-up of the patient was normal and had no side effects sign of surgical operation. Now, she referred to gastroenterologist for sudden odynophagia and dysphagia and then she was examed by endoscopy and no pathological findings were seen. Therefore, she was referred to ENT doctor because of cervical lymphadenopathy and slight fever, doubting retropharyngeal abscess symptom; however, no laboratory abnormalities and infection symptoms were observed. Upper respiratory tract endoscopy was prescribed for the patient by the ENT doctor which no pathological trace was found and then, she was advised for cervical CT scan and also she was then advised to refer to neurosurgeon, regarding the background of cervical spine surgery.
She was referred to us, while she has been operated by us in 20 years ago. But she had no neurologic and clinical symptoms in our checkup. So, as the first step, we were prepared for imaging of cervical lateral and then it was shown the dislocation of upper left plate screw and fusion between the C4 and C5 was seen (Figure 1). Then the patient was candidate for an immediate operation and the whole instrumentation removed, (Figure 2) while there was no trace of infection, pus, or inflammation. The patient’s instrument sent for bacterial culture and the result was negative.
The patient was sent for ENT physician and gastroenterologist and there was no need for any implementation. After 2 days, she was discharged from hospital in complete recovered condition and without any symptom of surgical operation.
We have studied a case about the screw pull out after 20 years, regarding that Anterior cervical discectomy and fusion (ACDF) that are the most common surgical operations of cervical spine. The side effects of this surgery are very rare [1,5] and some studies have been done around this procedure which show the slight side effects of this procedure. Instrumentation raises some side effects like screw pull out [6,7]. Lower and et al showed 18 percent of anterior cervical spine instrumentations become fail . esophagus tear after surgery is a common side effect but that is rare after failure of instrumentation, [4,9] however, mortality after esophagus perforation in this kind of patients is about 20 to 65 percent which depends upon the pull out delay and also, perforation causes mediastinitis, pleuritis, sepsis, pneumonia, and fistula . However, in seldom cases screw dislocation caused airway injuries and death .
The first case of screw dislocation and esophagus perforation was reported in 1971 . Kostas and et al have reported a case of screw dislocation and penetrating into digestive system after 16 months of surgical operation; however, the plates and screws have been pulled out by surgeons . Quadri and et al reported an operation screws pull out and esophagus perforations from an 85 years old man which took place 3.5 years after the surgical operation . In other study which were done by Lu and et al, they reported a case that screw dislocation caused esophagus perforation after 9 years . In a study done by Gazzeri and et al, screw pull out has been occurred after 11 years passed away surgical operation which caused esophagus perforation . The difference between the cases noted above and this case is that the screw pulled out after 20 years’ delay and the other difference is that in the most cases reported, screw pullout caused esophagus perforation; meanwhile, there was fortunately no complication which make the patient to refer to a physician after a while.
In most cases which are reported, screw pull out cause esophagus perforation, but in a rare case the screw pullout didn’t cause pharynx perforation . Esophageal perforation can bring some side effects from slight to deadly; so, immediate detection is very important and vital. The most reason which cause screw pullout can be including incorrect initial placement of screw or screw suboptimal place . In other cases which reported by Pompili and et al, incomplete screw lock caused screw dislocation . In cases that screw pulled out, immediate removing the instrument is advised. Esophagogram is advised for observing esophagus injuries. Moreover, diagnostic actions are advised for mediastinitis rollout, pneumonia, and sepsis .
Finally, it is concluded that however, instrumentation of anterior cervical spine is so common and has very slight side effects, dangerous consequences may take place in case of side effects. Delayed Screw pullout is very rare in this type of patients and may cause deadly injuries for them. Therefore, it is advised that the patients were under this surgical operation should be aware of likely side effects of screw pullout and esophagus perforation, because immediate detection of this complication is very helpful in recovery of patients.
Figure 1: Lateral cervical X-ray before surgery showed screw pull out.
Figure 2: Post Operation Imaging.
Citation: Rad FM, Kakhki I, Pishjoo M (2019) Delayed Screw Migration 20 Years after Anterior Cervical Spine Plating; A Case Report and Review of Literature. Clinical and Medical Case Reports Journal. Clin Med Case Rep J. 1: 001. CMCRJ-001.000001