The Role of the Sternocleidomastoid Muscle Flap for Esophageal Fistula Repair in Anterior Cervical Spine Surgery

In Brief Study Design. A retrospective study was undertaken which evaluated the medical records and imaging studies of a subset of patients managed by the spine service at Jackson Memorial Hospital who were diagnosed with an esophageal perforation in the setting of spinal surgery. Objective. To assess the safety and efficacy of a sternocleidomastoid muscle flap in the repair of esophageal perforation in the setting of anterior cervical spine surgery. Summary of Background Data. The management of an esophageal fistula in the setting of spine surgery is challenging and starts with a prompt and accurate diagnosis. In addition to broad spectrum intravenous antibiotics, several methods have been described to repair the fistula, which range from enteral tube feeding, direct repair, and/or repair with a local or free muscle flap. Methods. The review encompassed medical records, discharge summaries, operative reports, and imaging studies. Data were gathered with specific attention to demographics, primary pathology, mechanism of esophageal injury, method of spinal stabilization, method of esophageal repair, and time to initiation of oral intake. Follow-up interviews were conducted either in-person or by telephone. Results. Six patients were treated over the study period. There were 3 men and 3 women. The mean age was 52.8 years. Primary pathologies were penetrating trauma, blunt trauma (2 cases), degenerative disease (2 cases), and tumor. Mechanisms of esophageal injury were penetrating trauma, acute iatrogenic, chronic iatrogenic (3 cases), and intubation trauma. The time to diagnosis ranged from immediate to 10 months. The method of spinal stabilization was anterior autograft followed by posterior instrumentation in 4 of 6 patients. The method of esophageal repair was an inferiorly based sternocleidomastoid (SCM) flap in 4 cases, primary repair in 1 case, and esophageal diversion alone in 1 case. The time to oral intake averaged 59.2 days (range, 23–113 days) in those with a SCM flap versus 153.5 days (range, 119–188 days) in those treated without a flap. Conclusion. The use of an SCM flap for the repair of esophageal injury, in the setting of anterior cervical spine surgery, is a safe and effective tool. An SCM flap appeared to improve the time in initiating oral intake without any significant morbidity. A retrospective review of 6 cases of esophageal perforation associated with anterior cervical spine surgery treated at Jackson Memorial Hospital between January 2003 and December 2003. In 4 of the 6 cases, the esophageal perforation was managed with a sternocleidomastoid flap. The sternocleidomastoid flap carried no morbidity and reduced the time to resumption of oral intake from 153.5 days (primary repair patients) to 59.2 days (sternocleidomastoid flap patients).