anterior cervical discectomy and fusion is a commonly performed surgery for the treatment of spondylosis , radiculopathy , myelopathy , and trauma . esophageal perforation is an exceedingly rare complication following anterior cervical discectomy and fusion ( acdf ) . the incidence of these complications ranges from 0.02 to 1.52% although is higher when it is a result of trauma . we describe a case of a 24-year - old man who underwent acdf and corpectomy following a motor vehicle accident who developed delayed onset aspiration pneumonia and dysphagia requiring surgical repair of an esophageal perforation . to the best of our knowledge there has been no prior literature discussing airway management in patients who underwent esophageal repair for perforation following cervical spine surgery . we believe this paper will provide a deeper understanding to the intensivist in regards to postoperative airway management in this type of patient . a 24-year - old man presented to an outside hospital following a motor vehicle accident with cervical spine fractures of c5 - c7 , anterolisthesis of c6 and associated spinal cord transection with resulting quadriplegia . the patient was taken to the operating room and underwent anterior cervical decompression and fusion ( acdf ) of c5 - 7 , c6 corpectomy with polyetheretherketone ( peek ) cage and c4 - t1 posterior fusion [ figure 1a ] . postoperatively the patient did well and was discharged to a rehabilitation center at our institution . lateral cervical x - ray shows c4-t1 posterior fusion with c5-c7 acdf and peek cage at the level of c6 with no apparent hardware defects ( a ) ct neck demonstrated air surrounding the implant at c6 as well as the anterior fusion plate ( b ) barium swallow study showed a posterior esophageal barium leak at c5-c6 and a te - fistula . the contents of the fistula are seen tracking inferiorly t1 and is seen anterior to the fusion plate ( c ) barium swallow study done ten days postoperatively shows resolution of perforation ( d ) approximately four months following his surgeries the patient began to develop increased sputum production , cough and fever . , the aspiration was thought to be due to the patient 's poor pulmonary clearance from his immobility and quadriplegia . while on antibiotic therapy for aspiration pneumonia the patient developed acute dysphagia . computed tomography ( ct ) scan demonstrated air surrounding the implant at c6 as well as the anterior fusion plate [ figure 1b ] . barium swallow revealed an esophageal defect with contrast tracking down the prevertebral space to the level of t1 anterior to the cervical fusion plate as well as a tracheo - esophageal fistula [ figure 1c ] . the patient underwent removal of the anterior plate , which was visualized in the pharyngoesophagus during intraoperative video - assisted laryngoscopy , removal of peek cage and placement of antibiotic impregnated bone cement , primary repair in conjunction with a sternocleidomastoid muscle flap being placed on the esophageal defect [ figure 2 ] . postoperatively , the patient remained intubated with the ngt to remain in place for one week . the patient was extubated over a soft 22-french exchange catheter without incident and repeat barium swallow study demonstrated resolution of the esophageal perforation [ figure 1d ] . anterior cervical discectomy and fusion ( acdf ) has been the mainstay treatment of patients with radiculopathy or myelopathy attributed to cervical spine disease , particularly herniated nucleus pulposus . in the trauma setting , vertebral body fracture may require corpectomy in which acdf is typically performed in conjunction with posterior instrumentation . esophageal perforation is a more rare and potentially life threatening complication occurring in 0.02 - 1.52% of patients . identifying patients with esophageal perforation can be difficult as the clinical presentation and initial onset is highly variable . presentation with dysphagia , choking , aspiration , pain , fever or subcutaneous emphysema can all be postoperative complaints typically seen in up to 9.5% of patients . the placement of an anterior cervical plate improves fusion rates and reduces risk of graft migration . additionally , chronic compression of the esophagus against the anterior cervical plate during swallowing can result in pressure necrosis and eventually perforation and fistula formation . diagnosis of esophageal perforation can be challenging due to the delayed and variable clinical presentation . in addition to computed tomography ( ct ) scan , upper endoscopy , barium contrast studies , and bronchoscopy are the most informative studies to determine the location and extent of perforation . proper management of esophageal perforation is very important as its associated mortality rate is high . a conservative approach including nil per os ( npo ) , with temporal parenteral nutrition by either ng or peg tube and broad - spectrum intravenous antibiotics may be appropriate in a very select group of patients where perforation is incidentally found and are asymptomatic . spontaneous healing of these injuries may take four to twelve weeks however , this conservative approach is associated with a 20 - 45% rate of abscess formation . the use of a sternocleidomastoid ( scm ) muscle flap has been considered the gold standard to achieve and maintain perforation closure as without it esophageal sutures will invariably fail . the scm is a highly mobile and vascularized medium that can improve antibiotic delivery , wound healing and provides a physical barrier between the esophagus and the cervical spine . important considerations when extubating is the degree of healing following esophageal perforation repair , mallampati grade , as well as the possible need and risks of reintubation in an airway emergency . although most reports describe waiting approximately 10 - 14 days postoperatively before resuming oral feeds , our patient was successfully extubated and tolerated oral feeds suggesting this period of time to be sufficient for would healing . in our patient , although rare , esophageal perforation can occur following accidental esophageal intubation and is of clear concern in patients who underwent esophageal repair . risk of perforation is higher when inexperienced individuals attempt intubation , difficult intubation requiring multiple attempts , as well as in emergency scenarios . when the patient has satisfied all weaning parameters and has a present cuff leak we strongly recommend that an experienced anesthesiologist be present for extubation and have all appropriate airway devices available including a fiberoptic bronchoscope . the more rigid and thicker bougie should be avoided due to their risk of trauma . a small hole should be made in the facemask such that the exchange catheter may pass through while the patient receives 8 - 10 l of oxygen for typically 30 - 60 minutes . this will allow for a more controlled and safer reintubation in the event the patient fails extubation and therefore reduce the potential risk of reperforation . greater vigilance is required in the event reintubation is required as perforation of the surgical repair site is of great concern . therefore , it is our recommendation that an experienced anesthesiologist be present for extubation and that all appropriate airway devices are available including a fiberoptic bronchoscope .
anterior cervical discectomy and fusion ( acdf ) is a commonly performed surgery for the treatment of spondylosis , radiculopathy , myelopathy , and trauma to the cervical spine . 
 esophageal perforation is a rare yet serious complication following acdf with an incidence of 0.02 to 1.52% . 
 we describe a case of a 24-year - old man who underwent acdf and corpectomy following a motor vehicle accident who subsequently developed delayed onset esophageal perforation requiring surgical intervention . 
 we believe that the detailed review of the surgical management of esophageal perforation following cervical spine surgery will provide a deeper understanding for the intensivist in regards to postoperative airway management in these types of patients . 
 careful extubation over a soft flexible exchange catheter should take place to help reduce the risk of perforation in the event reintubation is required .