LAUSR

Esophageal perforation is known to be a rare complication of thoracic vertebral fractures. Traumatic esophageal injury reportedly occurs in only 0.01% of chest injuries. However, once esophageal perforation occurs, it can be lifethreatening and should be cautiously diagnosed. In this study, we present a case of a patient who sustained a thoracic vertebral fracture with diffuse idiopathic skeletal hyperostosis (DISH). This became complicated by an esophageal perforation, which led to pyogenic spondylitis and an epidural abscess. In this correspondence, we will review the case and briefly discuss its relevant literature. A 63-year-old male motorcyclist was injured in a traffic accident. He was rushed to the nearest hospital and was diagnosed with a posterior fracture dislocation of the right hip, a facial bone fracture, and a pulmonary contusion. He was ultimately transferred to our hospital for a higher level of care. At our hospital, closed reduction and direct traction were performed for the hip fracture dislocation. Hip surgery was also scheduled for a later time after the patient’s general condition improved. Unfortunately, surgery was delayed because the patient developed a prolonged fever. On day 7 of hospitalization, acute bilateral lower extremity paresis (modified Frankel classification; B3) developed, and magnetic resonance imaging (MRI) and computed tomography (CT) tests were thereafter ordered. The MRI revealed pyogenic spondylitis with an epidural abscess at T4-T5 (Fig. 1A, B), while the CT showed a vertebral fracture of T4 with DISH and free air in the mediastinum (Fig. 1C, D). Based on these studies, esophageal perforation induced by thoracic vertebral fractures with DISH was suspected. Moreover, because of the esophageal perforation, mediastinitis, pyogenic spondylitis, and an epidural abscess developed. The patient underwent emergency T1-T8 posterior fusion with laminectomy (Fig. 2). All screws were percutaneously inserted, and the penetrating endplate screws were used only in the caudal vertebrae. Additionally, surgical anterior mediastinal drainage through neck collar incision was conducted to treat the esophageal perforation and mediastinitis (Fig. 3). Alphastreptococcus was detected in both blood and abscess culture, and piperacillin-tazobactam was administered. Three months after surgery, the patient’s C-reactive protein level was noted to normalize, and the bacterial infection remained well controlled. The patient underwent a right-sided total hip replacement 7 months after the injury; eventually, his lower extremity paresis improved to modified Frankel classification D1. In our literature review, only nine previously reported cases of esophageal perforation associated with thoracic vertebral fractures have been published. Thus, esophageal perforation seems to be a very infrequent complication of thoracic vertebral fractures (Table 1). All reported cases were found to be caused by high-energy trauma, and all esophageal perforations occurred due to upper thoracic vertebral fractures between T1 and T4. This is because the esophagus is located close to the spine at the C5-T4 level. This mechanism of esophageal perforation is thought to be due to direct injury by anterior bone fragments of the fractured vertebra. Thoracic esophageal injury lacks specific symptoms and can be masked by other vital organ injuries, making it