Rare complication of the cervical spine trauma--traumatic esophageal fistula: case report and review of the literature.

BACKGROUND AND STUDY AIMS: Esophageal fistula due to cervical spine trauma is a rare, potentially fatal complication, which changes significantly the treatment and the prognosis of the trauma patient. There is scarce data regarding this associated pathology of cervical trauma and it consists only of isolated cases, most of them being reported as a complication of the surgical treatment. We present the case of a female patient who suffered a fall from a wagon and who was diagnosed at presentation with cervical fracture and esophageal fistula. Patient: A 65 years old female who suffered a fall from a train wagon presented for intense neck pain and bilateral brachial paresis. The MRI exam showed a C6-C7 fracture with bilateral facet dislocation in the context of a degenerative, spondylotic cervical spine. It also showed an anterior fragment from the C7 body, in contact with esophageal adventitia. The patient underwent surgery. RESULTS: A C6 corpectomy was performed, with arthrodesis with bone graft and cervical plate fixation. 24 hours after the procedure, the clinical signs of an esophageal fistula appeared and a CT-scan revealed the typical aspects of that complication. The patient underwent a second surgery in collaboration with the general surgeon with a good outcome and complete neurological recovery. CONCLUSION: In the case of cervical spine trauma the imaging exploration has to look for potential signs of lesions to the neighboring vital structures. Although a rare complication of cervical trauma, esophageal fistula represents a formidable complication and requires immediate surgical sanction, the only factor decisive for a good prognosis.

The pitfalls of differential diagnosis of lumbar spine epidural lesions--exemplification with two particular cases and a review of the literature.

BACKGROUND AND STUDY AIMS: Lumbar spinal epidural lesions could belong to a wide spectrum of pathologies. However, some cases present with rare conditions that can cause significant neurological deficit and raise serious diagnostic challenges. We present two such cases where the clinical picture and the imaging findings failed to elucidate the actual diagnosis, which came as an intraoperative and pathological surprise. PATIENTS: The first case is that of a 78-years-old male that presented for low back pain, bilateral S1 radicular sciatica, paraparesis, and difficulty walking. The neurologic exam showed the absence of the rotulian reflexes bilaterally, and a partial sensory loss in the crural dermatomes. The MRI showed an epidural mass, contrast enhancing at the L1-L2 level, suggestive for an extraxial tumor. The second case is that of a 62-year-old woman that presented for a hyperalgic sciatica involving the right S1 root with parestesias in the corresponding dermatome. MRI showed a cystic, contrast enhancing lesion in the L5-S1 recess, mimicking a cystic neuroma. Both patients underwent surgery and histopathological exams were performed from the excised pieces. RESULTS: In the first case the surgery resulted in complete removal of the pathological process and histopathological result returned chronic organized hematoma, concordant with the intraoperatory aspect. The evolution was good. In the second case the histopathological result came back as pulpous disk. Again the evolution was good with complete neurological recovery. CONCLUSION: In the presence of an epidural mass with clear clinical symptomatology, rare entities like chronic epidural hematoma or posterior migrated disk material should be always considered as a differential diagnosis in patients with suspicion of extradural chronic compressions. In these cases, only the intraoperatory and histopathological exams can provide a clear diagnosis.