Dear Editor, We have read with interest the paper by Dr. Seidl et al. “Infrahyoid muscle flap for pharyngeal fistulae after cervical spine surgery: a novel approach–report of six cases” [2]. They describe a rather elegant technique to repair perforation of the pharynx and the esophagus using the strap muscles as a vascularized flap. In their experience, closure of all the defects was achieved with no complications. In addition, they were able to remove the nasogastric tube within 2 weeks of the operations in all patients, which is a remarkable fact. They also compare the infrahyoid muscle flap with the sternocleidomastoid muscle (SCM), stating that the former has distinct advantages: clearly defined vascular blood supply and better capability to be modeled. In a previous similar study, we presented our experience of using the SCM flap to reconstruct esophageal fistulae after anterior cervical spine surgery [1]. We also achieved closure of all the defects using this technique. However, our patients stayed significantly longer on nasogastric feeding. This fact could be partly explained, because of our patient population: one of our cases had significant lower cranial nerve dysfunction secondary to a cervical chordoma, as we mention on the manuscript, and two other patients had a low level of consciousness for a significant time due to concomitant head trauma. We do not agree with the statement that the SCM flap has modeling limitations, since it is the bulkiest muscle on the anterior part of the neck, it is pliable, it has a multifocal blood supply, and therefore it can be fitted in many different ways without the need of using the whole muscle mass. Hence, its function can be mostly preserved (head rotation and deep inspiratory effort). In contrast, in the technique described by Dr. Seidl et al. the whole ipsilateral infrahyoid muscle group is used, and thus its function might be affected (deglutition and deep respiratory effort). Spinal surgeons should not forget that accessory respiratory musculature could be very important when dealing with patients affected by high spinal cord injuries. In addition, it might be easier for spinal surgeons, namely neurosurgeons or orthopaedic surgeons, to harvest the SCM flap rather than an infrahyoid muscle flap, since there is no need either to dissect the ansa cervicalis nor the superior thyroid artery and vein. We understand that head and neck surgeons might feel quite comfortable using the infrahyoid muscle flap, since it was originally designed to deal with otolaryngological conditions. Finally, we do concur with the authors that local vascularized flaps are the method of choice to repair pharyngeal and upper esophageal defects related to anterior cervical surgery.

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.