Peri-Plate Gas Detected on Cervical CT as an Exploratory Imaging Indicator of Esophageal Perforation After Anterior Cervical Spine Surgery

STUDY DESIGN: Exploratory, single-center retrospective observational study. OBJECTIVE: To evaluate candidate imaging markers associated with esophageal perforation in patients undergoing reoperative anterior cervical exploration more than 1 month after anterior cervical spine surgery (ACSS) with anterior cervical plate fixation, with particular attention to peri-plate gas on preoperative noncontrast computed tomography (CT). SUMMARY OF BACKGROUND DATA: Esophageal perforation after ACSS is a rare but potentially life-threatening complication. Preoperative recognition is important for planning multidisciplinary revision surgery, but diagnosis remains challenging in delayed revision settings because of adhesions, infection, or hardware-related changes. Although case reports have suggested that prevertebral or peri-implant gas may indicate occult esophageal communication, cohort-level evidence remains limited. METHODS: We reviewed ACSS procedures with anterior cervical plate fixation performed at a single institution between April 2002 and March 2025. Patients who underwent repeat anterior cervical exploration more than 1 month after the index surgery were included in the analysis. The primary outcome was esophageal perforation confirmed preoperatively, intraoperatively, or within 48 hours after revision surgery. Candidate markers were summarized using cross-tabulated diagnostic-performance estimates, and delayed infection was defined without gas-related imaging criteria. RESULTS: Among 1593 ACSS procedures with anterior cervical plate fixation, 39 underwent repeat anterior exploration, and 35 delayed revision cases were analyzed. Esophageal perforation was confirmed in 8 patients in the delayed-infection group. Peri-plate gas was observed in 7 patients, 6 of whom had esophageal perforation; among the 28 patients without peri-plate gas, 2 had esophageal perforation. This 2 × 2 distribution yielded 75.0% sensitivity, 96.3% specificity, 85.7% positive predictive value, 92.9% negative predictive value, and an area under the curve (AUC) of 0.856 (95% CI: 0.680-1.000). CONCLUSIONS: In this enriched cohort of delayed revision cases, peri-plate gas on noncontrast CT was a highly specific red-flag imaging finding associated with esophageal perforation. Despite limited events and cohort selection, peri-plate gas assessment may help select patients for targeted esophagography or endoscopy and early multidisciplinary preparation.