Expectoration of anterior cervical discectomy and fusion cage: a case report

Anterior cervical implant failure can lead to catastrophic sequalae and requires prompt evaluation and management to reduce significant morbidity. This case report describes a 51-year-old female who underwent a C2-3 and C3-4 anterior cervical discectomy and fusion (ACDF) with stand-alone, integrated plate-cage interbody devices for cervical spondylotic myelopathy (CSM). Initial procedure was performed at an outside institution. Unfortunately, no radiographic follow up was obtained by the primary surgeon during the initial post-operative period. Post-operatively she experienced persistent dysphagia and troubles swallowing. The patient was eventually seen by the ear, nose and throat (ENT) service at our institution. Eighteen months after the index procedure, a nasolaryngoscopy revealed exposure of her ACDF implant through the posterior aspect of her pharynx. The ENT service obtained radiographs and immediately contacted our Spine Surgery service. Repeat anterior approach with implant removal was planned; however, during the interim, the patient suffered a coughing fit and complete expectoration of the C2-3 implant with the locking screws in place had occurred. Patient experienced immediate relief of symptoms. Miraculously, the patient did not develop airway compromise, infection, or return of severe dysphagia symptoms. During continued follow up, no significant clinical sequelae of her anterior cervical soft tissue structures were identified. The patient chose to decline further surgical management of her cervical spine. This case report highlights a potentially catastrophic complication following ACDF. Several modifiable factors including implant design, C2-3 ACDF cage placement, use of post-operative radiographs, and patient education regarding need for consistent follow up may have prevented this complication. Implant extrusion is a rare, but potentially serious complication following ACDF. Presenting symptoms can be generalized and mild including pain, swelling, or worsening dysphagia. It is paramount to obtain orthogonal X-rays for routine follow-up of post-surgical ACDF patients, especially if dysphagia persists or worsens. Immediate surgical management in recommended if significant post-operative cage migration is encountered.