Expectoration of cervical spinal fusion hardware following delayed extrusion and pharyngoesophageal fistula formation: a case report
Patrick Sarette, Christine Motzkus
Contributions: (I) Conception and design: C Motzkus; (II) Administrative support: Both authors; (III) Provision of study materials or patients: C Motzkus; (IV) Collection and assembly of data: Both authors; (V) Data analysis and interpretation: Both authors; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors.
Background: Cervical fusion surgeries are among the most commonly performed neurosurgical cases and are generally well tolerated with infrequent presentation of late complications. However, on rare occasions, hardware may be expelled through fistulized tracts. Prompt consultation of specialty services is needed alongside initiation of broad-spectrum antimicrobials and stabilization of the cervical spine. We present this case to highlight the emergency department (ED) diagnosis of a rare complication of cervical fusion surgery and the dangers of triage bias.
Case Description: A mid-50s male with a past medical history of substance use disorder and vertebral osteomyelitis presented to a community ED with a chief complaint of dysphagia, odynophagia, and cough. He noted expectoration of his cervical fusion hardware to the triage nurse and was subsequently triaged to a behavioral health care area. Over the 3 days prior to presentation, he noted worsening of odynophagia and dysphagia culminating in a coughing fit and expectoration of cervical fusion hardware shortly prior to arrival to the ED. Based on his complaint and production of his hardware for examination by the ED physician, broad spectrum antibiotics were empirically initiated, and he underwent cervical X-rays which confirmed absence of the hardware. X-rays were followed by an esophagram to evaluate for esophageal perforation. Local neurosurgeons and otolaryngologists were consulted and recommended transfer to the tertiary center where the surgery had been performed. At the tertiary center, the patient underwent direct visualization with otolaryngology identifying a fistula. He was admitted to the hospitalist service pending definitive operative plans from neurosurgery and otolaryngology. He recovered well from surgery, completed a course of antimicrobials, and was noted to be doing well at his follow-up appointments. Unfortunately, the patient was subsequently lost to further follow-up.
Conclusions: Pharyngeal fistula formation is a rare but known complication of anterior cervical fusion surgery. A high level of suspicion must be maintained for patients presenting to the ED with dysphagia. Further, clinical care teams should be mindful of triage bias resulting in patients with objective abnormalities being placed in behavioral health care settings which could result in inappropriate workup or lack of recognition of serious conditions.
Keywords: Pharyngoesophageal fistula; cervical fusion; hardware extrusion; case report
Received: 17 February 2026; Accepted: 15 May 2026; Published online: 15 June 2026.
doi: 10.21037/jeccm-2025-1-57
Highlight box
Key findings
• Oropharyngeal fistulization can occur as a late complication of anterior cervical fusion surgery; prompt recognition and management of this complaint is challenging in the emergency department (ED). Triage bias may delay recognition of this unusual pathology.
What is known and what is new?
• Known complications of anterior cervical fusion surgery include hardware failure, infection, and fistula formation typically shortly after the initial surgery.
• This manuscript reports a delayed presentation of an oropharyngeal fistula in a patient mistakenly triaged as having a behavioral health complaint and details ED diagnostics and management of this rare presentation.
What is the implication, and what should change now?
• Clinicians should maintain a high degree of suspicion for post-operative complications in patients with a history of cervical fusion.
• Further, clinicians should maintain a high level of awareness of triage bias for patients roomed to behavioral care areas.
Introduction
Background
Anterior cervical fusions are commonly performed neurosurgical operations (1). Though overwhelmingly well-tolerated leading to significant relief from symptomatic cervical radiculopathy or myelopathy, common well-described post-operative complications include wound infections, epidural hematoma formation, and dysphagia. Esophageal fistulas are a known but exceedingly rare complication of anterior cervical spinal surgery, with reported incidence ranging from 0.04–1.49% (2-4). Ventral surgical approaches can be at increased risk of postoperative parapharyngeal fistula formation (5).
Rationale and knowledge gap
There are currently limited cases in the emergency department (ED) setting regarding the formation of a pharyngoesophageal fistula, subsequent hardware migration through the fistula tract, and expectoration of an intact fusion hardware construct years after the original fusion, with only two previous cases identified (6,7). This case illustrates an example of a pharyngoesophageal fistula identified in the ED and highlights the importance of maintaining a high index of suspicion for medical issues in patients triaged to behavioral care areas. Triage bias is difficult to overcome, and the stresses placed on triage in busy EDs can inadvertently lead to significant triage errors (8).
Objective
This case demonstrates a rare presentation of expectorated hardware by way of a pharyngoesophageal fistula in an otherwise stable patient nearly 8 years after initial placement. This case highlights unique aspects surrounding identification, diagnosis, and management of this rare complication when evaluated in the ED. We present the case noting how the patient’s prior surgical history, comorbidities, and social factors influenced both the presenting illness, ED diagnostic momentum, and follow-on re-operative course. We present this article in accordance with the CARE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-1-57/rc).
Case presentation
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
A male patient in his 50s with past medical history of hypertension, polysubstance use, and remote history of C4–5 disk osteomyelitis and epidural abscess presented to a community ED with the concerns of dysphagia, odynophagia, and cough for 3 days prior to presentation. In June 2017, 8 years prior to ED presentation, the patient was found to have C4–5 disk osteomyelitis, cervical spine epidural abscess, and consequent cervical spinal cord compression in the setting of intravenous drug use. At that time, he underwent anterior C4 and C5 corpectomy, evacuation of the epidural abscess, anterior C3–C6 arthrodesis and cervical plating, and C2–T2 posterolateral fixation.
He first noticed that his chronic dysphagia had acutely worsened over the last several days, accompanied by a metallic taste, sore throat and cough with scant amount of hemoptysis. Over this same time course, he had associated chills and “hot flashes”. On the day of presentation, the patient had an episode of coughing that produced two metallic pieces of hardware (Figure 1) that he reported were associated with spinal fusion surgery he had undergone nearly 8 years prior. After expectorating the hardware, he noted improvement in his throat pain. He was roomed in the behavioural health portion of the ED after an initial quick triage. He reported no chest pain, shortness of breath, or other symptomatic complaints. The patient reported recent tobacco use, marijuana use, and methamphetamine use.
On the day of ED presentation, his physical examination and presenting vital signs showed a blood pressure of 105/75, heart rate of 100 beats per minute, respiratory rate of 18 breaths per minute, oral temperature of 36.4 ℃, and room air oxygen saturation of 97%. He was well-appearing, non-toxic, and in no acute distress. He had a well-healed cervical-spine midline scar, no anterior neck tenderness to palpation, no stridor, and was easily managing his own secretions. Examination of the oropharynx did not reveal any visible laceration, defect, or bleeding lesions. His voice was mildly hoarse, but otherwise, he was appropriately phonating without difficulty. Physical examination of other organ systems was unremarkable. He produced the expectorated hardware constructs to show examiners.
While in the community ED, he underwent a number of laboratory and imaging studies. These tests included a complete blood count, basic metabolic panel, and serum lactate. These studies were significant for a leukocytosis of 14,100 WBC/mm3, thrombocytosis of 681,000 platelets/mm3, and elevated blood urea nitrogen and serum creatinine; respectively 44 mg/dL and 2.93 mg/dL. Further, venous lactate was 2.4 mmol/L. Cervical spine plain films were initially obtained which when compared to 2017 demonstrated absence of the hardware corresponding to the hardware the patient had produced (Figure 2). He was placed in a c-collar and empiric broad spectrum antibiotics and antifungals were initiated given concern for esophageal perforation along the anticipated tract of the hardware, and the patient was moved to a monitored room in the ED. Computed tomography (CT) imaging of the chest was unremarkable for acute findings and was specifically negative for radiographic evidence of esophageal perforation. However, CT neck and nasopharynx revealed a contrast-filled fistula tract measuring 8 mm at its widest point along the posterior wall of the supraglottic region extending into the retropharyngeal and prevertebral spaces (Figure 3A,3B). Additionally, right-sided paravertebral hypodense foci and soft-tissue swelling were noted, concerning for scarring versus phlegmon. No organized fluid collection was seen. Incidentally, there was noted to be hardware lucency at multiple levels of the posterior reconstructive hardware, suggestive of possible loosening. Both neurosurgery and otolaryngology were consulted at the community hospital and requested that the patient be transferred to the tertiary care center where his initial operation had been performed.
On arrival to the tertiary academic ED, the patient underwent flexible nasolaryngoscopy performed by otolaryngology which confirmed the presence of a large, linear pharyngoesophageal fistula along the posterior pharyngeal wall. Subsequent contrast-enhanced magnetic resonance imaging of the cervical and thoracic spine better elucidated the paravertebral soft-tissue swelling, revealing paravertebral myositis, osseous inflammation, and diffuse esophageal wall thickening suggestive of esophagitis (Figure 4). Neurosurgery and otolaryngology agreed with maintaining a rigid cervical collar and admission to a monitored bed on the hospitalist service. On admission, the hospitalist service consulted infectious disease, who advised continuing the broad-spectrum antibacterial and antifungal coverage. A nasogastric feeding tube was placed. A fluoroscopic esophagram with water-soluble contrast confirmed fistulous connection between the posterior hypopharynx and the retropharyngeal and prevertebral spaces. The original perioperative surgical plan as discussed between neurosurgery and otolaryngology teams involved 7 days of intravenous antibiotics prior to a combined case for definitive surgical solution. However, the patient was not willing to stay in the hospital for the week prior to surgery, so he was transitioned to an oral antimicrobial regimen of fluconazole 200 mg daily, amoxicillin-clavulanate 875–125 mg twice daily, and linezolid 600 mg twice daily and discharged home to return after the 7-day duration. The patient then returned as instructed 7 days after his original hospitalization for planned surgical exploration and repair as a joint case between the neurosurgery and otolaryngology teams. In the operating room, the posterior pharyngeal fistula was openly visualized extending into the spine below the level of the postcricoid mucosa. After careful dissection complicated by scar tissue formation, the pharyngeal defect was found to be approximately 3 cm in length. This was closed primarily with Vicryl sutures by otolaryngology. Neurosurgery then addressed the posterior aspect of the fistula, debriding the epithelium-lined layer with curette and electrocautery while taking care to avoid increasing the risk of cerebrospinal fluid (CSF) leak. Otolaryngology then resumed the case, addressing the large soft tissue defect that resulted from the previous careful dissection and debridement. A right sternocleidomastoid muscle flap was mobilized and used to cover the defect. A Penrose drain was placed into the defect, and the subplatysmal flaps and superficial tissues closed. An operative tracheostomy was placed, and the patient was post-operatively admitted to the intensive care unit.
The patient remained in the intensive care unit for 3 days post-operatively. Operative cultures grew Enterobacter cloacae, Escherichia coli, and Candida glabrata. On post-operative day 8, the tracheostomy was decannulated and on post-operative day 13, the patient passed a video-assisted fluoroscopic swallow study and was cleared for a regular diet. He was discharged to a subacute rehabilitation facility on post-operative day 15 for continued long-term intravenous antibiotics for cervical osteomyelitis for a duration of treatment of 4 weeks. On subsequent follow-up appointments with otolaryngology, neurosurgery, and infectious disease approximately 4–6 weeks after surgery, he was doing well without complaints. Figure 5 provides a timeline of the relevant patient care events.
Discussion
Pharyngeal or esophageal perforations are among the rarest complications following anterior cervical diskectomy and fusion, an otherwise common procedure (1). Despite their extremely low incidence, these complications can be devastating, with reported mortality rates of over 19% (9). Delayed presentation, cited as greater than 28–30 days post-operation, is often due to “hardware failure” or migration of hardware to the point of causing long-term pressure necrosis of the more anterior neck structures. However, delayed presentations spanning over a decade have also been described (10). Review of the literature suggests that common initial presentations of esophageal fistula include dysphagia, neck pain, odynophagia, fever, and subcutaneous emphysema (11-14).
Our patient presented to the ED hemodynamically stable and complained of the non-specific symptoms of cough, sore throat, subjective fever, and chills. Of note, he had several presentations over the prior year where a complaint of dysphagia was noted. The most specific, but most unusual, clinical indicator of the underlying pathology was certainly the expelled hardware that he produced at bedside. The rareness of this presentation, in addition to the patient’s past medical history of polysubstance abuse, may have resulted in significant triage bias with the patient initially being roomed in the psychiatric care portion of the ED.
A detailed search of the literature revealed only two reported cases of spinal hardware expectoration (6,7). In these cases, paroxysmal coughing resulted in the expulsion of intact surgical constructs 1 year post-operatively and three and a half years post-operatively. In the case of our patient, his ED presentation came after eight unremarkable years from the standpoint of his anterior spinal fusion. Though dramatic, it highlights the importance of maintaining a heightened index of clinical suspicion for pharyngeal injury in a patient with history of cervical fusion surgery, no matter how remote, who presents to the ED or other acute care setting. In other cases involving the formation of anomalous tract and diagnosis of esophageal perforation, time to diagnosis ranged from 0 days (indicating an intraoperatively discovered injury) to 18 years. Ventral transpharyngeal approaches place patients at higher risk of fistula formation as noted in prior case reports (5).
The initial ED management of this patient focused on prompt coverage with antimicrobials for prevention of mediastinitis, ensuring stability of the patient’s spine, and consultation of the appropriate specialists to facilitate transfer to the tertiary care center. Similar cases may be difficult to recognize at initial presentation if the defect is not able to be readily visualized on physical examination, and there was clinical concern for the stability of the remaining cervical spine. Accordingly, the patient’s cervical spine was immobilized promptly after recognition of the hardware failure. It was felt by neurosurgery that the patient’s spine was stabilized by bone fused around the posterior construct; however, the patient remained in a cervical collar as a precautionary measure throughout his ED stay and transfer. It is possible that other presentations of expectorated hardware, particularly those that occur more quickly after an initial surgery, would not be as fortunate to have this degree of clinical stability.
Regarding initial clinical investigation and treatment in the ED setting, it is important to assess for secondary complications of pharyngoesophageal injury to include aspiration pneumonia, esophageal rupture, spinal osteomyelitis, and mediastinitis. This can reasonably and expeditiously be accomplished with CT studies, ideally with intravenous contrast if not contraindicated. As demonstrated in the case of this patient whose operative cultures were growing both common oral flora as well as fungus, emergency physicians should retain a low threshold to initiate broad-spectrum antimicrobial coverage targeting both bacterial and fungal pathogens. Fistula formation puts the patient at high risk for development of mediastinitis; It is clinically remarkable that the patient was well appearing at the time of presentation. Similarly, concerns for fistula formation should prompt consultation with the appropriate surgical services to discuss direct visualization, advanced imaging, and expeditious surgical repair in a timely fashion.
This case report highlights important limitations in evaluation of delayed post-operative complications and pharyngeal fistulas in the ED. As previously noted, lack of familiarity with this complication by triage staff led to the patient being initially mis-triaged to a behavioural care area. Further, resources in community EDs may limit the ability to directly visualize pharyngeal fistulas if the necessary scope equipment is not readily available. Further, transfers of patients away from their local setting may lead to difficulties for the patient attending future specialist follow-up appointments. It may be helpful to engage social work and attempt to schedule follow-up appointments for multiple specialties for patients that are required to travel a significant distance from their local center for care.
Conclusions
Anterior cervical fusion surgeries, while common, are not without complications. Fistulas resulting from hardware migration necessitate prompt identification and treatment for potential further complications such as mediastinitis and cervical spine instability. ED evaluation should focus on prompt immobilization of the patient’s cervical spine, appropriate antimicrobial coverage for mediastinitis, and consultation with the appropriate surgical specialties to facilitate definitive care of the patient. Further, clinicians should be mindful of potential triage biases introduced when patients are roomed into psychiatric care areas and maintain a high index of suspicion for organic pathology.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-1-57/rc
Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-1-57/prf
Funding: None.
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2025-1-57/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Sarette P, Motzkus C. Expectoration of cervical spinal fusion hardware following delayed extrusion and pharyngoesophageal fistula formation: a case report. J Emerg Crit Care Med 2026;10:10.
