The insane path of two cervical intervertebral implants: late migration, esophageal ingrowth, and rectal excretion: an exceptional case report

Introduction

Motion preserving artificial cervical disc arthroplasty (ACDA) has been shown to be an effective and safe alternative to fusion in the cervical spine (1). Notably, there is no increased risk of postoperative dysphagia compared to anterior cervical dissection and fusion (ACDF) surgery. Since surgical access is mostly identical to ACDF there is no significant difference between the two treatment options regarding access-related complications (2). Implant migration in cervical disc arthroplasty is rare, in the area of about 0.3% (3). The disappearance of two cervical disc replacements, 10 years after surgery, has never been reported before (4). To our knowledge, the only ever-reported migration and presumed rectal excretion of cervical implants were about a cervical plate and screws (5,6). We present this case in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-23/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 Helsinki Declaration (as revised in 2013). 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 69-year-old male patient underwent a two-level ACDA (BRYAN© Cervical Disc, Medtronic, Dublin, Ireland) at C5/6 and C6/7 in the year 2008 due to chronic neck pain and bilateral upper extremity radiculopathy with numbness and muscle weakness.

No complications were reported intra- and postoperative. Postoperative X-rays showed proper fit and articulation of both cervical artificial discs as well as intact endplates with proper alignment of the posterior edges of the vertebral bodies (Figure 1). Postoperatively, the patient experienced major symptomatic improvement with a nearly complete pain reduction and completely regained sensomotoric functions.

Figure 1 Postoperative X-rays with proper fit and articulation of both cervical artificial discs as well as intact endplates with proper alignment of the posterior edges of the vertebral bodies. L: left side; Reklination: standing upright position in reclination; 20: non-relevant system-related markings.

In the year 2019, approximately 11 years after surgery, he experienced a sore throat, hoarseness, irritant coughing, and globus sensation for 6 months. An ear, nose, and throat (ENT) specialist diagnosed chronic laryngitis and treated the patient with systemic corticosteroids, which provided major relief.

In 2022, the patient’s family doctor referred him to a rheumatologist due to chronic myofascial pain in both legs. A magnet resonance imaging (MRI) of the cervical spine revealed ventral migration of a Bryan Disc, with the second one not visible in the cervical nor the thoracic spine MRI. A computer tomography (CT) scan of the neck, thorax, and abdomen (Figure 2: CT scout view), as well as an X-ray of the cervical spine (Figure 3), was obtained. Nevertheless, the second Bryan disc could still not be found. There was no malalignment of the cervical spine with a solid lateral fusion between C5 and C7.

Figure 2 CT scan scout view of the neck, thorax, and abdomen showing the absence of one of the two Bryan discs. H: non-relevant system-related markings. CT, computer tomography.

Figure 3 X-rays of the neck showing the absence of one of the two Bryan discs. There was no malalignment of the cervical spine with a solid lateral fusion between C5 and C7. R: right side; H and F: non-relevant system-related markings.

The attending rheumatologist referred the patient to our spine center, where the patient reported renewed episodes of hoarseness and globus sensation, similar to the symptoms in 2019. An ENT consultation was already planned. He presented with significantly restricted cervical spine movement in all directions, especially in inclination and rotation. Lateral tilt was almost abolished. However, there were no signs of cervical myelopathy or upper extremity radiculopathy nor was there a motor weakness in the upper extremity.

At first, the patient could not think of any cause that could have led to the migration of the BRYAN © Cervical Disc. However, he later recalled having experienced a bicycle accident in 2018 in which he had fallen on his forehead. Apart from a slight headache in the evening, he did not notice any consequences of the fall and therefore did not seek medical care.

We obtained an X-ray of the pelvis and lower extremities to rule out all possibilities of the dislocated disc. The second cervical artificial disc could not be found. During the first episode of chronic laryngitis, the patient did not recall coughing up or rectally excreting a disc prosthesis. Moreover, he had not vomited for several years.

We decided to surgically remove the second displaced artificial disc. Due to its retropharyngeal location with potential adhesions, an ENT surgeon was consulted. Surgery was planned to be performed endoscopic transoral with laser opening of the posterior pharyngeal wall and prosthesis removal. If this were not successful, the transcervical approach could be performed under the same anesthesia.

A CT scan of the cervical spine taken 3 months prior to surgery revealed that the remaining BRYAN © Cervical Disc was situated behind the larynx and in front of the lower C7. To confirm this, laryngoscopy was conducted by the ENT specialist and no signs of inflammation or perforation in the laryngeal or esophageal structures were observed, nor were there any indications of earlier perforations. However, it is suspected that the first cervical artificial disc may have perforated the esophagus many months ago, resulting in a small scar that was not visible during endoscopy. The precise location of the remaining cervical artificial disc could not be determined, leading to the decision to pursue an open approach during the laryngoscopy. Due to the disc’s anterior position relative to the cervical spine, anterolateral cervical access for segment C7/Th1 was selected. Even after extensive preparation and meticulous palpation, the dislocated remaining cervical artificial disc could not be found. Intraoperative fluoroscopy surprisingly showed no remaining BRYAN © Cervical Disc. Accordingly, surgery was aborted, and a postoperative CT scan was performed (Figure 4: CT scout view) which now showed no Bryan Cervical Disc at all. As shown in the midline sagittal CT images (Figure 5) a partial fusion of the affected segments has already taken place. Complete fusion could not yet be seen.

Figure 4 Postoperative CT scan scout views of the neck, thorax, and abdomen showing no Bryan Cervical Disc at all. CT, computer tomography.

Figure 5 Postoperative midline sagittal CT scan images showing partial fusion of the affected segments. Complete fusion could not yet be seen. CT, computer tomography.

The patient remained stable throughout the rest of his recovery and was able to be discharged home on the first day after the surgery.

During the 6-week follow-up examination, the patient reported initial dysphagia, which completely resolved after a few days.

The latest follow-up examination was performed 6 months after surgery. The patient presented free of any cervical issues and has no complaints currently. Furthermore, a control X-ray of the cervical spine was obtained (Figure 6) which showed no foraminal narrowing as well as preserved alignment in the cervical spine, cranio-cervical, and cervicothoracic transition. As the patient was free of any symptoms, no further CT imaging was performed.

Figure 6 Follow-up X-ray 6 months after surgery of the cervical spine showing no foraminal narrowing as well as preserved alignment in the cervical spine, cranio-cervical, and cervicothoracic transition. L: left side; stehend: standing upright position.

Discussion

This case report describes a very rare complication of cervical disc replacement surgery—the disappearance of not only one but two BRYAN © Cervical Disc.

The patient underwent a two-level artificial disc replacement surgery in 2008, which led to major relief of neck pain and radiculopathy. However, 11 years after surgery he presented with chronic laryngitis, which was later found to be caused by the migration of one of the two cervical artificial discs. The patient recalled having a bicycle fall in 2018 which may have caused the migration.

It’s important to note that the migration occurred several years after surgery and there were no prior clinical signs indicating instability or migration, which highlights the need for long-term follow-up and monitoring of patients who undergo spinal surgeries, especially where disc prostheses are implanted.

The patient’s case required a multidisciplinary approach with an ENT and spinal surgery specialist. The decision to surgically remove the remaining cervical artificial disc was made because of the assumed risk of further migration or esophageal ingrowth, which always involves the risk of infection. Intraoperative fluoroscopy surprisingly showed no remaining BRYAN © Cervical Disc, and the surgery was aborted.

The postoperative course was uneventful. The patient reported complete resolution of cervical issues and no complaints during the 6-week follow-up examination.

This case highlights the importance of considering the possibility of migration of an artificial disc in patients who have undergone cervical disc replacement surgery, even if it has been years since the surgery. In particular, patients presenting with symptoms of hoarseness, dysphagia, or globus sensation and a history of cervical disc replacement surgery should receive at least one low-threshold conventional X-ray of the affected segments.

Conclusions

In conclusion, the management of complications such as disc migration after cervical disc replacement surgery might require a multidisciplinary approach and careful consideration of the patient’s individual circumstances. This case report serves as a reminder of the need for ongoing surveillance and follow-up after spinal surgeries to ensure optimal outcomes for patients.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-23/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-23/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-23/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 Helsinki Declaration (as revised in 2013). 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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