Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spinal procedures in neurosurgery. Though rare, complications related to ACDF are not uncommon. Hematoma, dural injury, postoperative dysphagia, esophageal, pharyngeal injury, and Horner’s syndrome are few of the complications described in the literature [1],[2],[3],[4]. One of the grave complications associated with ACDF surgery is the extrusion of the implant through the operative site or through mouth. To the best of our knowledge, only one case of expectoration of implant construct through mouth after a bout of cough has been reported till date.

A 37-year-old young man presented to our OPD with complaint of expectoration of an anterior cervical plating and two screws (Figure 1A and Figure 1B) 7 days back. The patient had history of operated for C3-4 and C4-5 ACDF approximately 15 years back at some other hospital for cervical spine trauma. At presentation he was completely normal without any history of dysphagia, choking, aspiration pneumonitis, or fever. We advised an esophagus copy and bronchoscopy to look for the site of perforation but the patient denied as he was absolutely fine; however, we ask the patient to remain in follow-up regularly. A cervical spine X-ray done two years back (Figure 1C and Figure 1D) suggestive of upward migration of implant with two missing screws. We advised an X-ray cervical spine which suggestive of good fusion from C3 to C5 without any implant in situ (Figure 1E and Figure 1F).

Anterior cervical discectomy and fusion is one of the most frequently performed spinal procedures. Although rare, postoperative complications after ACDF are not inevitable. Esophageal tear can occur after ACDF surgery and migration of implant construct through this tear into the gastrointestinal tract have been reported previously by various authors [2],[5],[6],[7]. Pharyngeal perforation after ACDF is an extremely rare condition and only few cases have been reported in the literature till date [8]. It can happen either due to direct injury during surgery or many days after surgery with a very low reported incidence rate of 0.25–1.49% [9],[10]. They may have a benign course or may land up in fatal outcome, so early diagnosis of such cases and prompt management may save lives. Various factors may be responsible for those cases of implant extrusions but one of the most common predisposing factor for this complication is (after a close study of all the reported cases in literature) malpositioned implant during surgery [2],[5],[6],[7]. This is a rare and one of its kind of case report where the implant construct with two previously missing screws coughed out after 15 years of surgery and on follow-up patient was absolutely fine. According to the existing literatures each and every case is separate and is treated accordingly but the most important thing to keep in mind for avoiding such complications in future is the proper position of implant with good purchase of screws during the surgery.

Cough out implant after many years of surgery is a rare, but possible complication. Proper positioning of the implant construct with good purchasing of screws into the bone is the most important step to be kept in mind during surgery.