A loose screw or two

In May, 2010, a 65-year-old woman presented to our department holding a couple of screws that she had spat out the day before, without any history or recollection of swallowing them. She had no dysphagia or pain. Physical and neurological examinations were normal. She had a 30-year medical history of rheumatoid arthritis, which had resulted in a craniocervical fusion 23 years earlier due to instability of the atlantoaxial segment. On admission, plain radiographs of the cervical spine showed a stable cerclage of the vertebral arches of C1/C2 with normal range of movement in fl exion-extension fi lms (fi gure C). When we compared her radiographs with those taken postoperatively, we were surprised to see additional ventral plating from the clivus to the upper cervical spine (fi gure A). Abdominal radiography and CT showed an osteosynthesis plate and a screw in the right lower abdomen—the missing plate (fi gure D). On laryngoscopy, a small fi brin-coated mucosal dehiscence was detected in the upper pharynx. The edges of the defect were clean, and secondary healing had begun. No further mucosal defects were seen at gastroduoden oscopy. Despite intensifi ed prokinetic therapy, the plate remained stuck in the colon and it was eventually removed by colonoscopy (fi gure B). Our patient was discharged after an uneventful recovery. On follow-up laryngoscopy 3 months later, the mucosal defect of the pharynx had healed completely, and when last seen in August, 2010, she was doing well. Rheumatoid arthritis is a chronic, systemic infl ammatory disorder that aff ects mainly synovial joints. The development of pannus as a secondary hyperplasia of synovial cells, following the infl ammatory response of the synovial joint, leads to progressive destruction of the aff ected joints. At the craniocervical junction, the erosion of the odontoid process of the axis and the transverse ligament leads to atlantoaxial subluxation, which necessitates stabilisation of the aff ected segment, and sometimes resection of the dens axis and craniocervical stabilisation. Loosening of osteosynthesis materials and oesophageal perforations, mainly after surgery of the mid to lower anterior spine have been reported previously. The incidence of this complication is up to 1·49% with an associated mortality rate for oesophageal perforations up to 6% estimated from published data. Predisposing factors are initial malpositioning and subsequent loosening of the screws or plate, or infl ammatory processes around the osteosynthesis. In our patient, infl ammation due to rheumatoid arthritis might be the reason for the delayed loosening and migration of the plate. Perforation of cervical plates and screws into the oesophagus can lead to fi stulas or upper-airway obstruction. The clinical presentation may include coughing, odynophagia or dysphagia, cervical swelling, fever, and subcutaneous emphysema, or asympto matic presentation as in our patient. In patients with chronic infl ammatory disorders, special attention should be given to osteosynthetic joints, because rheumatoid arthritis can lead to loosening and migration of the implants, even after decades. Regular follow-up including radiographs of the aff ected joints is recommended, and special attention has to be given to the occurrence of any of the symptoms mentioned above. In the event of loosening or migration of osteosynthetic materials, a multi-disciplinary approach is recommended.