Posterior hypopharyngeal perforation following two-level anterior cervical discectomy and fusion: illustrative case.

backgroundPosterior hypopharyngeal perforation is a rare yet serious complication of anterior cervical discectomy and fusion (ACDF), especially at upper cervical levels where anatomical relationships are critical. Prompt recognition and tailored management are key to minimizing morbidity and achieving favorable outcomes. OBSERVATIONS: The authors report the case of a 54-year-old man who underwent ACDF at C3-5 for cervical disc prolapse. Within hours postoperatively, he developed a sore throat, hypersalivation, subcutaneous emphysema, and anterior neck swelling. Initial imaging showed emphysema without contrast leakage, prompting empiric conservative management with nothing by mouth, intravenous antibiotics, steroids, and proton pump inhibitor. A contrast-enhanced CT study on day 7 revealed a 5.3 × 4.7-mm (length × thickness) posterior hypopharyngeal fistulous tract with contrast leakage but no collection. The patient improved with nonoperative management and close outpatient follow-up, gaining 2 kg over 4 weeks. Follow-up imaging at week 4 confirmed tract resolution, and oral feeding was reintroduced with progressive dietary advancement. LESSONS: Early hypopharyngeal perforation following ACDF may present subtly. High clinical suspicion, even in the absence of early imaging findings, is essential. Contained injuries without systemic deterioration may be successfully treated with conservative therapy, including nutritional support and imaging-guided follow-up. This case underscores the importance of vigilance and individualized management. https://thejns.org/doi/10.3171/CASE25513.