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The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking. To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS. Systematic review and meta-analysis. Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence. The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=−0.31 [−3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= −3.30 [−8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=−2.94 days [−3.83, −2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=−0.69 days [−1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups. The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate. [ABSTRACT FROM AUTHOR]

Affective disorders, including depression and anxiety disorders, are becoming more prevalent among the general population and patients. The objective of this study was to examine the association between affective disorders and outcome measures in patients undergoing elective lumbar spinal fusion. A retrospective cohort study was conducted using the National Inpatient Sample database. Patients who underwent lumbar fusions between 2011-2018. Hospital charges, length of hospital stay, postoperatrive compliations. Patients were stratified into two groups: (1) with affective disorder and (2) without affective disorder. Propensity score matching was utilized to minimize effect of confounding variables. A total of 255,875 cases of lumbar fusions met inclusion criteria. A total of 25,843 (10.1%) patients carried the diagnosis of affective disorder and were significantly more likely to be non-White (45.1% vs 19.9%) and of older age group (59.2 vs 49.9 years) as compared to patients without affective disorders. Patients with affective disorder had longer hospital stay (6.1 vs 3.1 days) as well as increased hospital charges ($88,819 vs $78,650), (P <0.001). No difference was observed in the rates of postoperative complications or short-term mortality between the two groups. Our study found that affective disorders were significantly associated with increased length of hospital stay as well as increased total hospital charges in patients undergoing elective lumbar spinal fusion. Future studies are encouraged to further investigate the feasibility of perioperative screening and for affective disorders and addressing them accordingly. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Lung cancer's propensity for spinal metastasis significantly impacts morbidity and mortality. The role of somatic mutations in determining the prognosis of these metastases is crucial for treatment optimization. To assess how somatic mutations affect survival and neurological outcomes in lung cancer patients with spinal metastases. A retrospective analysis was performed on 76 lung cancer patients at Johns Hopkins from 2013 to 2023 with spinal metastases to evaluate the impact of specific mutations and targeted therapy on prognosis. Inclusion criteria were based on a diagnosis of lung cancer with spinal metastasis and available genetic profiling data. The study focused on the correlation between survival and mutation status, the efficacy of targeted therapy, and postoperative neurological recovery. Data on demographics, tumor biomarkers, treatment modalities, and outcomes were collected and analyzed for each patient. In our study, 76 patients were analyzed, 95% with non-small-cell lung cancer (NSCLC), predominantly adenocarcinoma (83%). Genetic sequencing and immunohistochemical staining identified 61 unique biomarkers. EGFR mutations correlated with a notable increase in median overall survival (MOS) to 3.40 years from 1.39 years (p=0.014). KRAS+ patients had a significantly lower MOS at 0.71 years, compared to 2.60 years for those without KRAS mutations (p=0.03). Napsin A expression was associated with a substantial improvement in MOS to 5.41 years from 1.39 years (p=0.01), underscoring its prognostic value. The application of targeted therapy resulted in a MOS of 3.40 years, significantly better than 1.28 years observed without such treatment (p<0.01), indicating its efficacy in NSCLC management. Given that 95% of our study cohort were diagnosed with NSCLC, the observed improvement in MOS with targeted therapy primarily reflects outcomes in this population. Furthermore, Napsin A positively influenced postoperative neurological outcomes, as evidenced by improved Frankel scores (p=0.001), suggesting a role in patient recovery. In survival analysis, the overall median survival was 1.35 years (IQR 3.60 years), with the median time to first metastasis at 1.00 year (IQR 2.31 years) from diagnosis. The median time to spinal metastasis closely followed at 0.97 years (IQR 2.40 years), demonstrating the aggressive nature of NSCLC with spinal involvement. No significant difference was noted between the timing of the first and spinal metastases (p=0.71), nor between the median survival times post-first and spinal metastases (p=0.32). Accelerated Failure Time Model (AFT) analysis revealed immunotherapy (TR=2.15, p=0.007) and targeted therapy (TR=2.20, p=0.001) significantly improved survival, while radiotherapy to spinal metastasis was negatively associated with it (TR=0.46, p=0.015). Somatic mutations, especially EGFR, KRAS, and Napsin A, markedly influence survival in lung cancer patients with spinal metastases. Napsin A and targeted therapy were associated with better patient outcomes, underscoring the need for personalized treatment strategies to improve survival and neurological function. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population. [ABSTRACT FROM AUTHOR]

Background Context: Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied.Purpose: To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States.Study Design/setting: A retrospective observational study.Patient Sample: Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019.Outcome Measures: The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019.Methods: Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006.Results: We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p<.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p<.001), and to have lower BMI (27.8 vs 31.5 kg/m2; p<.001), outpatient admission status (10.8% vs 4.0%; p<.001), and fewer bleeding disorders (0.0% vs 1.2%; p<.001). The proportion of non-GA spine operations increased from nearly 0% in 2005 to 2.1% in 2019. The increase in non-GA operations was statistically significant in cervical (0.0%-1.1%) and lumbar (0.0%-2.9%) operations. For non-GA lumbar operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (19.1%-5.4%, p<.05; 5.9%-2.8%, p<.05; 30.9 hours-24.9 hours, p<.05, respectively). Similarly, for non-GA cervical operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (20.1%-6.1%, p<.05; 6.7%-3.7%, p<.05; 27.0-20.0 hours p<.05, respectively).Conclusions: Our trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery. [ABSTRACT FROM AUTHOR]

Spinal cord injury (SCI) is a devastating condition that affects about 17,000 individuals every year in the United States, with approximately 294,000 people living with the ramifications of the initial injury. After the initial primary injury, SCI has a secondary phase during which the spinal cord sustains further injury due to ischemia, excitotoxicity, immune-mediated damage, mitochondrial dysfunction, apoptosis, and oxidative stress. The multifaceted injury progression process requires a sophisticated injury-monitoring technique for an accurate assessment of SCI patients. In this narrative review, we discuss SCI monitoring modalities, including pressure probes and catheters, micro dialysis, electrophysiologic measures, biomarkers, and imaging studies. The optimal next-generation injury monitoring setup should include multiple modalities and should integrate the data to produce a final simplified assessment of the injury and determine markers of intervention to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: C5 palsy affects approximately 5% to 10% of patients undergoing cervical spine surgery. It has a significant negative impact on patient quality-of-life outcomes and healthcare costs. Although >80% of patients improve, some are left with persistent, debilitating deficits. Our objective was to examine if electrodiagnostic testing could be used to successfully identify patients likely to experience complete, partial, and no recovery.Methods: Patients undergoing posterior cervical decompression and fusion at a single institution over a 10-year period were identified. Those experiencing postoperative C5 palsy were included. Outcomes examined included motor recovery of the affected deltoid as a function of time, and changes in electrodiagnostic testing as a function of time since injury. Electrodiagnostic testing included electromyography and was sub-analyzed by time of acquisition postinjury. Deltoid strength was graded on manual motor testing using the 5-point medical research council grading system.Results: Of 77 patients experiencing C5 palsy, 29 had postoperative electrodiagnostic testing. Patients experiencing complete recovery on average achieved functional (4/5) strength by 6-weeks post injury and 4+ per 5 strength by 6-months. Those experiencing partial recovery only achieved antigravity strength (3/5) by 6-weeks and low-function (4-/5) strength by 6-months. Electrodiagnostic testing performed 6-weeks to 6-months postinjury demonstrated that those experiencing complete recovery were more likely to have normal motor unit (MU) recruitment than those experiencing partial (p<.001) or no recovery (p=.008). The presence of ≥2+ fibrillation on tests acquired ≤6-weeks of injury identified patients unlikely to experience any recovery with a positive predictive value (PPV) of 88.9%. The presence of normal MU recruitment on tests acquired 6-weeks to 6-months postinjury identified patients likely to experience complete recovery with a PPV of 87.5%.Conclusions: Electrodiagnostic testing may be a valuable means of differentiating between patients with C5 palsy likely to experience complete, partial, or no recovery. Testing between 6-weeks and 6-months post onset may aid in identifying those least likely to have a complete recovery. No MUs at 4 to 6-months, or reduced units with strength that is not improving, portends a poor long-term outcome. In this population, peripheral nerve transfers may be considered sooner. [ABSTRACT FROM AUTHOR]

Background Context: Following spine surgery, delays in referral to rehabilitation facilities leads to increased length of hospital stay (LOS), increases costs, more risk of hospital acquired complications, and decreased patient satisfaction.Purpose: We sought to create a prediction calculator to determine the expected LOS after spine surgery and identify patients most likely to need postoperative nonhome discharge. The goal would be to facilitate earlier referral to rehabilitation and thereby ultimately shorten LOS, reduce costs, and improve patient satisfaction.Study Design: Retrospective.Patient Sample: We retrospectively reviewed all adult patients who underwent spine surgery for all indications between January and June 2018.Outcome Measures: Length of stay and discharge disposition.Methods: Demographic variables, insurance status, baseline comorbidities, narcotic use, operative characteristics, as well as postoperative length of stay and discharge disposition data were collected. Univariable and multivariable analyses were performed to identify independent predictors of LOS and discharge disposition.Results: Two hundred fifty-seven patients were included. Mean age was 59 years, 46% were females, and 52% had private insurance vs 7% with Medicaid and 41% with Medicare. The most commonly performed procedure was lumbar fusion (31.9%). Mean LOS after surgery was 4.8 days and 18% had prolonged LOS >7 days. Age, insurance type, marriage status, and surgical procedure were significantly associated with LOS and discharge disposition. The final model had an area under the curve of 89% with good discrimination. A web based calculator was developed: https://jhuspine1.shinyapps.io/RehabLOS/ CONCLUSIONS: This study established a novel pilot calculator to identify those patients most likely to be discharged to rehabilitation facilities and to predict LOS after spine surgery. Our calculator had a high predictive accuracy of 89% compared to others in the literature. With validation this tool may ultimately facilitate streamlining of the postoperative period to shorten LOS, optimize resource utilization, and improve patient care. [ABSTRACT FROM AUTHOR]

Background Context: Cervical spondylosis may lead to spinal cord compression, poor vascular perfusion, and ultimately, cervical myelopathy. Studies suggest a neuroprotective effect of renin-angiotensin system (RAS) inhibitors in the brain, but limited data exist regarding their impact on the spinal cord.Purpose: To investigate whether RAS blockers and other antihypertensive drugs are correlated with preoperative functional status and imaging markers of cord compression in patients with symptomatic cervical spondylosis.Study Design: Retrospective observational study.Patient Sample: Individuals with symptomatic degenerative cervical stenosis who underwent surgery.Outcome Measures: Imaging features of spinal cord compression and functional status (modified Japanese Orthopedic Association [mJOA] and Nurick grading scales).Methods: Two hundred sixty-six operative patients with symptomatic degenerative cervical stenosis were included. Demographic data, comorbidities, antihypertensive medications, and functional status (including mJOA and Nurick grading scales) were collected. We evaluated canal compromise, cord compromise, surface area of T2 signal cord change, and pixel intensity of signal cord change compared with normal cord on T2-weighted magnetic resonance imaging sequences.Results: Of 266 patients, 41.7% were women, 58.3% were men; median age was 57.2 years; 20.6% smoked tobacco; 24.7% had diabetes mellitus. One hundred forty-nine patients (55.8%) had hypertension, 142 (95.3%) of these were taking antihypertensive medications (37 angiotensin-II receptor blockers [ARBs], 44 angiotensin-converting enzyme inhibitors, and 61 other medications). Patients treated with ARBs displayed a higher signal intensity ratio (ie, less signal intensity change in the compressed cord area) compared with untreated patients without hypertension (p=.004). Patients with hypertension had worse preoperative mJOA and Nurick scores than those without (p<.001). In the multivariate analysis, ARBs remained an independent beneficial factor for lower signal intensity change (p=.04), whereas hypertension remained a risk factor for worse preoperative neurological status (p<.01).Conclusions: In our study, patients with hypertension who were treated with RAS inhibitors had decreased T2-weighted signal intensity change than untreated patients without hypertension. Patients with hypertension also had worse preoperative functional status. Prospective case-control studies may deepen understanding of RAS modulators in the imaging and functional status of chronic spinal cord compression. [ABSTRACT FROM AUTHOR]

Background: Of the more than 30,000 posterior cervical spine fusions performed annually, 7%-12% will be complicated by postoperative C5 palsy, a condition characterized by new-onset deltoid weakness with or without C5 dermatomal findings and biceps weakness. Posterior translation of the cervical spinal cord has been proposed as a risk factor for this complication.Purpose: To evaluate if C5 palsy can be predicted by spinal cord float back.Study Design/setting: Retrospective cohort.Patient Sample: Patients ≥18 years of age undergoing posterior cervical decompression between 2002 and 2017 for degenerative cervical spine pathologies.Outcome Measures: Occurrence of C5 palsy as evaluated by manual motor testing (MMT).Methods: We recorded baseline neurological status, operative notes, details of postoperative course, and both pre- and postoperative magnetic resonance imaging images. Float back was defined by the change in the distance between the spinal cord and posterior face of the C4/5 annulus from preoperative to postoperative imaging. C5 palsy was defined by new-onset deltoid weakness on MMT.Results: We identified 242 patients with a mean age of 62.4 years and mean follow-up of 27.9 months. Forty-two (17.4%) experienced postoperative C5 palsy. On univariable analysis, significant predictors of postoperative C5 palsy were mean C4/5 foraminal diameter (2.8 vs. 3.2 mm; p<.001), anterior projection of the C5 superior articular process (4.12 vs. 3.70 mm; p=.04), cord float back (0.35 vs. 0.28 cm; p=.02), undergoing laminectomy of the C5 (p=.02) or C4 and C5 levels (p=.02), and undergoing instrumented fusion extending one level above and below the C4/5 level. Foraminotomy of the C4/5 level was not predictive of postoperative palsy. On multivariable analysis mean C4/5 foraminal diameter (odds ratio=0.38 per mm; p<.01) predicted C5 palsy; cord float back at the C4/5 level was not predictive of C5 palsy.Conclusions: Spinal cord float back was not an independent predictor of C5 palsy on multivariable analysis. Only smaller foraminal diameter was independently predictive of postoperative C5 palsy. This suggests that chronic preoperative compression of the C5 roots, not postdecompression float back may be the biggest contributor to the etiology of postoperative C5 palsy. [ABSTRACT FROM AUTHOR]

Background Context: Recently, preclinical and clinical studies suggest an association between renin-angiotensin system (RAS) blockers and bone healing, particularly in the context of osteoporotic bone fractures.Purpose: To determine the correlation between the use of RAS inhibitors and fusion outcomes and neurologic status in anterior cervical discectomy and fusion (ACDF) surgery.Study Design: Retrospective observational study.Patient Sample: Patients who underwent ACDF for degenerative disorders.Outcome Measures: Spinal fusion status and neurologic function (modified Japanese Orthopedic Association [mJOA] and Nurick grading scales).Methods: A retrospective chart review was performed, including 200 patients who underwent ACDF for degenerative disorders with 1-year minimum follow-up. Demographic data, comorbidities, antihypertensive medication, neurologic examination, and fusion status were collected. Spinal fusion was assessed via plain cervical x-ray, resorting to dynamic radiographs and/or computer tomography (CT) in cases of uncertainty. Preoperative mJOA and Nurick scores and recovery rates were calculated to determine neurologic status.Results: Of the 200 patients (42.5% females, 57.5% males, median age of 53.7 years), 82 hypertensive patients were identified. Seventy-seven (93.9%) were taking antihypertensive medication as follows: 36.4% angiotensin-II receptor blockers (ARBs), 35.1% angiotensin-converting enzyme inhibitors (ACEIs), and the remaining patients were taking other medication. In the analysis of fusion rates, patients treated with ARBs exhibited a higher fusion rate, while those treated with ACEIs displayed a lower fusion rate compared to untreated nonhypertensive patients (p = .04 and .02, respectively). The difference in fusion rates between ARBs and ACEIs was also significant, with the former displaying higher rates (p < .001). Smoking exhibited a negative correlation with spinal fusion (p < .001). In the multivariate analysis, ARBs remained an independent factor for successful fusion (p = .02), while smoking remained a risk factor for failed fusion (p = .002). In the neurologic examination, ACEIs, hypertension status, and older age correlated with lower modified Japanese Orthopedic Association (mJOA) recovery rates (p = .001, <.001, and <.001, respectively) in the univariate analysis.Conclusions: In ACDF patients, we observed that ARBs were associated with higher fusion rates. Conversely, ACEIs and smoking were related to failed fusion. Prospective case-control studies are needed to confirm these RAS inhibitors effects on spinal fusion. [ABSTRACT FROM AUTHOR]

Suboptimal placement of pedicle screws may lead to neurovascular complications, pseudarthrosis, postoperative pain and the need for revision surgery. The objective of this study was to investigatethe accuracy of pedicle screw placement by freehand technique and to compare revision surgery rates among three different imaging verification pathways. Retrospective observational study. Adult patients who underwent freehand pedicle screw placement in the thoracic, lumbar or sacral levels in a single-institution between January 1, 2016, and June 30, 2020. The proportion of malpositioned screws defined as grades C-E on the Gertzbein-Robbins grading system and the number of patients requiring an additional revision surgery for screw malposition. Patients were stratified into three cohorts based on the intraoperative imaging modality used to assess the accuracy of screw position: intraoperative x-rays (cohort 1); intraoperative O-arm (cohort 2); or intraoperative computed tomographic (CT) scan (cohort 3). Postoperative CT scans were performed on all patients in cohorts 1 and 2. Postoperative CT scan was not required in cohort 3. A total of 9,179 pedicle screws were placed in the thoracic or lumbosacral spine in 1,311 patients. Of these, 210 (2.3%) screws were identified as Gertzbein-Robbins grades C-E on intra/postoperative CT scan; 137 thoracic screws and 73 lumbar screws (P< 0.001). A total of 409 patients underwent placement of 2,754 screws followed by intraoperative x-ray (cohort 1); 793 patients underwent placement of 5,587 screws followed by intraoperative O-arm (cohort 2); and 109 patients underwent placement of 838 screws followed by intraoperative CT scan (cohort 3). Postoperative CT scans identified 65 (2.4%) and 127 (2.3%) malpositioned screws in cohorts 1 and 2, respectively. Eleven screws (0.12%) were significantly malpositioned and required a second operation for screw revision. Nine patients (0.69%) required revision operations: 8 of these patients were from cohort 1 and one patient was from cohort 2. In cohort 3, 18 of 838 (2.1%) screws were identified as malpositioned by intraoperative CT-scan: 2 of these screws were revised intraoperatively during index procedure. No revision surgeries took place in this cohort. Freehand pedicle screw placement is safe and effective with a 97.7% accuracy rate (Gertzbein-Robbins grades A or B). Nine patients (0.69%) required screw revision. When compared to intraoperative x-Ray, intraoperative o-arm verification decreased the revision surgery rate for malpositioned screws from 0.37% to 0.02%. In addition, our analysis suggests that the use of intraoperative O-arm can obviate the need for postoperative CT scans. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Abstract: Background context: In vitro nondestructive flexibility testing of the CerviCore total disc replacement (TDR) was performed. It was hypothesized that TDR would not significantly alter biomechanics relative to intact, whereas rigid fixation would cause significant changes. Purpose: To assess the ability of a cervical metal-on-metal saddle-shaped TDR to replicate normal biomechanics in vitro. Study design: Human cadaveric flexibility experiment. Methods: Nine human cadaveric C3–T1 specimens were tested intact, after TDR and after anterior plating. Flexion, extension, lateral bending, and axial rotation were induced by pure moments; flexion-extension was then repeated using a simplified muscle force model with 70-N follower load. Optical markers measured three-dimensional intervertebral motion, and eight points of laminar surface strain were recorded near the left and right C5–C6 facet joints. Biomechanical parameters studied included range of motion (ROM), lax zone (LZ), angular coupling pattern, sagittal instantaneous axis of rotation (IAR), and facet loads normal to the facet joint plane. Mean values of parameters were compared statistically using repeated measures analysis of variance and Holm-Sidak tests. Results: Total disc replacement caused significant reduction in ROM during extension (p=.004) and significant reduction in LZ during lateral bending (p=.01). However, plating significantly reduced both ROM and LZ during flexion, extension, and lateral bending (p<.006). Sagittal IAR shifted relative to intact by 3.6 mm after TDR (p>.05) and 6.5 mm after plating (p>.05). Coupled axial rotation/degree lateral bending was 99% of intact after TDR but 76% of intact after plating (p=.15). Coupled lateral bending/degree axial rotation was 95% of intact after TDR but 85% of intact after plating (p=.43). Neither construct altered facet loads from intact. Conclusions: With regard to ROM, LZ, IAR, and coupling, deviations from intact biomechanics were less substantial after TDR than after plating. Facet load alterations were minimal with either construct. Our results show that this particular TDR permits ROM and maintains some measures of kinematics in a cadaver model. [Copyright &y& Elsevier]

Abstract: Background context: In recent years, the number of complex spinal surgeries has increased significantly in the elderly population, where the prevalence of low bone density is highest. Consequently, spine surgeons often treat osteoporotic patients who are associated with higher rates of instrumentation failure. Therefore, establishing a successful fusion requires an appropriate substrate for bone formation and local bone remodeling. The fusion process can be supported by therapies that seek to shift the balance of bone homeostasis to increased formation and reduced resorption. Purpose: Thorough understanding of the physiology of bone formation and adjunctive therapies can help improve fusion rates. Therefore, we present a thorough review of the latest pharmacologic agents used to enhance bone strength and surgical spinal fusion. Methods: Systematic review of literature. Results: Current knowledge on bone physiology has led to the development of several pharmacologic agents that enhance bone formation and strengthen the human skeleton. At present, natural supplements of vitamin D and calcium or synthetic medications like bisphosphonates are widely used before and after spine surgeries to enhance bone fusion. Additional physiologic agents, including testosterone, parathyroid hormone, calcitonin, and growth hormone, have been shown to improve bone mass density or spinal fusion in both animal and human studies. As in other medical fields, gene therapy has shown viability and promise with the use of both viral and nonviral vectors. Conclusions: Through the understanding of bone physiology, numerous natural and synthetic pharmacologic agents have been developed to enhance the body's skeleton and to improve outcomes of spinal fusion surgery. [Copyright &y& Elsevier]

Abstract: Background context: Ewing''s sarcoma is the most common childhood malignancy of bone, but it rarely occurs as a primary extraosseous epidural tumor. Purpose: To heighten awareness and treatment options of this rare (epidural) presentation of Ewing''s sarcoma. Study design: Case report. Methods: Retrospective review. Results: We present a 13-year-old boy with progressive low back and bilateral lower extremity pain and normal neurologic examination. Magnetic resonance imaging showed an extradural tumor in the dorsal epidural space from T11 to L1. He underwent a posterior laminoplasty and gross total resection of tumor; histopathological diagnosis was consistent with Ewing''s sarcoma. After surgery, the patient underwent adjuvant chemotherapy and irradiation. At 10 months follow-up, the patient is neurologically intact without evidence of residual disease. Conclusions: Ewing''s sarcoma of the epidural space should be considered in the differential diagnosis of epidural mass lesions. Because wide surgical margins cannot be obtained, close follow-up with a low threshold for reoperation is mandatory. [Copyright &y& Elsevier]

Comparative effectiveness research has a vital role in health reform and policies. Specialty training is one of these provider-side variables and surgeons who were trained in different specialties may have different outcomes upon performing the same procedure. To investigate the impact of spine surgeon specialty on early perioperative outcome of anterior cervical discectomy and fusion (ACDF). Retrospective, 1:1 propensity score-matched cohort study. A total of 21,211 patients who underwent ACDF between 2016-2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Outcomes included 30-day perioperative morbidity and mortality measures that are predefined in the ACS-NSQIP database. Patients were stratified by the specialty of surgeon performing the procedure (neurosurgery vs orthopedic surgery), and the number of levels operated on (single- vs multi-level surgery) Patients operated on by neurosurgeons were more likely to be older, smokers, of Hispanic ethnicity, functionally dependent, and to have higher BMI, an ASA class 3 or more, baseline dyspnea, bleeding disorders, and myelopathy. In both groups (single/multi-level ACDF), cases in the orthopedic surgery cohort were more likely to have shorter operation time (104 vs 133 minutes/ 138 vs 164 minutes), longer total hospital stay (41 vs 24 hours/ 46 vs 25 hours), higher return to operating room rates within the same admission (2.1% vs 0.7%/ 2.4% vs 0.6%), be discharged to destination other than home (4.6% vs 1.2%/ 4.9% vs 1.0%), be discharged after postoperative day 1 (11.9% vs 6.7%/ 18.9% vs 10.1%), higher perioperative blood transfusion rate (2.1% vs 0.4%/ 3.1% vs 0.6%) and higher sepsis rates (0.7% vs 0.2%/ 0.7% vs 0.1%). In the single-level ACDF group, cases in the orthopedic surgery cohort had higher readmission (4.1% vs 1.9%) and unplanned intubation rates (1.1% vs 0.1%). Other outcome measures and mortality rates were similar among the cohorts. Significant differences in early perioperative outcomes of patients undergoing ACDF by neurosurgeons and orthopedic surgeons were noted. These differences have significant clinical and cost implications for patients, physicians, payors and health systems. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Approximately 132,000 patients per year undergo anterior cervical discectomy and fusion (ACDF) in the United States. Although the utilization of instrumentation and bone graft alternatives has enhanced fusion rates, pseudarthrosis remains a problem, with incidence rates up to 56%. Renin-angiotensin system (RAS) modulators are typically used to treat arterial hypertension, which affects 50-80% of spinal fusion patients. Recent evidence suggests an association between RAS blockers and bone metabolism, particularly in the context of bone healing. In addition, preclinical and clinical studies have suggested a potential correlation between the use of RAS blockers and reduced osteoporotic fracture risk. We aimed to determine whether there was a correlation between the use of antihypertensive medication, particularly angiotensin-II type-1 receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs), and outcomes in anterior cervical discectomy and fusion (ACDF) surgery. Retrospective observational study. Degenerative disc disease patients who underwent ACDF. Spinal fusion status and neurological function (modified Japanese Orthopaedic Association [mJOA] and Nurick grading scales. A cohort of adult patients with symptomatic cervical degenerative disc disease who were operated upon using an allograft implant, and with a 1-year minimum follow-up was considered eligible. Information on demographic data, comorbidities (especially hypertension status), antihypertensive medication, neurological examination and fusion status were collected. Fusion criteria in static radiographs were increased opacification and bridging trabecular bone at the margins of the graft. In dynamic radiographs, fusion criteria were interspinous motion of < 1 mm and superjacent interspinous motion of < 4 mm. For CT scans, fusion was defined as solid bridging of bone across the disc space of the intended fusion. A total of 178 patients with cervical degenerative disc disease who underwent ACDF, with a median age of 53.7 (range 24-90) years, were included in the analysis. Median follow-up was 21.7 months. Out of the 82 hypertensive patients who were identified, 77 (93.9%) were taking antihypertensive drugs (28 [36.4%] received ARBs and 27 [35.1%] received ACEIs). The overall pooled fusion rate was 69.5%. Patients treated with ARBs exhibited a higher fusion rate compared to those who were untreated (88.9% vs 69.7%, respectively, p=.04). By contrast, patients treated with ACEIs displayed a lower fusion rate than untreated patients (45.8% vs 69.7%, respectively, p=.02). Comparisons between successful fusion and failed fusion groups identified treatment with ACEIs as risk factors for the development of pseudarthrosis. Treatment with ARBs displayed a trend towards being a favorable factor for fusion (RR=1.2, 95% CI 1.0, 1.5). In the multivariate nominal logistic analysis, ARB (p=.02) treatment remained an independent risk and beneficial factor, respectively, for fusion. In our retrospective study of a cohort of ACDF patients, treatment with ARBs was associated with an increased fusion rate, while treatment with ACEIs identified as risk factor for failed fusion. Further preclinical and clinical studies are needed to verify the beneficial effects of ARBs and deleterious influence of ACEIs on spinal fusion. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Cervical spondylosis may lead to spinal cord compression, poor vascular perfusion, and ultimately cervical myelopathy. The process whereby chronic compression may cause spinal cord damage has not been fully understood. However, multiple mechanisms such as inflammation, apoptosis, and vascular variations, are thought to be responsible for the neuronal loss, axonal degeneration, and myelin impairment seen in cervical spondylotic myelopathy (CSM). Studies reported a beneficial effect of renin-angiotensin system (RAS) blockers in the central nervous system, particularly in brain inflammation and stroke, but data on their influence on the spinal cord are limited. We aimed to determine if RAS blockers are correlated with preoperative functional status and radiological markers of spinal cord damage secondary to compression in patients with CSM. Retrospective cohort study. Symptomatic cervical spondylosis patients. Functional status (including modified Japanese Orthopedic Association [mJOA] and Nurick grading scales) and imaging characteristics (including % maximum canal compromise [MCC], % maximum spinal cord compromise [MSCC], increased signal intensity [ISI], signal intensity ration [SIR] and ISI surface area), all of which were evaluated on midsagittal T2-weighted MRIs. Adults with symptomatic degenerative cervical stenosis patients were included. Demographic data, comorbidities, antihypertensive medications (particularly RAS blockers), and functional status were collected. We assessed % canal compromise, % cord compromise, surface area of T2 signal cord change, and pixel intensity of signal cord change compared to normal cord on T2-weighted MRI sequences. Of the 267 patients, 41.6% were female and 58.1% male; median age of 57.2 years; 20.6% smokers; 24.7% diabetics. One hundred forty-nine patients (55.8%) had hypertension, of which 142 (95.3%) were taking antihypertensive medications: 37 angiotensin-II receptor blockers [ARBs], 44 angiotensin-converting enzyme inhibitors [ACEIs], and 61 other medications). Patients treated with ARBs displayed a higher signal intensity ratio (lower signal intensity change in the compressed cord area) compared to those untreated non-hypertensive patients (p=.004). Hypertensive patients had worse preoperative mJOA and Nurick scores compared to non-hypertensive patients (p<.001). In the multivariate analysis, ARBs remained an independent beneficial factor for lower signal intensity change (p=.04), while hypertension remained a risk factor for worse preoperative neurological status (p<.01), after adjusting for covariables that were significant in the univariate analyses or were considered relevant. In cervical spinal cord compression patients, hypertensive subjects treated with RAS inhibitors were associated with less signal intensity change (higher SIR) than untreated non-hypertensive patients. Also, hypertensive subjects under any antihypertensive medication displayed worse mJOA and Nurick scores compared to untreated non-hypertensive individuals. Further studies are warranted to verify the effect of RAS inhibitors in spinal cord damage. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT With the overall advancement in management of patients with human immunodeficiency virus (HIV) infection/AIDS, especially antiretroviral therapy regimens, HIV infection is now considered as a chronic disease and the longevity of these patients has significantly improved for the last two decades. As such, an increasing number of patients with HIV-infection are now potential candidates for elective surgical procedures such as spine surgery. In 2015, an estimated 1.1million adults and adolescents were living with HIV and 39,782 patients were newly diagnosed with HIV infection annually in 2016 (CDC data). Despite this increasing prevalence and incidence of the disease, the literature regarding clinical outcomes of spine surgery in patients with HIV is surprisingly scarce. As is the same as patients with other concurrent immunocompromising co-morbidities such as steroid use, diabetes mellitus, organ recipients, and/or chemo or radiation therapy, postoperative infection is one of the most concerning complications. Furthermore, bone mineral densities of HIV-infected patients are reported to be lower than noninfected controls, which could have some potential indications for worse long-term outcomes such as pseudoarthrosis. Thus, we aimed to characterize clinical outcomes of spine surgery in patients with HIV infection in order to facilitate judicious patient selection and comprehensive informed consent, which are of paramount importance in surgical decision-making processes for this high-risk cohort. PURPOSE Summarize clinical outcomes of spine surgery in patients with HIV, such as readmission rate, infectious complications, fusion rate, and mortality to address surgical indications for this specific cohort. STUDY DESIGN/SETTING Retrospective, single-center, propensity-matched cohort. PATIENT SAMPLE Patients who underwent spine surgery with HIV infection were included and compared with a matched-cohort without HIV infection OUTCOME MEASURES CD4 absolute count/uL, HIV-1 RNA copy numbers/mL, 30-day readmission rate, 90-day medical complication rate, one-year surgical site infectious complication rate, one-year fusion rate, and one-year mortality METHODS Single-center, retrospective data review from 2010 to 2016 yielded a total of 4,968 patients of spine surgery. Amongst those, 45 patients had HIV infection. Patients from the database were propensity-matched for age, sex, diagnoses, procedures, co-morbidities other than HIV at a 1:2 ratio, which yielded 90 matched-patients. Clinical outcomes of (A) 45 patients with HIV infection and (B) 90 matched-patients were compared and statistically analyzed. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t -tests. All reported p values are 2-sided and p values <.05 were regarded as statistically significant. RESULTS No statistically significant differences were noted for baseline characteristics including age, sex, diagnoses, procedures, and co-morbidities. There were no statistically significant intergroup differences in operative data such as operative time and operated levels. the HIV-infected patient group had higher rates of 30-day readmission (11.1% vs. 2.2%, P=.04), one-year surgical site infectious complication (13.3% vs. 3.3%, P=.06), and one-year pseudoarthrosis (17.8% vs. 4.4%, P=.02) as well as longer hospital stay (6.8days vs. 4.6days, p<.01) when compared with the control matched-cohort. Our post-hoc analysis only on 45 HIV-infected patients revealed that while HIV-1 RNA copy number with any cut-off values failed to predict 90-day medical complication rates, the cut-off value of CD4 absolute count <200/uL at the most recent preoperative encounter allowed us to stratify them into the two groups with regards to 90-day medical complication rates with statistical significance (44.4% (CD4<200) vs. 11.4% (CD4≥200), P=.04). CONCLUSIONS Spinal surgery in HIV-infected patients was associated with worse short- and long-term clinical outcomes, including higher rates of 30-day readmission, one-year infectious complication rate, and one-year pseudoarthrosis rate. Furthermore, CD4 absolute count may have some role in preoperative risk stratification. These results warrant further investigation of this cohort on multicenter, prospective basis, which should facilitate better patient selection for spine surgery and detailed informed consent, thereby potentially benefitting patients with HIV infection in the future. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Solid organ transplant is the mainstay of treatment for a wide variety of several end-stage organ diseases. The number of patients who will benefit from it is expected to increase due to improvement in distribution system for organs from donors, the discovery of novel immunosuppressive treatment/regimens, and better per- and post-operative management of these patients in general. Hence, an increasing number of these patients are becoming reasonable candidates for subsequent, elective surgeries such as spine surgery. Even though these patients are considered to be a high-risk group for surgery generally, clinical outcomes of spine surgery in patients with solid organ transplantation are not well-documented in the current literature partly due to its substantially rare incidence. Furthermore, prolonged use of steroids as well as immunosuppressant such as cyclosporine is associated with a decrease in bone mineral density. Thus, these outcome data might be of particular importance to consider surgical options for this high-risk cohort and inform them of specific risks and complications associated with spinal surgery after organ transplantation. PURPOSE Summarize clinical outcomes of spine surgery in solid organ recipients, such as readmission rate, infectious complications, and mortality, to facilitate clinical decision-making processes for this specific cohort. STUDY DESIGN/SETTING Retrospective, single-center, propensity-matched cohort. PATIENT SAMPLE Patients who underwent spine surgery at a single institution with previous history of solid organ transplantation were included and compared with a matched-cohort without solid organ transplantation. OUTCOME MEASURES Thirty-day readmission rate, 90-day medical complication rate, one-year infectious complication rate, one-year mortality, and functional outcomes such as ambulatory status, which was rated on a four-point scale (4, independently ambulatory; 3, requiring a cane; 2, requiring a walker; and 1, wheelchair bound). METHODS Single-center, retrospective data review from 2010 to 2016 yielded a total of 4,968 patients who underwent spine surgery. Amongst those, 28 patients had a previous history of solid organ transplantation. Patients from the database were propensity-matched for age, sex, body mass index (BMI), smoking status, diagnoses, procedures, co-morbidities other than diseases which had prompted organ transplantation at 1:2 ratio, which yielded 56 matched-patients. Clinical outcomes of (A) 28 patients with organ transplantation and (B) 56 matched-patients were compared and statistically analyzed. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t -tests. All reported p values are 2-sided and p values <.05 were regarded as statistically significant. RESULTS Baseline characteristics including age, sex, BMI, smoking, diagnoses, procedures, and co-morbidities (ASA scale) were similar between the two groups with no statistically significant difference, which validated our matching methods. There were no statistically significant intergroup differences in operative data such as operative time, estimated blood loss, operated levels, and use of bone morphogenetic protein-2. In terms of functional outcomes, postoperative improvement in ambulatory status was comparable between the two groups (A) 16.7% vs. (B) 18.1%, p>.99). However, the organ-recipient group resulted in longer hospital stays (A) 7.2days vs. (B) 4.3days, p<.01), higher rates of 30-day readmission (A) 14.3% vs. (B) 7.1%, P=.04), 90-day medical complication (A) 42.8% vs. (B) 17.9%, P=.02), one-year infectious complication (A) 14.3% vs. (B) 3.6%, P=.09), one-year reoperation (A) 14.3% vs. (B) 3.6%, P=.09) as compared with the control matched-cohort. CONCLUSIONS Spinal surgery after solid organ transplantation resulted in substantially increased complication rates when compared with the matched-control group, while other variables such as baseline characteristics, operative data, and functional outcomes were similar between the two groups. Careful patient selection, meticulous perioperative care, and thorough informed consent of potential complications would be imperative when performing spine surgery on this cohort. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT The surgical management of deformity, degenerative pathology, neoplasms, trauma and infection in the lumbosacropelvic spine remains a challenge due to high mechanical demand around this area, risks of pseudarthrosis, and invasive nature of the procedures. To date, two instrumentation techniques are primarily available: iliac screws (ISs) and S2-alar-iliac (S2AI) screws. Previous articles demonstrated lower rates of complications with S2AI screws as compared to ISs; however, none of them have focused on elderly patients who may harbor significant comorbidities, and as such, require more meticulous perioperative management, given these invasive and lengthy procedures. PURPOSE To report safety profile of S2AI in patients over 60 and address differences between S2AI screws and ISs. STUDY DESIGN/SETTING Single-center, retrospective, case-control study. PATIENT SAMPLE Single center, retrospective cohort who underwent lumbosacropelvic fixation with more than two-year follow-up. OUTCOME MEASURES Rates of complications such as mortality, unplanned reoperation, cardiorespiratory complications, transfusion-related complications and functional outcome measures such as visual analogue scale for back pain. METHODS Between October 2010, and December 2014, 171 sacropelvic fusion procedures with IS or S2AI screw instrumentation were performed in 161 patients. The inclusion criteria for this study were as follows: (1) patients over 60years old and (2) patients with more than two-year follow-up periods, which yielded 15 patients (IS) and 41 cases (S2AI), respectively. Rates of complications such as mortality, unplanned reoperation, pseudoarthrosis, cardiorespiratory complications, transfusion-related complications and functional outcome measures such as visual analogue scale for back pain and ambulatory status were collected and statistically analyzed. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t-tests. For the analyses on pain and functional outcomes, the perioperative comparisons for each group and intergroup comparisons were conducted using the Wilcoxon signed-rank test and the Mann–Whitney U test, respectively. All reported p values are 2-sided and p values <.05 were regarded as statistically significant. RESULTS Baseline characteristics such as age, sex, smoking history, diagnoses and comorbidities were similar in both groups. The S2AI group had lower rates of reoperation (19.5% vs 66.6%, p=.002), surgical site infection (0% vs. 16.0%, p<.001), wound dehiscence (0.0% vs. 20.0%, p<.001) and postoperative hyperkalemia (17.7% vs. 43.8%, p=.04) and had lower volume of estimated blood loss (EBL) [ml] (1817.5vs. 2775.6, p=.01) and transfused red blood cell units (4.6vs. 8.0, p=.001) than the IS group, while rates of mortality, L5-S1 pseudarthrosis, and other cardiorespiratory complications were similar in both groups. Pain relief and functional recovery were achieved in both groups without any significant intergroup differences. On multivariate analyses, use of S2AI screws over ISs, smoking, and operated levels were independent predictors of volume of transfusion. CONCLUSIONS Use of S2AI screws over ISs in the elderly was associated with lower rates of reoperation, surgical site infection, wound dehiscence and lower volume of EBL and RBC transfusion, while achieving similar clinical and functional outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Occipitocervical fusion is the gold standard stabilization method for several pathologies involving craniovertebral junctions, including basilar invagination, atlantoaxial trauma and neoplasm. However, its postoperative clinical course is oftentimes complicated by dysphagia and dyspnea, presumably due to loss of mobility across occiput-C1-C2 joints, which could lead to aspiration pneumonia and acute airway obstruction, respectively, and are life-threatening complications in this procedure. The exact mechanism and its predictors still remain widely unstudied, but a previous article involving healthy volunteers elaborated on the importance of the occipital and external acoustic meatus to axis angle (O-EAa, "the angle formed by the McGregor line and the line connecting the external acoustic meatus and the midpoint of the inferior end plate of C2"), when predicting the narrowest oropharyngeal airway space (nPAS, "the narrowest anterior–posterior distance from the posterior pharyngeal wall to the back of the tongue between the levels of the uvula tip and the epiglottis tip") on X-rays, which theoretically should directly correlate with postoperative dysphagia. Here, we aimed to evaluate whether pre- and postoperative radiographical measurements such as O-EAa and nPAS could predict postoperative dysphagia in adult patients who underwent occipitocervical fusion procedures. PURPOSE To identify predictors of postoperative dysphagia in patients with adult occiptocervical fusion surgery. STUDY DESIGN/SETTING Retrospective, single-center. PATIENT SAMPLE Patients who underwent occipitocervical fusion at a single institution. OUTCOME MEASURES Prolonged postoperative dysphagia (more than 30 days). METHODS Single-center, retrospective data review from 2010 to 2016 identified 57 patients who underwent spine surgery involving occipitocervical fusion procedures. Among those, 51 patients had more than one-year follow-up as well as an adequate postoperative assessment of swallowing functions. Clinical records of those 51 patients (average age: 53.3, female: 54%) were collected and statistically analyzed. A total of 16 patients (31.4%, group (A)) were diagnosed with postoperative dysphagia associated with occipitocervical fusion, who were compared with 35 patients without this complication (group (B)) in terms of baseline characteristics, operative data and radiographical findings including perioperative O-EAa and nPAS at patients' neutral positions. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t -tests. ROC curves were drawn to evaluate the diagnostic value of O-EAa and nPAS for postoperative dysphagia. Furthermore, the Pearson's correlation was assessed between O-EAa and nPAS. Finally, a multilinear regression model was created to identify factors influencing nPAS. All reported p values are two-sided and p values <.05 were regarded as statistically significant. RESULTS There were no statistically significant difference in terms of baseline characteristics including age, sex, BMI, smoking and comorbidities or operative data such as estimated blood loss, operative time and operated levels. While preoperative O-EAa and nPAS were similar between the two groups (P=.39 and.55, respectively), postoperative O-EAa ((A) 89.3° versus (B) 104.5°, p<.01) and nPAS ((A) 9.9 mm versus (B) 13.6 mm, P=.01) as well as perioperative changes in O-EAa ((dO-EAa), (A) −4.1° vs. (B) 0.6°, P=.01) and nPAS (dnPAS, (A) −2.0 mm vs. (B) 0.2 mm, P=.01) were significantly different. The cut-off value of dOEA-a <−2.4° to predict postoperative dysphasia yielded sensitivity of 81.8% and specificity of 100% (AUC=0.939), which was comparable to dnPAS >−1.1 (sensitivity 81.8%, specificity 100%). The Pearson's correlation coefficient between these two parameters were 0.747 (p<.001). In a linear regression analysis, nPAS (mm) was found to be affected by O-EAa (estimate=0.2, P=.04) and sex (estimate=−4.8 (female=1), P=.03), but not by BMI in this model (R square=0.42). CONCLUSIONS Perioperative changes in O-EAa and nPAS were associated with postoperative dysphagia. Intraoperatively, O-EAa measurement on fluoroscopic images could be utilized as a surrogate marker for nPAS, thereby potentially allowing us to decrease the risk of this crucial complication. These data may prompt multicenter, prospective studies to further validate them and translate them into better patient care in the future. [ABSTRACT FROM AUTHOR]