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Objective: Knowledge remains limited regarding cerebral blood flow autoregulation after cardiac arrest and during postresuscitation hypothermia. We determined the relationship of cerebral blood flow to cerebral perfusion pressure in a swine model of pediatric hypoxic-asphyxic cardiac arrest during normothermia and hypothermia and tested novel measures of autoregulation derived from near-infrared spectroscopy.Design: Prospective, balanced animal study.Setting: Basic physiology laboratory at an academic institution.Subjects: Eighty-four neonatal swine.Interventions: Piglets underwent hypoxic-asphyxic cardiac arrest or sham surgery and recovered for 2 hrs with normothermia followed by 4 hrs of either moderate hypothermia or normothermia. In half of the groups, blood pressure was slowly decreased through inflation of a balloon catheter in the inferior vena cava to identify the lower limit of cerebral autoregulation at 6 hrs postresuscitation. In the remaining groups, blood pressure was gradually increased by inflation of a balloon catheter in the aorta to determine the autoregulatory response to hypertension. Measures of autoregulation obtained from standard laser-Doppler flowmetry and indices derived from near-infrared spectroscopy were compared.Measurements and Main Results: Laser-Doppler flux was lower in postarrest animals compared to sham-operated controls during the 2-hr normothermic period after resuscitation. During the subsequent 4-hr recovery, hypothermia decreased laser-Doppler flux in both the sham surgery and postarrest groups. Autoregulation was intact during hypertension in all groups. With arterial hypotension, postarrest, hypothermic piglets had a significant decrease in the perfusion pressure lower limit of autoregulation compared to postarrest, normothermic piglets. The near-infrared spectroscopy-derived measures of autoregulation accurately detected loss of autoregulation during hypotension.Conclusions: In a pediatric model of cardiac arrest and resuscitation, delayed induction of hypothermia decreased cerebral perfusion and decreased the lower limit of autoregulation. Metrics derived from noninvasive near-infrared spectroscopy accurately identified the lower limit of autoregulation during normothermia and hypothermia in piglets resuscitated from arrest. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The inflammatory process is associated with cardiac diastolic dysfunction, which has been demonstrated to be an independent prognostic marker for the mortality of critically ill patients. We investigated the association among inflammatory cytokines (tumor necrosis factor-[alpha] and interleukin-6), diastolic heart failure, and the possible molecular mechanism. DESIGN: Prospective case-controlled cohort and molecular studies. SETTING: University hospital and research laboratory. SUBJECTS: Patients with a diagnosis of diastolic heart failure by echocardiography and matched control subjects from the general population (study group 1) and also subjects from the intensive care unit (study group 2). Sarcoplasmic reticulum Ca2+-ATPase (SERCA2) gene expression and diastolic calcium decay in HL-1 cardiomyocytes were used as molecular phenotypes of diastolic heart failure. INTERVENTIONS: Soluble plasma levels of tumor necrosis factor-[alpha] and interleukin-6 were measured in all subjects. An approximate 1.75-kb promoter of the SERCA2 gene was cloned to the pGL3 luciferase reporter. The effect of tumor necrosis factor-[alpha] and interleukin-6 on SERCA2 gene expression and diastolic calcium decay of HL-1 cardiomyocytes were investigated. MEASUREMENTS AND MAIN RESULTS: Patients with diastolic heart failure had significantly higher plasma levels of tumor necrosis factor-[alpha] and interleukin-6 than the control subjects. Significant correlations (p < .01 for each) were found for tumor necrosis factor-[alpha] and E/Em (r = .87) and E/A (r = -0.69), and for interleukin-6 and E/Em (r = .80) and E/A (r = -0.65). Cytokine levels were also correlated with diastolic function in critically ill patients (study group 2), and diastolic function improved significantly in association with decrease of cytokines. Tumor necrosis factor-[alpha], interleukin-6, and sera from critically ill patients downregulated the expression of the SERCA2 gene. Tumor necrosis factor-[alpha] and interleukin-6 also delayed the diastolic calcium reuptake and decay in cardiomyocytes. CONCLUSIONS: Through downregulation of SERCA2 gene expression, inflammatory cytokines may cause cardiac diastolic dysfunction by decreasing diastolic calcium reuptake. Our study may suggest novel therapeutic strategies for diastolic heart failure and critically ill patients by modulating inflammatory reactions. [ABSTRACT FROM AUTHOR]

Background: It is well known that age-related fibrosis, or decreases in the elastin-to-collagen ratio of the ligamentum flavum, along with hypertrophy of the ligamentum flavum, are associated with lumbar spinal stenosis. However, the molecular mechanism by which this fibrosis and hypertrophy develop is unknown. Tissue inhibitors of matrix metalloproteinase (TIMPs) are proteinase inhibitors that suppress extracellular matrix degradation. Elevated TIMP-1 and TIMP-2 expression has been implicated in various fibrotic diseases of the liver, kidney, lung, and heart. These TIMPs can also induce cellular proliferation and inhibit apoptosis in a wide range of cell types. These findings led us to postulate that TIMP-1 and TIMP-2 might also be associated with hypertrophy and fibrosis of the ligamentum flavum in lumbar spinal stenosis.Methods: We quantified and localized TIMP expression in ligamentum flavum tissues that had been obtained during surgery from thirty patients with spinal stenosis and from thirty gender-matched control patients with disc herniation. The thickness of the ligamentum flavum at the level of the facet joint was measured on axial T1-weighted magnetic resonance images. In addition, we examined ligamentum flavum tissues for the expression of markers of cellular proliferation and apoptosis.Results: The ligamentum flavum was significantly thicker in the patients with spinal stenosis (mean, 5.68 mm) than in the patients with disc herniation (mean, 2.70 mm) (p < 0.001). The concentration of TIMP-2 in the ligamentum flavum was significantly higher in the patients with spinal stenosis (mean, 12.62 ng/mL) than in those with disc herniation (mean, 8.85 ng/mL) (p = 0.028). TIMP-1 and TIMP-2 were detected in the cytoplasm of ligamentum flavum fibroblasts. TIMP-1 and TIMP-2 concentrations were associated with hypertrophy of the ligamentum flavum (p = 0.015 and p = 0.003, respectively). None of the samples from the patients with stenosis had evidence of proliferation of ligamentum flavum fibroblasts. The expression of markers for apoptosis was significantly higher in the patients with spinal stenosis (58.8%) than in those with disc herniation (26.6%) (p < 0.001).Conclusions: Increased TIMP expression has been implicated in fibrosis and hypertrophy of the extracellular matrix of several organs. Our results suggest that increased expression of TIMP-2 in ligamentum flavum fibroblasts is associated with fibrosis and hypertrophy of the ligamentum flavum in patients with spinal stenosis. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: Case description. OBJECTIVES.: To describe a rare case of traumatic lumbar disc rupture into the dural sac associated with a mild vertebral body compression fracture and review the pertinent medical literature. SUMMARY OF BACKGROUND DATA.: Intradural lumbar disc rupture is an uncommon and serious complication, particularly if it develops as an acute traumatic lesion. It can result in serious neurologic deficit if it is not treated in a timely and appropriate manner. METHODS.: A 51-year-old man presented with motor paraparesis (grade 2/5) and hypeesthesia at left L1 and L2 sensory dermatome after a traffic collision. Computed tomography scan revealed a compression fracture of the L1 body. Lumbar magnetic resonance imaging demonstrated an intradural mass-like lesion behind the L2 body and deviation of the cauda equina by this lesion. An emergency L2 laminectomy was performed for removal of intradural space occupying lesion and decompression of cauda equina. The mass lesion was removed in 1 piece, and other space occupying lesions were not found in the spinal canal. RESULTS.: Pathologic examination for intradural mass lesion demonstrated fibrocartilage such as disc material. After the operation, the patient's neurologic symptoms showed gradual improvement, and by postoperative day 18, he had made a full recovery. At his 1-year follow-up examination, the patient was completely independent and free from any neurologic deficits. CONCLUSION.: We report a rare case of traumatic lumbar disc rupture into the dural sac associated with a mild vertebral body compression fracture. Early diagnosis and prompt surgical intervention resulted in a good functional outcome. Lumbar disc rupture into the dural sac should be added to the differential diagnosis of acute traumatic spinal lesion causing spinal cord or cauda equina compression. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: Case description. OBJECTIVE.: To clinically and radiographically describe a traumatic spinal epidural hematoma (TSEH) without adjacent spinal column fracture or soft tissue injury that completely resolved, without surgical intervention. SUMMARY OF BACKGROUND DATA.: Symptomatic TSEH is an infrequent condition after spinal trauma, accounting for 0.5% to 1.7% of cases. It can result in permanent neurologic deficits if not treated in a timely and appropriate manner. METHODS.: A 50-year-old man presented with progressive lower motor weakness and sensory change at 2 days after blunt trauma to the upper back area. Neurologic examination revealed paraplegia and hypesthesia below the T4 sensory dermatome. Magnetic resonance imaging for cervicothoracic spine showed a space-occupying lesion in the dorsal spinal epidural space from C7 to T5. The lesion was consistent with acute stage hematoma of the spinal epidural space. RESULTS.: The patient was prepared for decompression surgery. However, the patient's neurologic symptoms began to improve (grade 4/5) at 2 hours after onset of paraplegia. Surgical intervention was delayed, and the patient was treated conservatively with close neurologic monitoring. Three days after onset of symptoms, the patient's neurologic symptoms recovered completely. The follow-up magnetic resonance imaging at 12 days after the event showed complete resolution of the epidural hematoma. CONCLUSION.: An unpredictable extensive epidural hematoma can occur after blunt trauma of the cervicothoracic spine in patients at low risk for hemorrhage. This case illustrates that immediate surgical intervention may not always be necessary in certain patients with TSEH. Conservative management with careful observation may play a role as a management option for patients initially presenting with severe neurologic dysfunction if neurologic recovery is early and sustained. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Case description. OBJECTIVE: To describe a patient with a recurrent primary spinal subarachnoid neurocysticercosis (NCC) that was successfully treated with surgical decompression and medical therapy at our center. SUMMARY OF BACKGROUND DATA: Spinal subarachnoid NCC is thought to be the secondary result from larval migration through the ventricular system into the spinal subarachnoid space. However, this entity can develop as a primary infection through blood stream or direct larval migration. It can result in high recurrence and severe neurologic morbidity if it is not treated in an appropriate manner. METHODS: A 50-year-old woman with treatment history of spinal NCC presented with back pain and radicular pain. The lumbar magnetic resonance imaging showed a cystic lesion with septation and slight rim enhancement after gadolinium administration at the L4-S1 area. We performed surgical removal of this lesion and postoperative medical therapy for complete eradication of the parasite. RESULTS: The histopathology was diagnostic for a cysticercal cyst. Adjuvant medical therapy with albendazole was administered for 30 days after surgery. The patient remained symptom-free for 1 year after surgery without any evidence of recurrence. CONCLUSION: We report a rare case of recurrent primary spinal subarachnoid NCC at L4-S1 area. In cases of primary spinal subarachnoid NCC can be treated by adequate combined approach with surgery and medical therapy. Spinal subarachnoid NCC should be added to the differential diagnosis of primary spinal intradural cysts, because this lesion can occur primarily. [ABSTRACT FROM AUTHOR]

Study Design: Case description. Objectives: To describe a case of intradural metastasis from a renal cell carcinoma (RCC) spread to the cauda equina, and review the pertinent medical literature. Summary Of Background Data: Intradural spinal metastasis is rare, accounting for 6% of all spinal metastases. Only 7 cases of intradural metastasis from a RCC to the cauda equina have been previously reported. Methods: A 41-year-old male presented with a 1-month history of severe back pain radiating to both legs. The patient underwent a right nephrectomy for treatment of a RCC 1-year before admission. Magnetic resonance imaging showed a well-demarcated, intradural extramedullary mass at the L2 vertebra. Results: After a total laminectomy, total excision of the tumor was achieved followed by rapid improvement of the back pain. The tumor was histologically verified as metastatic RCC, identical to that of a previous tumor specimen. The patient was asymptomatic on the 1-year follow-up. Conclusion: Although the majority of cauda equina tumors are primary tumors, intradural metastasis should be considered before surgery in patients with previously treated RCC. [ABSTRACT FROM AUTHOR]

Study Design: Prospective study of 31 patients who underwent anterior cervical fusion. Objective: To investigate the efficacy of polyetheretherketone (PEEK) cages and demineralized bone matrix (DBM) for anterior cervical discectomy and fusion (ACDF). Summary Of Background Data: Although high fusion rates can be achieved with autogenous bone grafts, donor-site morbidity affects the patient's satisfaction with the surgical outcome. Methods: Thirty-one consecutive patients treated with ACDF using the PEEK cage with DBM (Grafton, Osteotech, Inc., Shrewsbury, NJ) at 42 levels were prospectively evaluated with a minimum of 12-month follow-up (mean: 16 months). Twenty-one patients underwent a single-level ACDF, 9 patients underwent a 2-level ACDF, and 1 patient had a 3-level ACDF. The affected level was C3-C4 in 7 patients; C4-C5 in 9, C5-C6 in 16, and C6-C7 in 10. The neurologic outcomes were evaluated using the VAS score for neck and arm pain and the Japanese Orthopedic Association scoring system for myelopathy at 3, 6, and 12 months. The cervical lordosis and fusion status were assessed on radiographs including flexion/extension radiographs. Results: At 12 months, the radiographs demonstrated grades I, II, and III new bone formation at 1, 13, and 28 levels, respectively. There was a significant improvement in both the neck and arm pain and a significant improvement in the Japanese Orthopedic Association scores at the last follow-up. There was no case with implant-related complications such as cage failure or migration, and no complications associated with the use of Grafton. Conclusion: ACDF using the Solis cage packed with Grafton demonstrated good clinical and radiologic outcomes. The fusion rate was comparable with the published results of the traditional ACDF using tricortical iliac crest grafts. Therefore, the results of this study suggest that the ongoing use of the PEEK cage packed with DBM and autologous bone chips in ACDF is a safe and effective alternative to the gold standard of autologous iliac bone grafts. [ABSTRACT FROM AUTHOR]

Study Design: Case description. Objectives: To report a rare case of intraosseous malignant peripheral nerve sheath tumors (MPNST), and review the pertinent medical literature. Summary Of Background Data: The spinal MPNST that develops from spinal nerve roots and secondary bony erosion is well-known entity. However, primary intraosseous MPNSTs of the spine are extremely rare. Methods: A 41-year-old male presented with a 1-month history of radiating pain to his right shoulder and arm. Magnetic resonance images showed a large extradural mass extending from C6 to T1 with destruction of the posterior elements of C6, C7, and T1. Complete excision of the tumor and posterior stabilization were performed through a posterior approach. The tumor was noted to originate from the posterior element of C7. Results: The histopathology was diagnostic for a MPNST. Adjuvant chemotherapy was administered after surgery. The patient remained symptom-free for 30 months after surgery without local recurrence or metastasis. Conclusion: We report an intraosseous MPNST of the cervical spine. Complete surgical excision and adjuvant chemotherapy resulted in a good functional outcome. MPNST should be added to the differential diagnosis of primary bone tumors causing spinal cord compression. [ABSTRACT FROM AUTHOR]

Study Design: A case report. Objective: To describe an interesting patient who underwent open reduction and C1-C2 transpedicular screw fixation with interspinous wiring due to high-riding vertebral artery. Summary Of Background Data: Atlantoaxial rotatory fixation (AARF) is a rare complication found most frequently after trauma in children and young adults; the clinical diagnosis is difficult and often made late. Methods: We report a case of post-traumatic AARF associated with a facet fracture in an adult. Reduction proved difficult to obtain by skull traction and gentle manipulation. Therefore, after open reduction under general anesthesia, we performed C1-C2 transpedicular screw fixation with posterior wiring to avoid vertebral artery injury due to high-riding transverse foramen at the C2 vertebra. Results: The normal atlantoaxial relation was restored and the torticollis resolved. The patient remains neurologically intact and has radiographic documentation of fusion. Conclusion: Although technically demanding, C1-C2 transpedicular screw fixation combined with interspinous bone graft wiring after open reduction may be an alternative treatment option if conservative treatment fails to reduce AARF. [ABSTRACT FROM AUTHOR]

There are no reports comparing diet recovery between patients who underwent distal gastrectomy (DG) and those who underwent total gastrectomy (TG). The aim of the present study was to compare dietary habits and nutritional status after curative treatment with DG and TG in patients with gastric cancer. We retrospectively collected clinical data from 263 consecutive patients who underwent gastrectomy for gastric cancer without recurrence at a single-center between January 2016 and December 2022. Demographic data, diet questionnaires, and laboratory data were collected. Patients were divided into 2 groups: those who underwent DG and those who underwent TG. Dietary habits and nutritional status were compared between the groups from preoperation until the 36th postoperative month (POM). For the DG and TG groups, the diet volume increased similarly up to the 3rd POM. However, the diet volume of the DG group increased by approximately 10 percentage points compared to that of the TG group from the 6th POM to the 24th POM (77.7% vs 67.8%, P = .025) and 36th POM (77.8% vs 69.8%, P = .104). The volume of the DG group increased until the 24th POM, and the frequency of the DG group decreased until the 36th POM. In contrast, the diet volume of the TG group increased until the 3rd POM (P = .005) but then plateaued, and the diet frequency did not decrease until the 36th POM compared to the 1st POM (P > .05). Nutritional status did not significantly differ between the 2 groups. Patients who underwent TG had a lower diet volume and a greater diet frequency than DG patients did after 6 months. Postoperative nutrition education should be tailored differently for patients undergoing DG and TG. Specifically, TG patients should be educated to increase diet frequency rather than diet volume after surgery., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Clonal hematopoiesis (CH), which is characterized by variants of hematopoietic stem cells, increases the risk of subsequent myeloid neoplasms (MNs). This study aimed to investigate the prevalence and characteristics of CH variants in breast cancer (BC) patients treated with cytotoxic therapy (CT), focusing on those who developed MNs after cytotoxic therapy (MN-pCT). We retrospectively analyzed 107 BC patients from a biobank and sequenced peripheral blood and bone marrow samples from 31 CH-associated genes at 2 time points. We analyzed changes in CH for paired samples: T0 to T1 (before and after CT) and T1 to T2 (after CT vs greater CT exposure). Additionally, we compared CH variants in patients with and without MN-pCT. 29% of patients harbored CH variants that were restricted to 8 genes and DNMT3A was the most frequent variant. Among 54 patients with paired samples (T1 to T2), the variant allele frequency (VAF) of CH variants significantly increased after greater CT exposure (P = .02). However, there were no significant changes in VAF before and after CT. Five of the 9 patients who developed MN-pCT harbored CH variants. TP53 was the most frequently mutated gene, but it did not significantly affect MN-pCT risk compared to patients without CH variants. Although the presence of CH did not directly predict MN-pCT development in patients with BC, CT induced changes in CH genes. Further studies are required to determine the role of specific CH variants in the risk of MN-pCT and their potential as predictive biomarkers., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: It is difficult to identify disease entities underlying lymphadenopathy in the head and neck region based solely on imaging. This often results in metastatic squamous cell carcinoma (Sqcc)-induced lymphadenopathy being mistaken for lymphoma. This study aimed to analyze clinical characteristics and computed tomographic features that aid in distinguishing between metastatic Sqcc and lymphoma when lymphadenopathy resembles a large solitary lymphoma., Methods: The authors retrospectively enrolled 5 patients, managed between 2010 and 2024, with metastatic Sqcc mistaken for lymphoma and 9 patients with lymphadenopathy of 2 cm or larger due to lymphoma., Results: Among the 5 patients, 3 exhibited a homogeneous lymphadenopathy phenotype, whereas the remaining 2 displayed heterogeneous enhancement with multiple small necrotic areas within the affected masses. Measurement of the Hounsfield units (HU) for lymphadenopathy, the sternocleidomastoid muscle, and the submandibular gland (SMG) was conducted for each patient. The ratio of lymphadenopathy HU to the average HU of the sternocleidomastoid muscle and the SMG was significantly higher in patients diagnosed with metastatic Sqcc compared with those with lymphoma (P = 0.01)., Conclusion: In computed tomography scans, heterogeneous lymphadenopathy or enhancement levels that approach or exceed those of the SMG may indicate the likelihood of Sqcc rather than lymphoma., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Purpose of Review: Higher degrees of myopia are currently being treated with refractive surgery. However, there is limited characterization and outcomes data for this cohort. This article aims to review the literature on highly myopic patients who had refractive surgery and present a retrospective analysis of 149 patients (270 eyes) with high to extreme myopia (≤-5.0D SE) who underwent refractive surgery [laser-assisted subepithelial keratomileusis (LASIK), photorefractive keratectomy (PRK), or implantable collamer lense (ICL)] at a single practice., Recent Findings: There is substantial literature on the efficacy of LASIK, PRK, and phakic intraocular lenses for refractive error correction, but a dearth of studies on patients with high to extreme myopia undergoing different types of refractive surgery. Our study reveals that this cohort of patients has excellent outcomes with minimal complications., Summary: Our study reveals that the average preoperative myopia was highest in ICL patients (-10.03D), followed by PRK (-7.21D), and LASIK (-7.04D) patients. Not surprisingly, eyes with high myopia and thin corneas were offered and elected ICLs for their procedure. Highly myopic patients achieved outcomes consistent with data reported in the literature- average postoperative uncorrected visual acuity was 20/20 for LASIK and ICL eyes and 20/25 for PRK eyes., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Few studies have examined the risk factors associated with the type of acute respiratory failure (ARF) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). This study evaluated the clinical characteristics and prognosis of patients hospitalized for acute exacerbation of COPD based on the type of ARF. The medical charts of hospitalized patients with acute exacerbation of COPD between 2016 and 2021 were retrospectively reviewed. We classified ARF into 2 types: type 1 ARF with PaO2 < 60 mm Hg in room air or a ratio of arterial partial pressure to fractional inspired oxygen < 300, and type 2 ARF with PaCO2 > 45 mm Hg and arterial pH < 7.35. A total of 435 patients were enrolled in study, including 170 participants without ARF, 165 with type 1 ARF, and 100 with type 2 ARF. Compared with the non-ARF group, the frequency of high-flow nasal cannula, noninvasive ventilation, intensive care unit admissions, and in-hospital deaths was higher in the ARF group compared with the non-ARF group. The ARF group had higher 1-year mortality group (hazard ratio [HR], 2.809; 95% confidence interval [CI], 1.099-7.180; P = .031) and readmission within 1-year rates (HR, 1.561; 95% CI, 1.061-2.295; P = .024) than the non-ARF group. The type 1 ARF group had a higher risk of 1-year mortality (HR, 3.022; 95% CI, 1.041-8.774; P = .042) and hospital readmission within 1-year (HR, 2.053; 95% CI, 1.230-3.428; P = .006) compared with the non-ARF group. There was no difference in mortality and readmission rates between the type 1 and type 2 ARF groups. In conclusion, patients with type 1 ARF rather than type 2 ARF had higher mortality and readmission rates than those without ARF. The prognoses of patients with type 1 and type 2 ARF were similar., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Posterior lumbar interbody fusion (PLIF) is widely used to treat degenerative spondylolisthesis because it provides definitive decompression and fixation. Although it has several advantages, it has some disadvantages and risks, such as paraspinal muscle injury, potential intraoperative bleeding, postoperative pain, hardware failure, subsidence, and medical comorbidity. Lumbar decompressive bilateral laminectomy with interspinous fixation (DLISF) is less invasive and can be used on some patients with PLIF, but this has not been reported. To compare the efficacy and safety of DLISF in the treatment of low-grade lumbar spondylolisthesis with that of PLIF. We retrospectively analyzed the medical records of 81 patients with grade I spondylolisthesis, who had undergone PLIF or DLISF and were followed up for more than 1 year. Surgical outcomes, visual analog scale, radiologic outcomes, including Cobb angle and difference in body translation, and postoperative complications were assessed. Forty-one patients underwent PLIF, whereas 40 underwent DLISF. The operative times were 271.0 ± 57.2 and 150.6 ± 29.3 minutes for the PLIF and DLISF groups, respectively. The estimated blood loss was significantly higher in the PLIF group versus the DLISF group (290.7 ± 232.6 vs 122.2 ± 82.7 mL, P < .001). Body translation did not differ significantly between the 2 groups. Overall pain improved during the 1-year follow-up when compared with baseline data. Medical complications were significantly lower in the DLISF group, whereas perioperative complications and hardware issues were higher in the PLIF group. The outcomes of DLISF, which is less invasive, were comparable to PLIF outcomes in patients with low-grade spondylolisthesis. As a salvage technique, DLISF may be a good option when compared with PLIF., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Increasing clinical demands can adversely impact academic advancement, including the ability to deliver lectures and disseminate scholarly work. The virtual lecture platform became mainstream during the height of the coronavirus-19 pandemic. Lessons learned from this period may offer insight into supporting academic productivity among physicians who must balance multiple demands, including high clinical workloads and family care responsibilities. We evaluated perceptions on delivering virtual lectures to determine whether virtual venues merit continuation beyond the pandemic's initial phase and whether these perceptions differ by gender and rank., Methods: In a survey study, faculty who spoke in 1 of 3 virtual lecture programs in the Departments of Anesthesiology and Critical Care Medicine, Otolaryngology, and Radiology at a university hospital in 2020 to 2022 were queried about their experience. Speakers' motivations to lecture virtually and the perceived advantages and disadvantages of virtual and in-person lectures were analyzed using descriptive statistics and qualitative analyses., Results: Seventy-two of 95 (76%) faculty members responded (40% women, 38% men, and 22% gender undisclosed). Virtual lectures supported the speakers "a lot" to "extremely" with the following goals: enhancing one's reputation and credibility (76%), networking (70%), receiving feedback (63%), and advancing prospects for promotion (59%). Virtual programs also increased the speakers' sense of accomplishment (70%) and professional optimism (61%) by at least "a lot," including instructors and assistant professors who previously had difficulty obtaining invitations to speak outside their institution. Many respondents had declined prior invitations to speak in-person due to clinical workload (66%) and family care responsibilities (58%). Previous opportunities to lecture in-person were also refused due to finances (39%), teaching (26%), and research (19%) requirements, personal medical conditions or disabilities (9%), and religious obligations (5%). Promotion was a stronger motivating factor to lecture virtually for instructors and assistant professors than for associate and full professors. By contrast, disseminating work and ideas was a stronger motivator for associate and full professors. Associate and full professors also reported greater improvement in work-related well-being than earlier career faculty from the virtual lecture experience. Very few differences were found by gender., Conclusions: Virtual lecture programs support faculty who might not otherwise have the opportunity to lecture in-person due to multiple constraints. To increase the dissemination of scholarly work and expand opportunities to all faculty, virtual lectures should continue even as in-person venues are reestablished., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2023 International Anesthesia Research Society.)

Pellino-1 plays a role in regulating inflammation and immune responses, and its effects on tumours are complex, with different outcomes reported in various studies. Additionally, the role of Pellino-1 in diffuse large B-cell lymphoma (DLBCL) has not been thoroughly investigated. We aimed to examine the expression of Pellino-1 in tumour cells and tumour-infiltrating lymphocytes (TILs) separately and identify the clinicopathological significance of Pellino-1 expression in DLBCL. We evaluated Pellino-1 expression in 104 patients with DLBCL. The density of specific cell types was quantitatively analysed using digital image analysis after a multiplex immunofluorescence staining with Pellino-1, CD20, CD8, FOXP3, and PD-1. Pellino-1 expression was mostly observed in CD20+ tumour cells and CD8+ TILs. The high CD8+/Pellino-1+ group was significantly associated with the non-GCB subtype and higher numbers of Foxp3+ T-cells. Patients with high CD20+/Pellino-1+ and high CD8+/Pellino-1+ cell densities had significantly shorter event-free survival (EFS) rates. The multivariate Cox-regression analysis showed that CD20+/Pellino-1+ cell density and CD8+/Pellino-1+ cell density were independent poor prognostic factors for EFS. Furthermore, patients with low densities of both CD20+/Pellino-1+ and CD8+/Pellino-1+ cells demonstrated a prognosis superior to that of patients with high Pellino-1+ cell densities, either alone or in combination. Additionally, the multivariate analysis demonstrated that the combination of CD20+/Pellino-1+ and CD8+/Pellino-1+ cell densities was an independent prognostic factor for EFS and overall survival. Pellino-1 expression was observed in both tumour cells and TILs, particularly in cytotoxic T-cells, and was correlated with poor outcomes in DLBCL. Thus, Pellino-1 might have an oncogenic effect on DLBCL and might be a potential target for improving cytotoxic T-cell activity., (Copyright © 2024 Royal College of Pathologists of Australasia. Published by Elsevier B.V. All rights reserved.)

Rationale: Diagnosing intralymphatic histiocytosis can be challenging due to its rarity. We present a case of intralymphatic histiocytosis in the upper eyelid of a Korean patient. We treated the condition by surgical debulking and intralesional triamcinolone injection., Patient Concerns: A 59-year-old man was referred to our clinic with a 7-year history of unilateral swelling in the right upper eyelid. He had previously been treated with long-term oral steroids and immunosuppressants, but his eyelid swelling persisted. Unilaterally non-pitting erythematous edema was localized on the right upper eyelid without any itching or pain. His best corrected visual acuity at presentation was 20/20 for both eyes. Enhanced orbital computerized tomography revealed edematous soft tissue thickening in the right upper eyelid. In the laboratory testing, the erythrocyte sedimentation rate showed an increase of 19, and the antinuclear antibody titer was positive with a homogeneous pattern., Diagnoses: We diagnosed the patient with intralymphatic histiocytosis based on the histopathological findings., Intervention: We attempted surgical debulking and biopsy on the right upper eyelid due to the persistent symptoms and the absence of a definitive diagnosis., Outcomes: The patient has demonstrated significant improvement after receiving an intralesional triamcinolone injection in the right upper eyelid following the surgery and is currently under follow-up with no signs of recurrence., Lesson: Ophthalmologists should consider intralymphatic histiocytosis in cases of persistent eyelid swelling that do not respond to treatment, even in Asian patients. Surgical debulking and intralesional triamcinolone injections may be beneficial for improvement., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Wrist pain on the ulnar side is often caused by ulnar impaction syndrome (UIS). Idiopathic UIS requires surgical treatment when conservative treatment fails. The 2 main surgical procedures used are the wafer procedure and ulnar shortening osteotomy (USO) of the metaphysis or diaphysis. This review aimed to analyze comparative studies of the 2 procedures in UIS to determine clinical outcomes and complications., Methods: One prospective and 5 retrospective comparison trials were retrieved from the PubMed, Embase, and Cochrane Library databases. The primary outcomes were treatment effectiveness; pain visual analog scale (VAS), disabilities of the arm, shoulder, and hand (DASH) score, Mayo wrist, and Darrow scores. The incidence of postoperative complications formed the secondary outcome., Results: The selected studies included 107 patients who underwent the wafer procedure (G1) and 117 patients who underwent USO (G2). The wafer procedure had the benefits of less postoperative immobilization and an early return to work. However, there were no significant differences in the postoperative pain improvement and functional scores. All 6 studies reported high total complication rates and reoperation with USO. The most frequent complication was implant-related discomfort or irritation; subsequent plate removal was the most common reason for a secondary operation., Conclusions: There was no difference in pain improvement or the postoperative functional score between the groups. Nevertheless, postoperative complications were the major pitfalls of USO. As the specialized shortening system advances further, a high-level study will be necessary to determine the surgical option in UIS., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Nasogastric tube feeding is often used to provide optimal nutrition and hydration in patients with aspiration pneumonia. However, evidence regarding radiologic indicators for successful nasogastric tube weaning is lacking. We investigated whether thoracic skeletal muscle assessment can be useful for predicting successful weaning from nasogastric tube feeding in patients with aspiration pneumonia. This longitudinal, observational study included subjects with aspiration pneumonia who underwent a videofluoroscopic swallowing study (VFSS) and chest computed tomography (CT) in Boramae Medical Center, from January 2012 to December 2019. We estimated the area under the receiver operating characteristics curve (AUC) to evaluate the predictive performance of skeletal muscle and visceral fat parameters and VFSS results for successful weaning from nasogastric tube feeding. A board-certified radiologist measured muscle and fat areas. Muscle and fat volumes were segmented and measured using an externally validated convolutional neural network model. Among the 146 included patients, nasogastric tube feeding was successfully transitioned to oral feeding in 46.6%. After adjusting for covariables related to successful weaning, skeletal muscle areas, indices, and volume indices were positively associated with successful nasogastric tube weaning. Although VFSS results and skeletal muscle parameters alone showed suboptimal performance for predicting successful weaning, a prediction model combining skeletal muscle index at the T4 level and VFSS results improved the prediction performance to an acceptable level (AUC ≥ 0.7). Skeletal muscle index measured at the T4 level may be a useful supplementary indicator for predicting successful weaning from nasogastric tube feeding in patients with aspiration pneumonia., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: The purpose of this article is to provide a review of the literature on refractive lens exchange and present a retrospective analysis of 55 patients who underwent refractive lens exchange at a single practice., Recent Findings: Our study substantiates refractive lens exchange as an important option for presbyopic patients, hyperopic patients or patients with extremely high refractive error who desire spectacle independence., Summary: Our study reveals that the refractive lens exchange population is younger than the average cataract population and their primary motivations are to resolve hyperopic or myopic refractive errors, gain spectacle independence, and address near vision loss. A variety of presbyopia-addressing intraocular lens options are available and we present our experience with multifocal, extended depth-of-focus, light-adjustable, and monofocal lenses., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Neurenteric cysts are rare benign lesions that are usually located in the lower cervical and upper thoracic spine and extremely rare in the craniovertebral junction. It is generally challenging to completely remove the neurenteric cysts of the craniovertebral junction. We report the cases of 2 patients with neurenteric cyst in the ventral craniovertebral junction managed using different treatment strategies., Patient Concerns: The first patient was a 64-year-old man. He man was admitted with headache, posterior neck pain, and a tingling sensation in both the forearms. The second patient was a 53-year-old woman. She was admitted with tingling sensations and numbness in both the hands and feet., Diagnoses: Cervical spine magnetic resonance imaging showed 2 intradural extramedullary cystic lesions in case 1 and a C2 to C3 intradural extramedullary cystic mass in case 2., Interventions and Outcomes: The patient of the case 1 underwent a left C1 to C2 hemi-laminectomy and the cysts were completely removed. Eleven years after the surgery, there was no recurrence. In case 2, we performed a left C2 to C3 hemi-laminectomy and removed only a part of the outer membrane to enable sufficient communication with the surrounding normal subarachnoid space. After removing the cyst wall, the patient underwent C1 to 2 trans articular screw fixation to prevent cervical instability. Ten years after surgery, there was no recurrence of the cyst or new lesions., Lessons: Clinicians should consider neurenteric cyst in the differential diagnosis of arachnoid cyst or epidermoid cyst. If performing a complete surgical removal is difficult, partial surgical removal, using a cysto-subarachnoid shunt and stabilization, such as screw fixation, could be an alternative treatment option to reduce the risk of mortality and morbidity., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Pharyngocutaneous fistula (PCF) caused by a previous anterior cervical spine fixation plate more than a decade ago has not been reported yet. A 70-year-old man with dysphagia was diagnosed as supraglottic cancer. After partial laryngectomy and concurrent chemoradiation, due to increasing arytenoid lesion, total laryngectomy was followed. Pharyngocutaneous fistula occurred but resolved spontaneously. However, retropharyngeal granulation tissue emerging from the anterior cervical spine fixation plate caused delayed PCF. Dysphagia and PCF resolved after fixation plate removal., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objectives: The objective of this study was to determine factors affecting the survival of pedicled latissimus dorsi (LD) flap., Materials and Methods: Medical records of 20 pedicled LD flap patients for head and neck reconstruction by a single operator from 2015 to 2019 in a tertiary hospital were reviewed. Factors including flap size and pedicle's length from the most distal end of the flap to the axilla (Fp) and from the most distal end of the defect to the axilla (Dfp) were assessed. Partial flap loss requiring procedures and total loss were considered as failure. Descriptive statistics, the Pearson χ 2 test, and linear-by-linear association analysis were performed., Results: Seventy percent of patients showed success. There was no significant difference in various factors including preoperative body mass index, underlying diseases such as hypertension and diabetes, preoperative treatment either radiation or chemotherapy, lab results, and operation time between the survival and the failure group. Rotation arc (Dfp/Fp) showed significant difference between 2 groups ( P =0.001). Unlike Fp, Dfp tend to be shorter on the success group ( P =0.053)., Conclusions: Low rotation arc through shorter Dfp affects survival of pedicled LD flap significantly., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Introduction: Parapharyngeal space salivary gland tumors are very rare. The authors sought to examine the clinical features, treatment methods, and treatment results of parapharyngeal space salivary gland tumors in our hospital., Methods: The authors retrospectively enrolled 15 patients who were finally diagnosed as having parapharyngeal space salivary gland tumors from January 2010 to January 2021., Results: All parapharyngeal space salivary gland tumors arose from the prestyloid compartment. This study included 3 males and 12 females. The main symptoms were incidental diagnosis during imaging tests, followed by neck discomfort, oral mass, neck mass, and headache. Surgical methods for parapharyngeal space salivary gland tumors were performed in the following order: transcervical approach (n = 10), transcervical-parotid approach (n = 3), transoral approach (n = 1), and transparotid approach (n = 1). Pleomorphic adenoma was the most common tumor among parapharyngeal space salivary gland tumors., Conclusions: In the surgery of parapharyngeal space salivary gland tumors, a transcervical or transcervical-parotid approach was mainly used by predicting the origin site through radiologic examinations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Background: The Δ160E mutation in TNNT2 , which encodes troponin T, is a rare pathogenic variant identified in patients with hypertrophic cardiomyopathy and is associated with poor prognosis. Thus, a convenient human model recapitulating the pathological phenotype caused by TNNT2 Δ160E is required for therapeutic development., Methods: We identified a heterozygous in-frame deletion mutation (c.478&#95;480del, p.Δ160E) in TNNT2 in a patient with familial hypertrophic cardiomyopathy showing progressive left ventricular systolic dysfunction, leading to advanced heart failure. To investigate the pathological phenotype caused by Δ160E, we generated a set of isogenic induced pluripotent stem cells carrying the heterozygous Δ160E, homozygously corrected or homozygously introduced Δ160E using genome editing and differentiated them into cardiomyocytes (Hetero-Δ160E-, wild type-, and Homo-Δ160E-induced pluripotent stem cells [iPSC]-derived cardiomyocytes [iPSC-CMs])., Results: Hetero-Δ160E-iPSC-CMs exhibited prolonged calcium decay, relaxation impairment, and hypertrophy compared to wild type-iPSC-CMs. Notably, these phenotypes were further exacerbated in Homo-Δ160E-iPSC-CMs. Overexpression of R-GECO-fused Δ160E mutant troponin T prolonged decay time and time to peak of the myofilament-localized calcium transient in iPSC-CMs, indicating that sarcomeric calcium retention with Δ160E may affect intracellular calcium concentration. High-content imaging analysis detected remarkable nuclear translocation of NFATc1, especially in Homo-Δ160E-iPSC-CMs, indicating that the Δ160E mutation promotes hypertrophic signaling pathway in a dose-dependent manner. Increased phosphorylation of CaMKIIδ (calcium/calmodulin-dependent protein kinase IIδ) and phospholamban at Thr17 was observed in Homo- and Hetero-Δ160E-iPSC-CMs. Epigallocatechin-3-gallate, a calcium desensitizing compound, shortened prolonged calcium decay and relaxation duration in Δ160E-iPSC-CMs., Conclusions: Isogenic iPSC-CMs recapitulate the prolonged calcium decay, relaxation impairment, and subsequent calcium-regulated signaling pathways caused by the TNNT2 Δ160E mutation and can serve as a human model for therapeutic development to prevent hypertrophic cardiomyopathy pathology.

This study aimed to evaluate the influence of subsidence in patients who performed stand-alone anterior cervical discectomy and fusion (ACDF) by analyzing the long-term clinical and radiological outcomes. This retrospective study enrolled 53 patients with 79 segments with degenerative cervical disease treated with stand-alone ACDF with ≥5 years of follow-up. Segmental angle (SA), cervical sagittal alignment (CSA), subsidence, and fusion were analyzed. Visual analog scale (VAS) scores and neck disability index (NDI) were also evaluated. Subsidence occurred in 24 (45.2%) patients and 38 segments (48.1%) at the last follow-up. The mean VAS score and NDI had improved in both the subsidence and non- subsidence groups. The mean SA at the last follow-up had increased to 1.3° ± 8.5° in the subsidence group and to 1.5° ± 5.2° in the non-subsidence group compared with the post-operative SA (P < .001). The overall mean CSA at the last follow-up increased over time in both the groups compared with the post-operative CSA (P = .003). The fusion rate at 1 year after surgery was 86.8% and 82.9% in the subsidence and non-subsidence groups, respectively. However, the differences in the SA, CSA, and fusion rates between the groups were not statistically significant (P = .117, .98, and .682, respectively). Subsidence after stand-alone ACDF occurs to a certain capacity; however, it does not appear to significantly influence the radiological and clinical outcomes if foramen decompression is adequately and sufficiently provided in a long-term follow-up study. In contrast, subsidence appears to positively affect the fusion rate in the short-term follow-up., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

This study aimed to investigate whether changes in the bone turnover markers (BTMs) during teriparatide therapy for osteoporotic vertebral compression fractures could reflect therapeutic effects by analyzing the relationship between clinical and radiological features and BTMs. A total of 33 patients with 51 osteoporotic vertebral compression fracture segments were included. Plain radiographs and BTM levels were evaluated at the pretreatment and at 3 months after teriparatide treatment. Based on serial vertebral compression ratio analysis, the progression of fracture was defined as a vertebral compression ratio decrease of ≥10%, relative to the pretreatment values. All segments were divided into 2 groups: the "maintain" group with 32 (62.7%) segments and the "progression" group with 19 (37.3%) segments. After the teriparatide treatment, serum osteocalcin and serum C-terminal telopeptide of type I collagen levels (P = .028 and .008, respectively), and change amounts of them were significantly larger, increasing (P = .001) in the progression group. The vitamin D (25OH-D) levels were significantly lower (P = .038) in the progression group; however, the relative changes in the 25OH-D levels between the 2 groups, before and after the treatment, were not significantly different (P = .077). The parathyroid hormone (PTH) levels were reduced by the teriparatide treatment in both groups, while the decrease in PTH concentration after the treatment was significantly more pronounced in the progression group (P = .006). Significant increase in the osteocalcin and serum C-terminal telopeptide of type I collagen levels and a simultaneous decrease in the PTH levels during the teriparatide treatment suggest that clinicians should assume the progression of fracture., Competing Interests: All authors associated with this submission have no financial conflicts of interest to disclose. The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Since it is a widely known fact that smoking cessation is beneficial physically and cognitively, efforts should be made to enable smokers to quit smoking through policy. Intensive care smoking cessation camps generally show a high smoking cessation success rate, but research is needed to determine which smokers should be admitted due to costeffectiveness. Although many studies have been conducted to find factors related to smoking cessation success, there is still controversy about the will and success rate of smoking cessation of elderly smokers. We performed this study to determine behavior characteristics and smoking cessation success rates in nonelderly and elderly smokers who participated in an intensive care smoking cessation camp. Heavy smokers participating in an intensive care smoking cessation camp at Chonnam National University Hospital between the August 2015 and December 2017 were classified into elderly (age ≥65 years old) or nonelderly (age <65 years old) groups after excluding missing data. Smokers were followed up at 4 weeks, 6 weeks, 12 weeks, and 6 months from the start of abstinence by self-report, measurement of carbon monoxide expiration levels or cotinine testing. A total of 351 smokers were enrolled in the study. At the 6-month follow-up, 56 of 107 (52.3%) elderly smokers and 109 of 244 (44.7%) nonelderly smokers continued to abstain from smoking. Elderly smokers showed a higher smoking cessation rate than that of nonelderly smokers, but it was not statistically significant (OR = 1.36, 95%CI: 0.862, 2.145). The most common causes of cessation failure in both groups were stress and temptation, followed by withdrawal symptoms. Smoking cessation rates in the elderly are comparable to that in the nonelderly after an intensive care smoking cessation camp. Intensive care smoking cessation camps can help both elderly and nonelderly smokers who intend to quit smoking by providing motivation, education and medication. Smoking cessation should be strongly recommended regardless of age., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose of Review: Despite affecting approximately 1.8 billion individuals worldwide, until recently, a pharmacologic treatment for presbyopia was not available. This special commentary reviews the treatment of presbyopia with a focus on the recently approved medication Vuity (pilocarpine 1.25%, Allergan, an AbbVie Company)., Recent Findings: Vuity is a re-engineered formulation of pilocarpine 1.25% specifically designed for the treatment of presbyopia. Recently published results from the GEMINI 1 Phase 3 clinical trial reported improvement in distance corrected near vision without significant compromise in distance vision. No unexpected safety findings were reported with mild headache being the most common adverse event. Notably, there were no reported cases of retinal detachment or angle closure during the 30-day phase 3 clinical trials., Summary: Vuity is the first treatment designed and FDA approved to treat the growing presbyopia market. Phase 3 clinical trials demonstrated its ability to improve near vision without significant compromise in distance vision. We recognize this paradigm shift in the treatment of presbyopia and anxiously await additional treatment options for this ubiquitous condition., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Oblique lumbar interbody fusion (OLIF) is an effective and safe surgical technique widely used for treating spondylolisthesis; however, its use is controversial because of several associated complications, including endplate injury. We report a rare vertebral body fracture following OLIF in a patient with poor bone quality., Patient Concerns: A 72-year-old male patient visited our clinic for 2 years with lower back pain, leg radiating pain, and intermittent neurogenic claudication., Diagnoses: Lumbar magnetic resonance imaging revealed L4-5 stenosis., Intervention: We performed OLIF with percutaneous pedicle screw fixation and L4 subtotal decompressive laminectomy. We resected the anterior longitudinal ligament partially for anterior column release and inserted a huge cage to maximize segmental lordosis. No complications during and after the operation were observed. Further, the radiating pain and back pain improved, and the patient was discharged. Two weeks after the operation, the patient visited the outpatient department complaining of sudden recurred pain, which occurred while going to the bathroom. Radiography and computed tomography revealed a split fracture of the L5 body and an anterior cage displacement. In revision of OLIF, we removed the dislocated cage and filled the bone cement between the anterior longitudinal ligament and empty disc space. Further, we performed posterior lumbar interbody fusion L4-5, and the screw was extended to S1., Outcomes: After the second surgery, back pain and radiating pain in the left leg improved, and he was discharged without complications., Lesson: In this case, owing to insufficient intervertebral space during L4-5 OLIF, a huge cage was used to achieve sufficient segmental lordosis after anterior column release, but a vertebral body coronal fracture occurred. In patients with poor bone quality and less flexibility, a huge cage and over-distraction could cause a vertebral fracture; hence, selecting an appropriate cage or considering a posterior approach is recommended., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)