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Study Design: Retrospective cohort study of prospectively accrued data., Objective: To evaluate a large, prospective, multicentre dataset of surgically treated degenerative cervical myelopathy (DCM) cases on the contemporary risk of C5 palsy with surgical approach., Summary of Background Data: The influence of surgical technique on postoperative C5 palsy after decompression for DCM is intensely debated. Comprehensive, covariate-adjusted analyses are needed using contemporary data., Methods: Patients with moderate to severe DCM were prospectively enrolled in the multicenter, randomized, Phase III CSM-Protect clinical trial and underwent either anterior or posterior decompression between Jan 31, 2012 and May 16, 2017. The primary outcome was the incidence of postoperative C5 palsy, defined as the onset of muscle weakness by at least one grade in manual muscle test at the C5 myotome with slight or absent sensory disruption after cervical surgery. Two comparative cohorts were made based on the anterior or posterior surgical approach. Multivariate hierarchical mixed-effects logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI) for C5 palsy., Results: A total of 283 patients were included, and 53.4% underwent posterior decompression. The total incidence of postoperative C5 palsy was 7.4% and was significantly higher in patients who underwent posterior decompression compared with anterior decompression (11.26% vs. 3.03%, P =0.008). After multivariable regression, the posterior approach was independently associated with greater than four times the likelihood of postoperative C5 palsy ( P =0.017). Rates of C5 palsy recovery were comparable between the two surgical approaches., Conclusion: The odds of postoperative C5 palsy are significantly higher after posterior decompression compared to anterior decompression for DCM. This may influence surgical decision-making when there is equipoise in deciding between anterior and posterior treatment options for DCM., Level of Evidence: Therapeutic Level-II., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives : Many risk factors for postoperative C5 palsy (PC5P) have been reported regarding a "cord shift" after a posterior approach. However, there are few reports about shoulder traction as a possible risk factor of anterior cervical surgery. Therefore, we assessed the stretched nerve roots when shoulder traction was applied on cadavers. Materials and Methods : Eight cadavers were employed in this study, available based on age and the presence of foramen stenosis. After dissecting the sternocleidomastoid muscle of the cadaver, the shoulder joint was pulled with a force of 2, 5, 8, 10, 15, and 20 kg. Then, the stretched length of the fifth nerve root was measured in the extra-foraminal zone. In addition, the same measurement was performed after cutting the carotid artery to accurately identify the nerve root's origin. After an additional dissection was performed so that the superior trunk of the brachial plexus could be seen, the stretched length of the fifth and sixth nerve roots was measured again. Results : Throughout the entire experiment, the fifth nerve root stretched out for an average of 1.94 mm at 8 kg and an average of 5.03 mm at a maximum force of 20 kg. In three experiments, the elongated lengths of the C5 nerve root at 8 kg and 20 kg were 1.69/4.38 mm, 2.13/5.00 mm, and 0.75/5.31 mm, respectively, and in the third experiment, the elongated length of the C6 nerve root was 1.88/5.44 mm. Conclusions : Although this was a cadaveric experiment, it suggests that shoulder traction could be the risk factors for PC5P after anterior cervical surgery. In addition, for patients with foraminal stenosis and central stenosis, the risk would be higher. Therefore, the surgeon should be aware of this, and the patient would need sufficient explanation.

Competing Interests: The authors have no conflicts of interest to disclose.

Introduction: Spinal cord infarction (SCI) is a rare disease representing nearly 1% of all strokes with a wide variety of symptoms at presentation. SCI diagnosis is very challenging owing to its low incidence and the variety of symptoms, and could be misdiagnosed with neuromyelitis optica spectrum disorders (NMOSD)., Case Presentation: We describe the case of an 18-year-old girl who presented to the emergency department with acute neck pain and flaccid paralysis of the left upper and lower extremities. Few hours later, she developed apnea and was endotracheally intubated. Brain MRI was normal but spinal cord MRI revealed non-enhancing longitudinal abnormal high T2 signal intensity extending from C1 to C5. The patient underwent steroid therapy with methylprednisolone (1 g daily for 7 consecutive days) combined with physiotherapy. She was extubated after 3 weeks and discharged after 30 days of hospitalization with a muscle force of 4/5 in her left extremities., Discussion: Idiopathic SCI in adolescence is a rare but often devastating disorder with unknown pathophysiology, however, some specific conditions in adolescent such as mechanical stresses on the immature spine can be considered as risk factors for SCI development. Early diagnosis and treatment can improve outcomes in SCI., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: Ultrasonography is not chosen as the common imaging modality to diagnose spinal cord diseases. The present report indicates good diagnostic efficacy of ultrasonography for identifying spinal cord compressed by subcutaneous mass when scanning through the defected vertebral laminae and spinous process., Case Description: A five-month-old female Holstein calf presented with progressive hindlimb paralysis following a surgical resection of a back mass conducted at 21 days of age. The mass was subsequently histopathologically diagnosed as a pulmonary choristoma. Alongside hindlimb paralysis, the calf developed a swollen back at the lumbar region where the mass was removed. This suggested regrowth of the resected mass, causing injury to the underlying spinal cord. Ultrasonography identified the subcutaneous involvement of the capsular mass, which had three anechoic cavities separated by the echogenic septal structures. The spinal cord could be ultrasonographically demonstrated as adjacent to the mass through the defected vertebral laminae and spinous process in the second and third lumbar vertebras. Ultrasound-guided centesis allowed the collection of purulent exudates in which Escherichia coli was isolated. Myelography and subsequent computed tomography (CT) revealed a partial blockage of the intradural flow of contrast media at the levels of the second and third lumbar vertebras, diagnosed as spina bifida on the CT images. When applying ultrasonography to the spinal cord within a saline pool soon after the subcutaneous abscess was successfully resected, the spinal cord was characterized by the interrupted and partly extended hyperechogenic line of the central canal within the echogenic parenchyma. The echotexture of the spinal cord showed damage due to compression from the subcutaneous abscess. The animal had a sub-optimal postoperative outcome, including limited improvement of the neurological signs., Conclusion: In the present case, combining ultrasonography, radiography (myelography), and CT was very effective for diagnosing spina bifida, with the subcutaneous abscess inducing spinal cord compression. Additionally, using intraoperative ultrasonographic scanning to evaluate the degree of spinal cord damage can contribute to predicting the postoperative outcome., Competing Interests: The authors declare that there is no conflict of interest.

Background: Patients with spinal meningioma may present preoperatively with paralysis and sensory deficits. However, there is a paucity of detailed evaluations and a lack of consensus regarding imaging findings that are predictive of neurological symptoms in patients with spinal meningioma., Methods: Herein, a total of 55 patients who underwent surgical resection of spinal meningiomas in eight hospitals between 2011 and 2021 were enrolled. Patient characteristics, degree of muscle weakness, sensory disturbances, and the presence of bowel/bladder dysfunction (BBD) before surgical treatment were evaluated using medical records. Patients with American Spinal Injury Impairment Scale grades A-C and the presence of BBD were classified into the paralysis (+) group. Patients with sensory disturbances were assigned to the sensory disturbance (+) group. Based on magnetic resonance (MR) and computed tomography images, the tumor location was classified according to the spinal level and its attachment to the dura mater. To evaluate tumor size, the tumor occupation ratio (OR) was calculated using the area and distance measurement method in horizontal MR images, and the maximum length and area of the tumor in the sagittal plane were measured., Results: Of all patients, 85 % were women. The mean age of patients at surgery was 69.7 years. Twenty-eight (51 %) and 41 (75 %) patients were classified into the paralysis (+) and sensory disturbance (+) groups, respectively. The average tumor length and area in the sagittal plane were 19.6 mm and 203 mm 2 , respectively; OR-area and diameters were 70.3 % and 72.3 %, respectively. In univariate analyses, tumor length and area in the sagittal plane were significant risk factors for paralysis. OR-diameter, symptom duration, and a low MIB-1 index correlated with sensory disturbances. Multivariate logistic regression analysis demonstrated that the area and length of the tumor in the sagittal plane were significantly correlated with paralysis, whereas the OR-diameter and symptom duration significantly correlated with sensory disturbances. The cut-off values for the area and length of the tumor in the sagittal plane to predict paralysis were 243 mm 2 and 20.1 mm, respectively., Conclusions: Preoperative paralysis in patients with spinal meningiomas was significantly associated with sagittal tumor size than with high tumor occupancy in the horizontal plane. Sensory disturbances were associated with high occupancy in the horizontal plane. Patients with spinal meningiomas > 20 mm in length or 243 mm 2 in area in the sagittal plane are at risk of developing paralysis and could be considered for surgery even in the absence of paralysis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Competing Interests: Competing interests: None.

Background: Acute flaccid paralysis (AFP) is a complex clinical syndrome with various aetiologies. If untreated, AFP may lead to death due to failure of respiratory muscles. Tick paralysis, which is a noninfectious neurologic syndrome of AFP, occurs following tick attachment, engorgement, and injection of tick saliva toxins. There is no specific diagnostic test for tick paralysis, and mortality increases as definitive diagnosis is delayed. Although metabolomic investigation of tick saliva was conducted, there is a lack of research on metabolomic evaluation of hosts affected by tick paralysis., Objectives: Thus, the aim of this study is to investigate metabolomic changes in serum samples of dogs with tick paralysis due to Rhipicephalus sanguineus using NMR-based metabolomics and to identify potential diagnostic/prognostic markers., Materials and Methods: Forty dogs infested with R. sanguineus, with clinical findings compatible with AFP and with a confirmed tick paralysis diagnosis ex juvantibus, constituted the Paralysis Group. Ten healthy dogs, which were admitted either for vaccination and/or check-up purposes, constituted the Control Group. After the confirmation tick paralysis, medical history, vaccination and nutritional status, body surface area and estimated tick numbers of all the dogs were noted. Physical examination included body temperature, heart and respiratory rate, capillary refill time evaluation and Modified Glasgow Coma Scale calculation. Serum samples were extracted from venous blood samples of all the dogs and were prepared for NMR analysis, and NMR-based metabolomics identification and quantification were performed., Results: NMR-based serum metabolomics of the present study revealed distinct up/down-regulated expressions, presenting a promising avenue. Moreover, it was observed that energy metabolism and especially liver functions were impaired in dogs with tick paralysis, and not only the respiratory system but also the kidneys were affected., Conclusion: It was concluded that the present approach may help to better understand the pathological mechanisms developing in cases of AFP due to tick paralysis., (© 2024 The Author(s). Veterinary Medicine and Science published by John Wiley & Sons Ltd.)

Purpose: To report the surgical outcome of synovial osteochondromatosis, a rare tumor of the cervical spine, in a 6-year-old boy., Methods: A 6-year-old boy presented with muscle weakness in the right deltoid (2) and biceps (4) during a manual muscle test. Magnetic resonance imaging showed a 3 × 2 × 1.5 cm mass within the spinal canal at the C4-6 level, compressing the cervical spinal cord from the right side. Computed tomography revealed hyperintense areas within the tumor and ballooning of the right C4-5 and C5-6 facet joints., Results: After a biopsy confirmed the absence of malignancy, a gross total resection was performed. The pathological diagnosis of synovial osteochondromatosis was established. Postoperatively, muscle weakness improved fully in the manual muscle test, and there were no neurological findings after 3 months. However, the patient is under careful follow-up owing to the detection of a regrowth site within the right C4-5 and C5-6 intervertebral foramen 2 years postoperatively., Conclusions: Synovial osteochondromatosis of the cervical spine in children is rare, and this is the first report of its regrowth after surgery. Synovial osteochondromatosis should be included in the differential diagnosis of pediatric cervical spine tumors., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Life sometimes provides unannounced challenges that threaten the structure of our existence. This personal account of an ob-gyn's encounter with paralysis will illustrate the impact of one such experience., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

A ganglion cyst is a benign mass consisting of high-viscosity mucinous fluid. It can originate from the sheath of a tendon, peripheral nerve, or joint capsule. Compressive neuropathy caused by a ganglion cyst is rarely reported, with the majority of documented cases involving peroneal nerve palsy. To date, cases demonstrating both peroneal and tibial nerve palsies resulting from a ganglion cyst forming on a branch of the sciatic nerve have not been reported. In this paper, we present the case of a 74-year-old man visiting an outpatient clinic complaining of left-sided foot drop and sensory loss in the lower extremity, a lack of strength in his left leg, and a decrease in sensation in the leg for the past month without any history of trauma. Ankle dorsiflexion and great toe extension strength on the left side were Grade I. Ankle plantar flexion and great toe flexion were Grade II. We suspected peroneal and tibial nerve palsy and performed a screening ultrasound, which is inexpensive and rapid. In the operative field, several cysts were discovered, originating at the site where the sciatic nerve splits into peroneal and tibial nerves. After successful surgical decompression and a series of rehabilitation procedures, the patient's neurological symptoms improved. There was no recurrence.

Objective: To review the research progress of C 5 palsy (C 5 P) after cervical surgery, providing new clinical intervention ideas for the C 5 P patients., Methods: The relevant literature domestically and abroad was extensively consulted and the latest developments in the incidence, risk factors, manifestations and diagnosis, prevention, and intervention measures of C 5 P were systematically expounded., Results: C 5 P is characterized by weakness in the C 5 nerve innervation area after cervical decompression surgery, manifested as limited shoulder abduction and elbow flexion, with an incidence rate more than 5%, often caused by segmental spinal cord injury or mechanical injury to the nerve roots. For patients with risk factors, careful operation and preventive measures can reduce the incidence of C 5 P. Most of the patients can recover with conservative treatment such as drug therapy and physical therapy, while those without significant improvement after 6 months of treatment may require surgical intervention such as foraminal decompression and nerve displacement., Conclusion: Currently, there has been some advancement in the etiology and intervention of C 5 P. Nevertheless, further research is imperative to assess the timing of intervention and surgical protocol.

The aim of this study was to describe the gross and histopathological features of a neurological syndrome in endangered Western Australian Carnaby's black cockatoos (Zanda laitirostris) that was first observed in 2012. The syndrome, named hindlimb paralysis syndrome in Carnaby's cockatoos (CHiPS), is characterized by annual outbreaks of hindlimb paralysis with occasional loss of deep pain and cloacal tone, typically occurring between January and March. Previous limited investigations suggested a possible toxic aetiology. Full gross necropsy and histopathology examinations were performed on 17 CHiPS cases and on 11 control birds for reference. Histopathological examination was carried out on all major organs including brain, spinal cord, brachial plexus, sciatic nerve and wing and hindlimb muscles. Gross and histopathological examinations did not elucidate a definitive cause of the clinical signs seen in CHiPS cases. There were no substantial gross or histopathological changes within the brain, spinal cord, sciatic nerve or brachial plexus that could explain the hindlimb paralysis. The most noteworthy changes were seen in the hindlimb and wing muscles, with a monophasic to polyphasic myopathy present in the hindlimb muscles of 15 of the 17 CHiPS cases and in the wing muscles in 11 of those cases. The cause and significance of the myopathy is unclear and requires further investigation. Based on the above findings, the most likely differential diagnoses include neurotoxicoses (eg, organophosphate, organochlorine and carbamate) and, less likely, myotoxicosis (eg, ionophore toxicosis), nutritional myopathy (eg, vitamin E/selenium deficiency) or botulism., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The Pavlik harness has been used for approximately a century to treat developmental dysplasia of the hip (DDH). Femoral nerve palsy is a documented complication of Pavlik harness use, with an incidence ranging from 2.5% to 11.2%. Rare reports of brachial plexus palsy have also been documented. The primary purpose of the current study was to evaluate the incidence of various nerve palsies in patients undergoing Pavlik harness treatment for DDH. Secondary aims were to identify patient demographic or hip characteristics associated with nerve palsy., Methods: We performed a retrospective review of patients diagnosed with DDH and treated with a Pavlik harness from February 1, 2016, to April 1, 2023, at a single tertiary care orthopaedic hospital. Hip laterality, use of a subsequent rigid abduction orthosis, birth order, breech positioning, weight, and family history were collected. The median (and interquartile range [IQR]) or mean (and standard deviation [SD]) were reported for all continuous variables. Independent 2-sample t tests and Mann-Whitney U tests were conducted to identify associations between the variables collected at the initiation of Pavlik harness treatment and the occurrence of nerve palsy., Results: Three hundred and fifty-one patients (547 hips) were included. Twenty-two cases of femoral nerve palsy (4% of all treated hips), 1 case of inferior gluteal nerve palsy (0.18%), and 2 cases of brachial plexus palsy (0.37%) were diagnosed. Patients with nerve palsy had more severe DDH as measured by the Graf classification (p < 0.001) and more severe DDH as measured on physical examination via the Barlow and Ortolani maneuvers (p = 0.003)., Conclusions: Nerve palsies were associated with more severe DDH at the initiation of Pavlik harness use. Upper and lower-extremity neurological status should be scrutinized at initiation and throughout treatment to assess for nerve palsies. The potential for femoral, gluteal, and brachial plexus palsies should be included in the discussion of risks at the beginning of treatment. Families may be reassured that nerve palsies associated with Pavlik harness can be expected to resolve with a short break from treatment., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H864)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: The authors have no conflicts of interest or financial disclosures to report.

Objectives: We evaluated the time course of the American Spinal Cord Injury Association (ASIA) impairment scale (AIS) for up to three months in participants within 72 h after traumatic spinal cord injury (TSCI) with complete paralysis. We aimed to determine the most useful sacral-sparing examination (deep anal pressure [DAP], voluntary anal contraction [VAC], S4-5 light touch [LT], or pin prick [PP] sensation) in determining AIS grades., Design: Retrospective cohort study., Setting: Spinal Injuries Center, Fukuoka, Japan., Participants: Among 668 TSCI participants registered in the Japan Single Center study for Spinal Cord Injury Database (JSSCI-DB) between January 2012 and May 2020, we extracted the data of 80 patients with AIS grade A within 72 h after injury and neurological level of injury (NLI) at T12 or higher., Interventions: None., Outcome Measures: The sacral-sparing examination at the time of the change to incomplete paralysis was compared to the AIS determination using a standard algorithm and with each assessment including the VAC, DAP, S4-5LT, and S4-5PP examinations at the time of AIS functional change. Agreement among assessments was evaluated using weighted kappa coefficients. The relationship was evaluated using Spearman's rank correlation coefficients., Results: Fifteen participants (18.8%) improved to incomplete paralysis (AIS B to D) within three months after injury. The single assessment among the sacral-sparing examinations with the highest agreement and strongest correlation with AIS determination was the S4-5LT examination ( k  = 0.89, P  < 0.01, r  = 0.84, P  < 0.01)., Conclusions: The S4-5LT examination is key in determining complete or incomplete paralysis due to its high discriminatory power.

A neurologist puzzles over the etiology of her physician grandmother's paralysis in an attempt to localize her lesion and discovers what matters most about her grandmother's history and illness.

Case: A 69-year-old man underwent a C3-4 anterior cervical discectomy and fusion and developed postoperative hypoglossal and glossopharyngeal palsies that resolved with symptomatic treatment., Conclusion: Cranial nerve palsy is a rare and possibly under-reported injury after higher-level cervical spine surgery. Conscientious positioning and awareness of these nerves during surgical exposure are crucial to minimizing cranial nerve palsies. Proper workup to identify these palsies and differentiate them from other complications is necessary to guide proper treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C292)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Systematic review and meta-analysis., Objective: Using a network meta-analysis (NMA), this study aimed to compare the risks of C5 palsy after three different procedures of anterior cervical decompression., Summary of Background Data: C5 palsy is a well-known complication affecting the quality of life after anterior procedures. Due to the limited evidence on the various procedures available, we evaluate the basis for selection to prevent palsy and achieve maximal decompression in cases spanning 3-6 levels., Materials and Methods: We conducted a comprehensive search for C5 palsy and complications after 3representative procedures, including anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and their combination (hybrid), involving 3 to 6 intervertebral levels. The incidence of C5 palsy was compared using a NMA., Results: We identified 1655 patients in 11 studies who met inclusion criteria. Sixty-nine patients (4.2%) developed delayed C5 palsies. The incidences among ACDF, ACCF, and hybrid cases were 2.3% (16/684, 95% CI: 1.4% to 3.8%), 6.4% (39/613, 95% CI: 4.7% to 8.6%), and 3.9% (14/358, 95% CI: 2.3% to 6.5%), respectively ( P < 0.01). A NMA was performed for 15 pairwise comparisons across the 3 procedure arms: ACDF versus hybrid, 7/232 (3.0%) versus 11/234 (4.7%); hybrid versus ACCF, 14/301 (4.3%) versus 18/224 (8.0%); ACCF versus ACDF, 38/523 (7.8%) versus 16/619 (2.6%). Compared with ACDF, the risk of C5 palsy was significantly higher in ACCF (odds ratio: 2.72, 95% CI: 1.47 to 5.01), whereas ACDF versus hybrid did not significantly differ in risk (odds ratio: 1.56, 95% CI: 0.68 to 3.60)., Conclusion: We determined that ACCF was associated with a higher risk of postoperative C5 palsy than ACDF in cases spanning 3 to 6 intervertebral levels. If practicable, ACDF surgery may be an appropriate choice for cases requiring anterior decompression of 3 to 6 levels., Level of Evidence: Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Biological reconstruction by replanting the resected tumor-bearing segment is preferred by some surgeons when caring for a patient with a bone sarcoma. Frozen autografts are advantageous because they are cost-effective, provide an excellent fit, permit the maintenance of osteoinductive and osteoconductive properties, and are not associated with transmission of viral disease. The pedicle frozen autograft technique, in which only one osteotomy is made for the freezing procedure, keeping the affected segment in continuity with the host bone and soft tissue instead of two osteotomies, maintains the affected segment with the host bone and soft tissue. This could restore blood flow more rapidly in a frozen autograft than in a free-frozen autograft with two osteotomies., Questions/purposes: (1) In what proportion of patients was union achieved by 6 months using this technique of frozen autografting? (2) What complications were observed in a small series using this approach? (3) What was the function of these patients as determined by Musculoskeletal Tumor Society (MSTS) score? (4) What proportion of patients experienced local recurrence?, Methods: Between 2014 and 2017, we treated 87 patients for primary sarcomas of the femur, tibia, or humerus. Of those, we considered patients who could undergo intercalary resection and showed a good response to neoadjuvant chemotherapy as potentially eligible for this technique. Based on these criteria, 49% (43 patients) were eligible; a further 9% (eight) were excluded because of inadequate bone quality (defined as cortical thickness less than 50% by CT assessment). We retrospectively studied 32 patients who were treated with a single metaphyseal osteotomy, the so-called pedicle freezing technique, which uses liquid nitrogen. There were 20 men and 12 women. The median age was 18 years (range 13 to 48 years). The median follow-up duration was 55 months (range 48 to 63 months). Patients were assessed clinically and radiologically regarding union (defined in this study as bony bridging of three of four cortices by 6 months), the proportion of patients experiencing local recurrence, the occurrence of nononcologic complications, and MSTS scores., Results: Three percent (one of 32) of the patients had nonunion (no union by 9 months). The median MSTS score was 90%, with no evidence of metastases at the final follow-up interval. Nine percent (three of 32) of our patients died. The local recurrence rate was 3.1% (one of 32 patients). The mean restricted disease-free survival time at 60 months (5 years) was 58 months (95% CI 55 to 62 months). Twenty-five percent of patients (eight of 32) experienced nononcologic complications. This included superficial skin burns (two patients), superficial wound infection (two patients), deep venous thrombosis (one patient), transient nerve palsy (two patients), and permanent nerve palsy (one patient)., Conclusion: This treatment was reasonably successful in patients with sarcomas of the femur, tibia, and humerus who could undergo an intercalary resection, and this treatment did not involve the epiphysis and upper metaphysis. It avoids a second osteotomy site as in prior reports of freezing techniques, and union was achieved in all but one patient. There were few complications or local recurrences, and the patients' function was shown to be good. This technique cannot be used in all long-bone sarcomas, but we believe this is a reasonable alternative treatment for patients who show a good response to neoadjuvant chemotherapy, those in whom intercalary resection is feasible while retaining at least 2 cm of the subchondral area, and in those who have adequate bone stock to withstand the freezing process. Experienced surgeons who are well trained on the recycling technique in specialized centers are crucial to perform the technique. Further study is necessary to see how this technique compares with other reconstruction options., Level of Evidence: Level IV, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Stroke is a leading cause of paralysis, most frequently affecting the upper limbs and vocal folds. Despite recent advances in care, stroke recovery invariably reaches a plateau, after which there are permanent neurological impairments. Implantable brain-computer interface devices offer the potential to bypass permanent neurological lesions. They function by (1) recording neural activity, (2) decoding the neural signal occurring in response to volitional motor intentions, and (3) generating digital control signals that may be used to control external devices. While brain-computer interface technology has the potential to revolutionize neurological care, clinical translation has been limited. Endovascular arrays present a novel form of minimally invasive brain-computer interface devices that have been deployed in human subjects during early feasibility studies. This article provides an overview of endovascular brain-computer interface devices and critically evaluates the patient with stroke as an implant candidate. Future opportunities are mapped, along with the challenges arising when decoding neural activity following infarction. Limitations arise when considering intracerebral hemorrhage and motor cortex lesions; however, future directions are outlined that aim to address these challenges., Competing Interests: Disclosures Drs Fry, Opie, and Oxley are employees of Synchron. Drs Fry, Opie, and Oxley report stock options from Synchron. Dr Brannigan reports consulting fees from Synchron. Drs Opie and Oxley report issued and pending patents for sensing or stimulating activity of neural tissue. P. Mitchell reports compensation from Stryker Corporation for consultant services; compensation from Medtronic USA, Inc, and Stryker Corporation for other services. The other author reports no conflicts.

Introduction: Median nerve injuries occur in approximately 3% of pediatric elbow fracture dislocations. These rare injuries can be difficult to diagnose, and the results are poor in delay cases. Surgical timing is one of the most important prognostic factors. We aimed to present three patients with median nerve palsy who were referred to our clinic late, and according to these cases, we emphasized the expected time frame for exploration based on our anatomical cadaver study., Materials and Methods: Between 2008 and 2010, three patients were referred to our clinic because of median nerve paralysis after a treated elbow dislocation. The mean interval between injury and referral was 15 (min: 13-max: 18) months, and the mean age of the patients was 15 (13-18) years. Neurolysis was performed in two patients, and for the third patent, after neurolysis, axonal continuity was observed to be disrupted so sural nerve grafting was performed with four cables. Tendon transfers were performed in all patients. A total number of 20 upper extremities of 10 cadavers were dissected. Due to its proximal innervation and ease of assessment, the muscle innervation of the flexor pollicis longus (FPL) was planned to be evaluated. The distance from the medial epicondyle is calculated in the cadaver study where the nerve injury is found., Results: The mean length from the medial epicondyle to the motor innervation of FPL was calculated in each specimen and found to be 101.99 millimeters (mm) (range: 87.5-134.2). The mean longest innervation of FPL was 110.83 mm from (range 87.5-148.1) the medial epicondyle calculated by including each specimens longest nerve length. Knowing that the healing time of a nerve lesion is 1 mm per day, we calculated that the recovery of FPL would take approximately 4 months., Conclusion: When nerve healing is expected to be 1 mm a day in axonotmesis type injury, after the median nerve palsy following elbow dislocation, thumb flexion should be achieved in the following 4 months generally if the nerve was not entrapped in the joint. This cadaver-based study objectively defined how long to wait for the innervation of the FPL in median nerve injuries in elbow fracture dislocations.

Introduction: The Air-Q Self Pressurized Airway Device with Blocker (SP Blocker) was compared to the Proseal Laryngeal Mask Airway (PLMA) during positive pressure ventilation regarding the primary outcome (oropharyngeal leak pressure [OLP]), secondary outcomes (peak inspiratory pressure [PIP], inspired tidal volume [ITV], expired tidal volume [ETV], leak volume [LV] and leak fraction [LF]), insertion time, ventilation score, fiber-optic glottis view score, and postoperative laryngopharyngeal parameters (LPM)., Material and Methods: Adult healthy female patients scheduled for elective gynecological laparotomies under general anesthesia using controlled mechanical ventilation were recruited to a prospective randomized comparative clinical trial. Exclusion criteria were body mass index (BMI) ≥ 35 kg m -2 , El-Ganzouri score ≥ 5, upper airway problems, hiatus hernia or pregnancy. Patients were classified into an SP Blocker group ( n = 75) and a PLMA group ( n = 75). Primary and secondary outcomes were assessed initially and at fixed time points after successful insertion of devices., Results: Initially after successful device insertion: the SP Blocker group showed statistically significant higher mean OLP (cmH 2 O) (29.46 ± 2.11 vs. 28.06 ± 1.83 respectively; 95% CI: -2.037 to -0.76, P < 0.0001), lower mean PIP (cmH 2 O) (15.49 ± 0.61 vs. 17.78 ± 1.04 respectively; 95% CI: 2.02 to 2.56, P < 0.0001), higher mean ITV (mL) (411 ± 30 vs. 403 ± 15 respectively; 95% CI: -15.65 to -0.347, P = 0.041), higher mean ETV (mL) (389 ± 12 vs. 354 ± 11 respectively; 95% CI: -38.72 to -31.29, P < 0.0001), lower mean LV (mL) (22 ± 18 vs. 49 ± 10 respectively; 95% CI: 22.3 to 31.7, P < 0.0001) and lower mean LF (%) (5 ± 2.04 vs. 12 ± 6.8 respectively; 95% CI: 5.38 to 8.62, P < 0.0001) than the PLMA group. Mean insertion time (seconds) was shorter in the SP Blocker group than the PLMA group (16.39 ± 2.81 vs. 18.63 ± 3.44 respectively; 95% CI: 1.23 to 3.25, P < 0.0001). The SP Blocker group offered a better fiber-optic glottis view score than the PLMA group without differences concerning ventilation score and LPM., Conclusions: SP Blocker provided as safe anesthesia during controlled mechanical ventilation as PLMA.

Background: Low arachidonic acid (AA) levels are reportedly associated with unfavorable outcomes in intracerebral hemorrhage (ICH)., Objective: We aimed to clarify whether serum AA levels might be associated with a good recovery from severe motor paralysis in the early stage of hospitalization., Methods: From among consecutive ICH patients between October 2012 and December 2021, patients with a sum of upper and lower extremity National Institutes of Health stroke scale (NIHSS) scores of 4-8 at admission (severe motor paralysis) were included. We defined good early recovery from severe motor paralysis as a sum of upper and lower extremity NIHSS scores of 0-3 on day 7 after admission, and that of individual upper and lower extremities as NIHSS scores of 0-1 on day 7 after admission. We aimed to assess whether serum AA levels might be associated with good early recovery from severe motor paralysis., Results: We screened 377 consecutive ICH patients, including 140 with severe motor paralysis (88 (63%) males, median age 64 years). Recovery from severe motor paralysis was seen in 48 (34%). Higher AA levels (PR 1.243, 95% CI 1.042 to 1.483, p = 0.016) were independently associated with good overall recovery, and good recovery of upper and lower extremities separately (upper extremity: PR 1.319, 95% CI 1.101 to 1.580, p = 0.003; lower extremity: PR 1.293, 95% CI 1.115 to 1.499, p = 0.001)., Conclusions: Higher AA levels may contribute to a good early motor recovery in patients with severe motor paralysis due to ICH., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:, (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the complications associated with microwave ablation (MWA) in treating persistent/recurrent hyperparathyroidism (HPT) post-surgical or ablative treatments., Materials and Methods: From January 2015 to December 2022, 87 persistent/recurrent HPT patients (primary HPT [PHPT]: secondary HPT [SHPT] = 13:74) who underwent MWA after surgical or ablative treatment were studied. Grouping was based on ablation order (initial vs. re-MWA), prior treatment (parathyroidectomy [PTX] vs. MWA), and etiology (PHPT vs. SHPT). The study focused on documenting and comparing treatment complications and analyzing major complication risk factors., Result: Among the 87 patients, the overall complication rate was 17.6% (15/87), with major complications at 13.8% (12/87) and minor complications at 3.4% (3/87). Major complications included recurrent laryngeal nerve (RLN) palsy (12.6%) and Horner syndrome (1.1%), while minor complications were limited to hematoma (3.4%). Severe hypocalcemia noted in 21.6% of SHPT patients. No significant differences in major complication rates were observed between initial and re-MWA groups (10.7% vs. 13.8%, p  = 0.455), PTX and MWA groups (12.5% vs. 15.4%, p  = 0.770), or PHPT and SHPT groups (15.4% vs. 13.5%, p  > 0.999). Risk factors for RLN palsy included ablation of superior and large parathyroid glands (>1.7 cm). All patients recovered spontaneously except for one with permanent RLN palsy in the PTX group (2.1%)., Conclusion: Complication rates for MWA post-surgical or ablative treatments were comparable to initial MWA rates. Most complications were transient, indicating MWA as a viable and safe treatment option for persistent/recurrent HPT patients.

Background: COVID-19 (Coronavirus disease 2019) pandemic is the main medical problem around the world from the end of 2019. We found until now many symptoms of this disease, but one of the most problematic was thrombosis. Wide recommendation on COVID-19 treatment was pharmacological thromboprophylaxis. In some papers we found that clinicians face the problem of bleeding in those patients. Is still unknown that coronavirus could led to the coagulopathy., Case Presentation: We described case report of patient who with COVID-19 disease present femoral nerve palsy caused by the iliopsoas hematoma. There were no deviations in coaguology parameters, patient got standard thromboprophylaxis, besides above probably COVID-19 was risk factor of hematoma formation. Non-operative treatment was applied, thrombophylaxis was discontinued. In the follow up in the radiological exam we saw reduction of the haematoma and patient report decrease of symptoms., Conclusions: We should assess individually patient with COVID-19 according to thrombosis risk factors. Probably we should be more careful in ordering thrombophylaxis medications in COVID-19 patients., (© 2023. The Author(s).)

Nerve injuries after reverse total shoulder arthroplasty (rTSA) are rare, and fortunately, most patients recover without long-term sequelae. However, irreversible deltoid paralysis due to brachial plexus or axillary nerve injury is devastating, as the deltoid is the main force of movement of the humerus after rTSA. Denervation of the deltoid results in weakness in abduction, forward flexion, and elevation, as well as varying degrees of chronic pain and shoulder instability. Treatment options for chronic deltoid denervation after axillary nerve or brachial plexus injuries are limited, since nerve repair, graft, or transfer procedures are ineffective. Trapezius tendon transfers, including the Saha technique, have been used to treat chronic deltoid weakness in native shoulders. Here, the authors present a modified Saha technique to improve shoulder motion and stability in patients with chronic deltoid paralysis following rTSA. (Journal of Surgical Orthopaedic Advances 32(4):276-280, 2023).

Purpose: Information regarding frequency, details of neurological signs and recovery patterns of patients with secondary hypokalaemic paralysis (HP) is limited. This study aimed to analyse the frequency, aetiology, clinical features and recovery patterns of patients with secondary HP., Methods: The clinical and laboratory records of 18 consecutive patients with secondary HP aged ≥ 18 years admitted to our hospital between April 2011 and March 2022 were reviewed. Patients with inherited hypokalaemic periodic paralysis were excluded., Results: Of the 18 patients, 16 had a common aetiology: chronic alcoholism, diarrhoea or an imbalanced diet. Initial symptoms, such as fatigue, were often atypical. Three patients had prominent asymmetric limb weakness and four had predominant upper limb weakness. On admission, the mean serum potassium and creatine kinase (CK) levels of the patients were 1.90 mmol/L and 4488 U/mL, respectively. Ten patients (56%) had decreased potassium levels after admission, despite potassium replacement treatment (rebound hypokalaemia). Twelve patients presented with increased CK levels even after 2-5 days (delayed hyperCKaemia). Low serum magnesium levels significantly correlated with rebound hypokalaemia., Conclusions: Secondary HP can be caused by a variety of conditions, but mainly occurs due to lifestyle conditions/disorders. Secondary HP often presents with atypical symptoms, and the initial symptoms can be non-specific. Rebound hypokalaemia and delayed hyperCKaemia are common in secondary HP, despite potassium replacement. As such, careful serial monitoring is needed for patients with secondary HP., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Lifting the temporal and mid-face areas creates a very dynamic change in the facial appearance and different planes of dissection were described before. In this article, a new plane of dissection is described which allows the surgeon to perform a very quick and safe dissection in both the temporal and mid-face regions. Patients were operated on using the presented technique and brow lift, cantopexy, and mid-facelift were performed. The outcome of the surgery was analyzed by the authors from standardized photos before and 6 months after the surgery with measurements of the brow and lateral canthus. The plane of dissection is just over the subgaleal fascia which is actually the sub-superficial musculoaponeurotic system layer in the mid-face. This plane of dissection is easy and quick and creates a very mobile mid-face and temporal flap. Forty female patients were operated using the presented technique with a mean follow-up period of 15 months, the longest follow-up was 26 months. No major complication was encountered in these patients. In 5 patients, transient unilateral frontal branch palsy was encountered. In 1 patient, bilateral temporal area depression was observed 8 months after the surgery and treated with a fat injection under local anesthesia. One patient had alopecia in the temporal suture line which can be covered with hair. Temporal facelift is a versatile method with long-lasting results due to its important features; creating a very mobile flap for suspension dissection area, a large surface for adherence, and numerous sutures sharing the tension on the key sutures. Despite its slightly difficult early healing period, the technique should be kept in mind for the rejuvenation of the periorbital area and mid-face. Level of Evidence: Level I., Competing Interests: Informed consents explaining the procedure were taken from the patients before the surgery.The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: This study aimed to investigate the recent 10-year trends in cervical laminoplasty and 30-day postoperative complications., Methods: This retrospective multi-institutional cohort study enrolled patients who underwent laminoplasty for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament. The primary outcome was the occurrence of all-cause 30-day complications. Trends were investigated and compared in the early (2008-2012) and late (2013-2017) periods., Results: Among 1095 patients (mean age, 66 years; 762 [70%] male), 542 and 553 patients were treated in the early and late periods, respectively. In the late period, patients were older at surgery (65 years vs. 68 years), there were more males (66% vs. 73%), and open-door laminoplasty (50% vs. 69%) was the preferred procedure, while %CSM (77% vs. 78%) and the perioperative JOA scores were similar to the early period. During the study period, the rate of preservation of the posterior muscle-ligament complex attached to the C2/C7-spinous process (C2, 89% vs. 93%; C7, 62% vs. 85%) increased and the number of laminoplasty levels (3.7 vs. 3.1) decreased. While the 30-day complication rate remained stable (3.9% vs. 3.4%), C5 palsy tended to decrease (2.4% vs. 0.9%, P = 0.059); superficial SSI increased significantly (0% vs. 1.3%, P = 0.015), while the decreased incidence of deep SSI did not reach statistical significance (0.6% vs. 0.2%)., Conclusions: From 2008 to 2017, there were trends toward increasing age at surgery and surgeons' preference for refined open-door laminoplasty. The 30-day complication rate remained stable, but the C5 palsy rate halved., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The phrenic nerve is commonly injured with trauma to the brachial plexus. Hemi-diaphragmatic paralysis may be well-compensated in healthy individuals at rest but can be associated with persistent exercise intolerance in some patients. This study aims to determine the diagnostic value of inspiratory-expiratory chest radiography compared to intraoperative stimulation of the phrenic nerve for assessing phrenic nerve injury associated with brachial plexus injury., Methods: Over a 21-year period, the diagnostic utility of three-view inspiratory-expiratory chest radiography for identification of phrenic nerve injury was determined by comparison to intraoperative phrenic nerve stimulation. Multivariate regression analysis was used to identify independent predictors of phrenic nerve injury and having an incorrect radiographic diagnosis., Results: A total of 237 patients with inspiratory-expiratory chest radiography underwent intraoperative testing of phrenic nerve function. Phrenic nerve injury was present in approximately one-fourth of cases. Preoperative chest radiography had a sensitivity of 56%, specificity of 93%, positive predictive negative of 75%, and negative predictive value of 86% for identification of a phrenic nerve palsy. Only C5 avulsion was found to be a predictor of having an incorrect diagnosis of phrenic nerve injury on radiography., Conclusion: While inspiratory-expiratory chest radiography has good specificity for detecting phrenic nerve injuries, a high number of false negatives suggest that it should not be relied upon for routine screening of dysfunction after traumatic brachial plexus injury. This is likely multifactorial and relates to variation in diaphragm shape and position, as well as limitations regarding static image interpretation of a dynamic process., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Competing Interests: The authors declare that they have no conflict of interest.

Objective: Cervical expansile open-door laminoplasties (EOLPs) have an open side and a hinge side, with the open side being bridged by grafts or miniplates. The authors explored the possibility that the open-door side might have a greater incidence of C5 palsy due to a greater stretch of the ipsilateral C5 nerve root., Methods: This study was a retrospective review of prospectively collected data over a period of 25 years specifically assessing surgical complications. Included were patients who underwent EOLP for myelopathy, radiculopathy, or mild central cord injuries (American Spinal Injury Association Impairment Scale [AIS] grade D). Exclusion criteria included preexisting C5 weakness; patients with AIS grade A, B, or C injury; and added instrumentation or additional surgical procedures. Patients were monitored postoperatively for C5 palsy or any other complications. A comparison group included patients who underwent cervical laminectomy and fusion (CLF)., Results: A total of 327 laminoplasties were collected, and 31 patients were excluded because of severe spinal cord injury (AIS grades A-C), 3 for preoperative C5 weakness, and 21 for instrumentation or additional surgical procedures. Thus, 272 patients were analyzed with a mean age of 59.9 years (range 22-88 years). Diagnoses at presentation were cervical myelopathy (84.1%), central cord syndrome (7.2%), cervical myeloradiculopathy (3.4%), ossification of the posterior longitudinal ligament (1.9%), and other (3.4%). The most common complications were C5 palsy (n = 7, 2.6%) and wound infection (n = 7, 2.6%). Of the 7 cases of postoperative C5 palsies in this study, 6 occurred on the side of the open door. Of the C5 palsies, 2 were mild, 3 were moderate, and 2 were severe. Two of the 7 C5 palsies had a delayed (> 24 hours) onset. The C5 palsy incidence after CLF was 2.7% with no side preference., Conclusions: C5 palsy after cervical decompression for myelopathy is a known occurrence, with a rate of 2.6% in the current study. The authors found that C5 palsies more commonly occur on the open side of the laminoplasty. This could be due to a greater manipulation of the nerve root on the side of the open door or greater stretch of the C5 root on the open-door side. If clinical symptoms and anatomical stenosis are symmetric, the authors recommend creating the laminoplasty hinge on the patient's dominant side to minimize potential loss of dominant proximal arm function.

Sjogren's syndrome is a rare chronic autoimmune disease characterised by dry eyes and dry mouth due to autoimmune destruction of the lacrimal and salivary glands, which can occur concurrently with other autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, or thyroiditis. It can lead to renal complications such as interstitial nephritis and glomerulonephritis, with distal/ type 1 renal tubular acidosis which may result in life-threatening electrolyte imbalance. We present a case of a 35-year-old female who presented with complaints of multiple episodes of muscle weakness. Type 1 renal tubular acidosis was discovered to be the cause of her symptoms which lead to the subsequent diagnosis of Sjogren's syndrome. This is rare presentation of Sjogren's syndrome, and it poses a challenge to diagnosis. Early detection and diagnosis of Sjogren's syndrome might be difficult due to existing diagnostic criteria, which contributes to a higher likelihood of missed diagnosis., Keywords: case reports; hypokalemia; renal tubular acidosis; Sjogren's syndrome.

Introduction: the number of wild poliomyelitis cases, worldwide, dropped from 350,000 cases in 1988 to 33 in 2018. Acute flaccid paralysis (AFP) surveillance is a key strategy toward achieving global polio eradication. The 2014 Ebola virus disease (EVD) epidemic in West Africa infected over 28,000 people and had devastating effects on health systems in Guinea, Liberia, and Sierra Leone. We sought to assess the effects of the 2014 Ebola outbreak on AFP surveillance in Guinea and Liberia., Methods: a retrospective cross-sectional analysis was performed for Guinea and Liberia to evaluate EVD´s impact on World Health Organization (WHO) AFP surveillance performance indicators during 2012-2015., Results: both Guinea and Liberia met the WHO target non-polio AFP incidence rate nationally, and generally sub-nationally, prior to the EVD outbreak; rates decreased substantially during the outbreak in seven of eight regions in Guinea and 11 of 15 counties in Liberia. Throughout the study period, both Guinea and Liberia attained appropriate overall targets nationally for "notification" and "stool adequacy" indicators, but each country experienced periods of poor regional/county-specific indicator performance., Conclusion: these findings mirrored the negative effect of the Ebola outbreak on polio elimination activities in both countries and highlights the need to reinforce this surveillance system during times of crisis., Competing Interests: The authors declare no competing interests., (Copyright: Grace Umutesi et al.)

Thyrotoxic periodic paralysis (TPP) is an acute complication of hyperthyroidism. Thyrotoxic periodic paralysis is treatable, and the management consists of potassium correction, beta-blockers, and antithyroid drug (ATD) therapy. While TPP is well described in the literature, we describe a case of TPP with urticarial dermographia (UD) that resolved with a short course of antihistamines while continuing ATD therapy. To the best of our knowledge, this is the first reported case of UD after methimazole (MMI) therapy in a TPP patient. A 25-year-old Cambodian active duty male with no significant past medical history presented to the emergency department with acute loss of lower extremity muscle tone with hypokalemia in the setting of previously undiagnosed Graves' disease (GD). He was started on MMI but within 2 weeks developed a rash consistent with UD. This was successfully treated with a second-generation antihistamine while continuing his MMI. Thyrotoxic periodic paralysis is primarily treated by controlling the underlying thyroid disease causing paralysis. Methimazole is commonly chosen as a treatment due to its rapid efficacy and long duration of action. However, adverse effects like UD can occur. Current recommendations are that minor cutaneous reactions can be treated with antihistamines for the management of Graves' disease. However, this case and others show that even moderate reactions can be managed in this manner. In a patient with TPP with UD after treatment with MMI, it is reasonable to attempt a trial of antihistamine before changing to another ATD., (© The Association of Military Surgeons of the United States 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Delayed C5 weakness is a known entity in cervical spine surgery, although with varied clinical presentation and poorly understood mechanism of action. We describe the first case in the literature of a bilateral C5 palsy leading to bilateral phrenic nerve dysfunction following a posterior cervical decompression and fusion., Case Report: A 76-year-old male presented with low back pain and was diagnosed as myelopathic. On initial neurological examination, he could not ambulate without assistance and was unsteady on tandem gait. The initial cervical MRI and CT scan showed advanced multilevel degenerative changes of the cervical spine with severe cord compression and myelomalacia. The patient underwent C3-C6 posterior cervical decompression & fusion (PCDF). He awoke with his baseline examination without neurophysiological monitoring changes intraoperatively or C5 root EMG activity. Post-operative MRI of the cervical spine was performed and showed an excellent decompression. The patient was neurologically stable and discharged to a rehabilitation facility. Patient developed a delayed bilateral C5P on postoperative day (POD) 74. Delayed bilateral C5P and phrenic nerve damage was determined to cause this patient's dyspnea. PM&R consult recommended placement of diaphragmatic pacers. However, clinically his respiratory function, as well as motor deficits, have gradually improved., Conclusion: Bilateral diaphragmatic paralysis, a severe complication of cervical spine surgery, may cause respiratory distress and upper limb weakness. C5P, the underlying cause, may arise from various factors. Early detection and management of diaphragmatic weakness with physical therapy and pacers are crucial, emphasizing the need for vigilance by healthcare professionals and surgeons., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)