{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:51:16Z","timestamp":1782867076368,"version":"3.54.5"},"reference-count":34,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,6,26]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Dysphonia resulting from injury to the recurrent laryngeal nerve (RLN) is a known risk of anterior cervical spine surgery (ACSS). While the main mechanism underlying this injury is unclear, high endotracheal tube (ETT) cuff pressures have been linked to postoperative dysphonia. This study was performed to assess intraoperative ETT cuff pressures and how patient and surgical variables influence them.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>\n                      A retrospective observational study was conducted using intraoperative cuff pressures collected from patients who underwent ACSS from January 2024 to March 2025 at a single institution. ETT cuff pressure was measured after intubation, manual adjustment, and, finally, placement of cervical retractors. Data for 3 months after surgery were collected via retrospective chart review. Additionally, 5 cadaveric specimens were obtained for experimentation. After intubation of a specimen, cuff pressure was set to 20\u201330 cm H\n                      <jats:sub>2<\/jats:sub>\n                      O and remeasured following cervical retraction.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>\n                      Among the 39 patients included in the study, ETT cuff pressures at the start of surgery often exceeded safe levels, with a mean pressure of 72.6 \u00b1 37.7 cm H\n                      <jats:sub>2<\/jats:sub>\n                      O (IQR 81). These elevated levels were significantly associated with obesity and female sex. Despite manual adjustment, ETT cuff pressures were again elevated following airway retraction, with a mean of 50.5 \u00b1 19.9 cm H\n                      <jats:sub>2<\/jats:sub>\n                      O (IQR 31.5). Cuff pressures were also increased with caudal surgery and an advanced age. A cadaveric model demonstrated that caudal cervical approaches, as compared to rostral ones, yielded a significantly greater increase in ETT cuff pressure following retraction (p &lt; 0.0001). The side of approach was not a significant determinant of pressure elevation at either cervical level of approach.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>Retraction of cervical tissues during ACSS significantly increases ETT cuff pressure to unsafe levels, increasing the risk of RLN injury. Frequent ETT cuff pressure monitoring and adjustment are necessary to reduce RLN exposure to elevated pressures and potentially reduce the risk of dysphonia after ACSS.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2026.2.spine251178","type":"journal-article","created":{"date-parts":[[2026,6,24]],"date-time":"2026-06-24T00:00:56Z","timestamp":1782259256000},"page":"1-7","source":"Crossref","is-referenced-by-count":0,"title":["Risk factors for elevated endotracheal tube cuff pressure in anterior cervical spine surgery"],"prefix":"10.3171","author":[{"given":"Jonathan","family":"Goulazian","sequence":"first","affiliation":[{"name":"Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akshaya","family":"Raman","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nana-Hawwa","family":"Abdul-Rahman","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kyle","family":"Affolter","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amila","family":"Niksic","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter C.","family":"Gerszten","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nitin","family":"Agarwal","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"D. Kojo","family":"Hamilton","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carl","family":"Snyderman","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh; and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"6","key":"b1","series-title":"J Neurosurg","first-page":"602","article-title":"The anterior approach for removal of ruptured cervical discs","volume":"15","author":"Cloward RB","year":"1958","unstructured":"Cloward RB. The anterior approach for removal of ruptured cervical discs. J Neurosurg. 1958;15(6):602\u2013617. doi:10.3171\/jns.1958.15.6.0602"},{"issue":"3","key":"b2","series-title":"J Bone Joint Surg Am","first-page":"607","article-title":"The treatment of cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion","volume":"40-A","author":"Smith GW","year":"1958","unstructured":"Smith GW, Robinson RA. The treatment of cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am. 1958;40-A(3):607\u2013624. doi:10.2106\/00004623-195840030-00009"},{"key":"b3","series-title":"Operative Otolaryngology: Head and Neck Surgery","first-page":"709","article-title":"Transcervical approaches to the cervical spine","author":"Snyderman CH","year":"2008","unstructured":"Snyderman CH, Kassam AB. Transcervical approaches to the cervical spine. In: Myers EN, Carrau RL, Eibling DE, eds. Operative Otolaryngology: Head and Neck Surgery, 2nd ed. WB Saunders; 2008:709\u2013718. doi:10.1016\/B978-1-4160-2445-3.50083-2"},{"issue":"4","key":"b4","series-title":"Asian J Neurosurg","first-page":"669","article-title":"Anterior approach to the cervical spine: elegance lies in its simplicity","volume":"16","author":"Arumalla K","year":"2021","unstructured":"Arumalla K, Bansal H, Jadeja J,  Anterior approach to the cervical spine: elegance lies in its simplicity. Asian J Neurosurg. 2021;16(4):669\u2013684. doi:10.4103\/ajns.AJNS_313_20"},{"issue":"9","key":"b5","series-title":"Laryngoscope","first-page":"1467","article-title":"Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury","volume":"110","author":"Kriskovich MD","year":"2000","unstructured":"Kriskovich MD, Apfelbaum RI, Haller JR. Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury. Laryngoscope. 2000;110(9):1467\u20131473. doi:10.1097\/00005537-200009000-00011"},{"issue":"2 Suppl","key":"b6","series-title":"J Neurosurg","first-page":"170","article-title":"Intraoperative electromyographic assessment of recurrent laryngeal nerve stress and pharyngeal injury during anterior cervical spine surgery with Caspar instrumentation","volume":"91","author":"Jellish WS","year":"1999","unstructured":"Jellish WS, Jensen RL, Anderson DE, Shea JF. Intraoperative electromyographic assessment of recurrent laryngeal nerve stress and pharyngeal injury during anterior cervical spine surgery with Caspar instrumentation. J Neurosurg. 1999;91(2 Suppl):170\u2013174.  doi:10.3171\/spi.1999.91.2.0170"},{"issue":"6","key":"b7","series-title":"Anesth Analg","first-page":"1318","article-title":"Endotracheal tube cuff pressure increases significantly during anterior cervical fusion with the Caspar instrumentation system","volume":"76","author":"Sperry RJ","year":"1993","unstructured":"Sperry RJ, Johnson JO, Apfelbaum RI. Endotracheal tube cuff pressure increases significantly during anterior cervical fusion with the Caspar instrumentation system. Anesth Analg. 1993;76(6):1318\u20131321. doi:10.1213\/00000539-199376060-00023"},{"issue":"6","key":"b8","series-title":"Pediatr Qual Saf","first-page":"e619","article-title":"Endotracheal tube cuff pressures in the operating room of a pediatric hospital: a quality improvement initiative","volume":"7","author":"Moon KM","year":"2022","unstructured":"Moon KM, Donaworth S, Hagele MS, Kim SS, Willer BL, Tobias JD. Endotracheal tube cuff pressures in the operating room of a pediatric hospital: a quality improvement initiative. Pediatr Qual Saf. 2022;7(6):e619. doi:10.1097\/pq9.0000000000000619"},{"issue":"1","key":"b9","series-title":"Arch Otolaryngol Head Neck Surg","first-page":"51","article-title":"Dysphonia and dysphagia following the anterior approach to the cervical spine","volume":"127","author":"Winslow CP","year":"2001","unstructured":"Winslow CP, Winslow TJ, Wax MK. Dysphonia and dysphagia following the anterior approach to the cervical spine. Arch Otolaryngol Head Neck Surg. 2001;127(1):51\u201355. doi:10.1001\/archotol.127.1.51"},{"issue":"3","key":"b10","series-title":"AANA J","first-page":"203","article-title":"Improving endotracheal cuff inflation pressures: an evidence-based project in a military medical center","volume":"88","author":"Turner MA","year":"2020","unstructured":"Turner MA, Feeney M, Deeds LJL. Improving endotracheal cuff inflation pressures: an evidence-based project in a military medical center. AANA J. 2020;88(3):203\u2013208."},{"issue":"9","key":"b11","series-title":"Laryngoscope","first-page":"1967","article-title":"Current practices in endotracheal tube size selection for adults","volume":"131","author":"Cao AC","year":"2021","unstructured":"Cao AC, Rereddy S, Mirza N. Current practices in endotracheal tube size selection for adults. Laryngoscope. 2021;131(9):1967\u20131971. doi:10.1002\/lary.29192"},{"issue":"4","key":"b12","series-title":"Laryngoscope","first-page":"1822","article-title":"Characterization of endotracheal tube cuff pressure-volume in simulated and cadaveric tracheas","volume":"136","author":"Harris A","year":"2026","unstructured":"Harris A, Niksic A, Affolter K, Snyderman CH. Characterization of endotracheal tube cuff pressure-volume in simulated and cadaveric tracheas. Laryngoscope. 2026;136(4):1822\u20131829. doi:10.1002\/lary.70245"},{"issue":"6","key":"b13","series-title":"Materials (Basel)","first-page":"456","article-title":"Mechanical characterization and constitutive modeling of human trachea: age and gender dependency","volume":"9","author":"Safshekan F","year":"2016","unstructured":"Safshekan F, Tafazzoli-Shadpour M, Abdouss M, Shadmehr MB. Mechanical characterization and constitutive modeling of human trachea: age and gender dependency. Materials (Basel). 2016;9(6):456. doi:10.3390\/ma9060456"},{"issue":"6","key":"b14","series-title":"Surg Radiol Anat","first-page":"877","article-title":"Regional variations and sex-related differences of stiffness in human tracheal ligaments","volume":"46","author":"Fukushige K","year":"2024","unstructured":"Fukushige K, Okubo T, Shan X, Takeuchi T, Misaki N, Naito M. Regional variations and sex-related differences of stiffness in human tracheal ligaments. Surg Radiol Anat. 2024;46(6):877\u2013883. doi:10.1007\/s00276-024-03361-6"},{"issue":"3","key":"b15","series-title":"Laryngoscope Investig Otolaryngol","first-page":"e70140","article-title":"Size matters: endotracheal tube sizes and glottic stenosis familiarity among intubating physicians","volume":"10","author":"Chwa JS","year":"2025","unstructured":"Chwa JS, Shuman EA, O\u2019Dell K. Size matters: endotracheal tube sizes and glottic stenosis familiarity among intubating physicians. Laryngoscope Investig Otolaryngol. 2025;10(3):e70140. doi:10.1002\/lio2.70140"},{"issue":"6","key":"b16","series-title":"Laryngoscope","first-page":"1225","article-title":"Selection and placement of oral ventilation tubes based on tracheal morphometry","volume":"121","author":"Coordes A","year":"2011","unstructured":"Coordes A, Rademacher G, Knopke S,  Selection and placement of oral ventilation tubes based on tracheal morphometry. Laryngoscope. 2011;121(6):1225\u20131230. doi:10.1002\/lary.21752"},{"key":"b17","series-title":"J Clin Neurosci","first-page":"111427","article-title":"Neuromonitoring of recurrent laryngeal nerve using continuous intraoperative neuromonitoring system during anterior cervical spine surgery: a porcine model study","volume":"139","author":"Kim DS","year":"2025","unstructured":"Kim DS, Goh TS, Cho YJ, Lee JS. Neuromonitoring of recurrent laryngeal nerve using continuous intraoperative neuromonitoring system during anterior cervical spine surgery: a porcine model study. J Clin Neurosci. 2025;139:111427. doi:10.1016\/j.jocn.2025.111427"},{"issue":"6","key":"b1","series-title":"J Neurosurg","first-page":"602","article-title":"The anterior approach for removal of ruptured cervical discs","volume":"15","author":"Cloward RB","year":"1958","unstructured":"Cloward RB. The anterior approach for removal of ruptured cervical discs. J Neurosurg. 1958;15(6):602\u2013617. doi:10.3171\/jns.1958.15.6.0602"},{"issue":"3","key":"b2","series-title":"J Bone Joint Surg Am","first-page":"607","article-title":"The treatment of cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion","volume":"40-A","author":"Smith GW","year":"1958","unstructured":"Smith GW, Robinson RA. The treatment of cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am. 1958;40-A(3):607\u2013624. doi:10.2106\/00004623-195840030-00009"},{"key":"b3","series-title":"Operative Otolaryngology: Head and Neck Surgery","first-page":"709","article-title":"Transcervical approaches to the cervical spine","author":"Snyderman CH","year":"2008","unstructured":"Snyderman CH, Kassam AB. Transcervical approaches to the cervical spine. In: Myers EN, Carrau RL, Eibling DE, eds. Operative Otolaryngology: Head and Neck Surgery, 2nd ed. WB Saunders; 2008:709\u2013718. doi:10.1016\/B978-1-4160-2445-3.50083-2"},{"issue":"4","key":"b4","series-title":"Asian J Neurosurg","first-page":"669","article-title":"Anterior approach to the cervical spine: elegance lies in its simplicity","volume":"16","author":"Arumalla K","year":"2021","unstructured":"Arumalla K, Bansal H, Jadeja J,  Anterior approach to the cervical spine: elegance lies in its simplicity. Asian J Neurosurg. 2021;16(4):669\u2013684. doi:10.4103\/ajns.AJNS_313_20"},{"issue":"9","key":"b5","series-title":"Laryngoscope","first-page":"1467","article-title":"Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury","volume":"110","author":"Kriskovich MD","year":"2000","unstructured":"Kriskovich MD, Apfelbaum RI, Haller JR. Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury. Laryngoscope. 2000;110(9):1467\u20131473. doi:10.1097\/00005537-200009000-00011"},{"issue":"2 Suppl","key":"b6","series-title":"J Neurosurg","first-page":"170","article-title":"Intraoperative electromyographic assessment of recurrent laryngeal nerve stress and pharyngeal injury during anterior cervical spine surgery with Caspar instrumentation","volume":"91","author":"Jellish WS","year":"1999","unstructured":"Jellish WS, Jensen RL, Anderson DE, Shea JF. Intraoperative electromyographic assessment of recurrent laryngeal nerve stress and pharyngeal injury during anterior cervical spine surgery with Caspar instrumentation. J Neurosurg. 1999;91(2 Suppl):170\u2013174.  doi:10.3171\/spi.1999.91.2.0170"},{"issue":"6","key":"b7","series-title":"Anesth Analg","first-page":"1318","article-title":"Endotracheal tube cuff pressure increases significantly during anterior cervical fusion with the Caspar instrumentation system","volume":"76","author":"Sperry RJ","year":"1993","unstructured":"Sperry RJ, Johnson JO, Apfelbaum RI. Endotracheal tube cuff pressure increases significantly during anterior cervical fusion with the Caspar instrumentation system. Anesth Analg. 1993;76(6):1318\u20131321. doi:10.1213\/00000539-199376060-00023"},{"issue":"6","key":"b8","series-title":"Pediatr Qual Saf","first-page":"e619","article-title":"Endotracheal tube cuff pressures in the operating room of a pediatric hospital: a quality improvement initiative","volume":"7","author":"Moon KM","year":"2022","unstructured":"Moon KM, Donaworth S, Hagele MS, Kim SS, Willer BL, Tobias JD. Endotracheal tube cuff pressures in the operating room of a pediatric hospital: a quality improvement initiative. Pediatr Qual Saf. 2022;7(6):e619. doi:10.1097\/pq9.0000000000000619"},{"issue":"1","key":"b9","series-title":"Arch Otolaryngol Head Neck Surg","first-page":"51","article-title":"Dysphonia and dysphagia following the anterior approach to the cervical spine","volume":"127","author":"Winslow CP","year":"2001","unstructured":"Winslow CP, Winslow TJ, Wax MK. Dysphonia and dysphagia following the anterior approach to the cervical spine. Arch Otolaryngol Head Neck Surg. 2001;127(1):51\u201355. doi:10.1001\/archotol.127.1.51"},{"issue":"3","key":"b10","series-title":"AANA J","first-page":"203","article-title":"Improving endotracheal cuff inflation pressures: an evidence-based project in a military medical center","volume":"88","author":"Turner MA","year":"2020","unstructured":"Turner MA, Feeney M, Deeds LJL. Improving endotracheal cuff inflation pressures: an evidence-based project in a military medical center. AANA J. 2020;88(3):203\u2013208."},{"issue":"9","key":"b11","series-title":"Laryngoscope","first-page":"1967","article-title":"Current practices in endotracheal tube size selection for adults","volume":"131","author":"Cao AC","year":"2021","unstructured":"Cao AC, Rereddy S, Mirza N. Current practices in endotracheal tube size selection for adults. Laryngoscope. 2021;131(9):1967\u20131971. doi:10.1002\/lary.29192"},{"issue":"4","key":"b12","series-title":"Laryngoscope","first-page":"1822","article-title":"Characterization of endotracheal tube cuff pressure-volume in simulated and cadaveric tracheas","volume":"136","author":"Harris A","year":"2026","unstructured":"Harris A, Niksic A, Affolter K, Snyderman CH. Characterization of endotracheal tube cuff pressure-volume in simulated and cadaveric tracheas. Laryngoscope. 2026;136(4):1822\u20131829. doi:10.1002\/lary.70245"},{"issue":"6","key":"b13","series-title":"Materials (Basel)","first-page":"456","article-title":"Mechanical characterization and constitutive modeling of human trachea: age and gender dependency","volume":"9","author":"Safshekan F","year":"2016","unstructured":"Safshekan F, Tafazzoli-Shadpour M, Abdouss M, Shadmehr MB. Mechanical characterization and constitutive modeling of human trachea: age and gender dependency. Materials (Basel). 2016;9(6):456. doi:10.3390\/ma9060456"},{"issue":"6","key":"b14","series-title":"Surg Radiol Anat","first-page":"877","article-title":"Regional variations and sex-related differences of stiffness in human tracheal ligaments","volume":"46","author":"Fukushige K","year":"2024","unstructured":"Fukushige K, Okubo T, Shan X, Takeuchi T, Misaki N, Naito M. Regional variations and sex-related differences of stiffness in human tracheal ligaments. Surg Radiol Anat. 2024;46(6):877\u2013883. doi:10.1007\/s00276-024-03361-6"},{"issue":"3","key":"b15","series-title":"Laryngoscope Investig Otolaryngol","first-page":"e70140","article-title":"Size matters: endotracheal tube sizes and glottic stenosis familiarity among intubating physicians","volume":"10","author":"Chwa JS","year":"2025","unstructured":"Chwa JS, Shuman EA, O\u2019Dell K. Size matters: endotracheal tube sizes and glottic stenosis familiarity among intubating physicians. Laryngoscope Investig Otolaryngol. 2025;10(3):e70140. doi:10.1002\/lio2.70140"},{"issue":"6","key":"b16","series-title":"Laryngoscope","first-page":"1225","article-title":"Selection and placement of oral ventilation tubes based on tracheal morphometry","volume":"121","author":"Coordes A","year":"2011","unstructured":"Coordes A, Rademacher G, Knopke S,  Selection and placement of oral ventilation tubes based on tracheal morphometry. 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