Imaging Evaluation Of Patients Research Articles

Individualized treatment strategy for patients with rheumatoid arthritis based on imaging evaluation

Purpose: To study the effect of individualized treatment strategy based on imaging evaluation in patients with rheumatoid arthritis (RA).
 Methods: Eighty patients with RA of the wrist treated in the Second Affiliated Hospital of Nanjing Medical University, China from January 2018 to December 2022 were assigned to control and study groups. Conventional methods were used for treating control subjects, based on RA laboratory index results, while the study group received individualized treatment based on RA laboratory index results and results of imaging evaluation. Before and after treatment, serum levels of rheumatoid factor (RF) and C-reactive protein (CRP) were assayed using immunoturbidimetry. Erythrocyte sedimentation rate (ESR) was determined by Wei method. Imaging examination - ultrasound or magnetic resonance imaging (MRI) - was carried out in study group before and after treatment. Disease activity score 28 (DAS28) and score on the visual analogue scale (VAS) were evaluated before and after treatment, and the curative effect in the two groups was compared based on curative effect evaluation.
 Results: In both groups, post-treatment values of RF, CRP and ESR were lower than the corresponding pre-treatment levels, but were significantly smaller in study group (p < 0.05). The DAS28 and VAS scores of the two groups after treatment were significantly lower (p < 0.05) than the pretreatment levels, but the DAS28 and VAS scores were significantly lower in study group (p < 0.05). Treatment efficacy in study group (95.0 %) was significantly higher than in control patients (77.5 %, p = 0.0476). The results of imaging indicators showed significantly reduced post-treatment synovial thickness and joint effusion in study group patients when compared with control patients (p < 0.01).
 Conclusion: Individualized treatment strategy for RA patients based on imaging results enhances curative effectiveness, reduces disease activity, relieves pain, and improves the quality of life of patients.

Chronic lateral ankle ligament instability - Current evidence and recent management advances

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.

Use of a Foot-Induced Digitally Controlled Resistance Device for Functional Magnetic Resonance Imaging Evaluation in Patients with Foot Paresis.

Neurological deficits from a stroke can result in long-term motor disabilities, including those that affect walking gait. However, extensive rehabilitation following stroke is typically time limited. Establishing predictive biomarkers to identify patients who may meaningfully benefit from additional physical therapy and demonstrate improvement is important to improve the patients' quality of life. Detection of neuroplastic remodeling of the affected region and changes in the activity patterns excited while performing suitable motor tasks could have valuable implications for chronic stroke recovery. This protocol describes the use of a digitally controlled, magnetic resonance-compatible foot-induced robotic device (MR_COFID) to present a personalized foot-motor task involving trajectory following to stroke-affected subjects with gait impairment during functional magnetic resonance imaging (fMRI). In the task, foot flexion is performed against bi-directional resistive forces, which are tuned to the subject's strength in both the dorsiflexion and plantar flexion directions, while following a visual metronome. fMRI non-invasively uses endogenous deoxyhemoglobin as a contrast agent to detect blood oxygenation level-dependent (BOLD) changes between the active and resting periods during testing. Repeated periodic testing can detect therapy-related changes in excitation patterns during task performance. The use of this technique provides data to identify and measure biomarkers that may indicate the likelihood of an individual benefitting from rehabilitation beyond that which is currently provided to stroke patients.

Computed tomography, angiographic and scintigraphic semiotics of diseases of the kidneys and adrenal glands

The computer tomographic, angiographic and scintigraphic examination of patients with renal and adrenal tumprs is performed and their semiotics is covered comprehensively. The computer tomographic densitometry makes it possible to perform the differential diagnosis of the cystic formations of kidneys. The characteristic of secondary lesions of kidneys in metastatic speading or malignant tumor growth from other organs is given. The computer tomographic, angiographic and scintigraphic examinations in revealing the diseases of kidneys, adrenal glands and ureters have high resolution. The angiography is used on its own or as a significant addition to the computer tomography in evaluation of patients with renal and adrenal diseases.

Magnetic resonance imaging in the evaluation of idiopathic frequent premature ventricular complexes with normal ventricular function

Abstract Background The role of cardiac magnetic resonance (CMR) imaging in the diagnostic evaluation of patients with frequent premature ventricular complexes (PVCs) and normal left ventricular ejection fraction (LVEF) remains unclear. Existing data has been predominantly derived from highly selected populations, that may overestimate the true prevalence of abnormal findings on CMR in this patient population. Purpose The aim of this study was 2-fold: 1) to establish the prevalence of CMR imaging abnormalities in a cohort with normal LVEF and high PVC burden; 2) to identify predictors of CMR imaging abnormalities in patients with frequent PVCs and normal LVEF. Methods In this cohort study, 211 patients (age 53.2±19 years; 41% male) with frequent PVCs (≥5%/24 h), of normal LVEF (≥50% by echocardiography) and no known underlying structural heart disease were prospectively enrolled from 2016–2020. Of these, 166 (79%) patients were symptomatic from their PVCs in the form of palpitations, fatigue, chest pain, dizziness, and/or dyspnea. Patients underwent CMR imaging (1.5 Tesla) with a late gadolinium enhancement (LGE) protocol at the time of enrollment for the detection of scarring and/or fibrosis. Results Patients had a median baseline echocardiographic LVEF of 60% (± 5%) with 195 (92%) of patients having a normal native QRS morphology. Median PVC burden of the study cohort was 16% (± 14%). CMR LGE abnormalities were found in 19 (9%) patients including 17 scans with non-ischemic LGE and 2 with ischemic LGE. Age >60 (odds ratio [OR]: 3.20, 95% confidence interval [CI]: 1.20–8.51, p=0.020), male sex (OR: 4.67, 95% CI: 1.61–13.50, p=0.004), history of hypertension (OR: 3.43, 95% CI: 1.31–8.97, p=0.012), native QRS duration (OR: 1.03, 95% CI: 1.00–1.05, p=0.031), and history of non-sustained ventricular tachycardia (OR: 2.81, 95% CI: 1.03–7.68, p=0.044) were significantly associated with the presence of imaging abnormalities on CMR. Dominant PVC origin from the left ventricle had a positive trend (OR: 2.60, 95% CI: 0.99–7.66, p=0.083) to association with CMR imaging abnormalities. On multivariate analysis, male sex (OR: 4.10, 95% CI: 1.40–12.04, p=0.010) and history of hypertension (OR: 2.89, 95% CI: 1.08–7.75, p=0.035) remained significantly associated with the presence of CMR abnormalities. There was no association between CMR imaging abnormalities and the burden of PVCs or the number of PVC morphologies. Conclusion In this cohort, only 9% of patients with apparently idiopathic frequent PVCs and normal LVEF had concealed myocardial abnormalities on CMR imaging. Male sex and history of hypertension were associated with a higher rate of CMR abnormalities. Funding Acknowledgement Type of funding sources: None.

Clinical Presentation, Patient Assessment, Anatomy, Pathophysiology, and Imaging of Pelvic Venous Disease.

Pelvic venous disorders (PeVDs) can result in several different clinical presentations, but can be challenging to distinguish from other etiologies of chronic pelvic pain (CPP). Clinical evaluation of CPP patients optimally should be performed in a multidisciplinary fashion and patients who may have PeVD should be referred for consultation with a vascular interventionalist whose evaluation would utilize an imaging workup to search for pelvic varices. Additionally, it is critical to quantify the quality-of-life effects of all CPP to determine the impact on the patient's overall health. Diagnostic imaging, including transabdominal and transvaginal ultrasound, computed tomography, magnetic resonance imaging, and venography, can be utilized to identify pelvic varices, as well as venous reflux and obstruction leading to CPP. The use of the SVP tool is important to classify PeVD patients based on their clinical symptoms, varicose veins, and pathophysiology for precise clinical communication and for reporting clinical research. The goal of this publication is to delineate the clinical presentation, anatomy, pathophysiology, and imaging evaluation of patients with CPP suspected of having PeVD.

Mitral Valve Prolapse, Arrhythmias, and Sudden Cardiac Death: The Role of Multimodality Imaging to Detect High-Risk Features.

Mitral valve prolapse (MVP) was first described in the 1960s, and it is usually a benign condition. However, a subtype of patients are known to have a higher incidence of ventricular arrhythmias and sudden cardiac death, the so called “arrhythmic MVP.” In recent years, several studies have been published to identify the most important clinical features to distinguish the benign form from the potentially lethal one in order to personalize patient’s treatment and follow-up. In this review, we specifically focused on red flags for increased arrhythmic risk to whom the cardiologist must be aware of while performing a cardiovascular imaging evaluation in patients with MVP.

Anatomical Variations, Mimics, and Pitfalls in Imaging of Patients with Epilepsy.

Epilepsy is among one of the most common neurologic disorders. The role of magnetic resonance imaging (MRI) in the diagnosis and management of patients with epilepsy is well established, and most patients with epilepsy are likely to undergo at least one or more MRI examinations in the course of their disease. Recent advances in high-field MRI have enabled high resolution in vivo visualization of small and intricate anatomic structures that are of great importance in the assessment of seizure disorders. Familiarity with normal anatomic variations is essential in the accurate diagnosis and image interpretation, as these variations may be mistaken for epileptogenic foci, leading to unnecessary follow-up imaging, or worse, unnecessary treatment. After a brief overview of normal imaging anatomy of the mesial temporal lobe, this article will review a few important common and uncommon anatomic variations, mimics, and pitfalls that may be encountered in the imaging evaluation of patients with epilepsy.

Palpable Masses after Mastectomy: Differentiating Benign Postoperative Findings from Recurrent Disease.

Due to postoperative changes, imaging evaluation of patients with palpable masses after mastectomy can be challenging. There is considerable overlap between the imaging characteristics of recurrent disease and benign postoperative findings in patients with or without breast reconstruction. US is the initial modality of choice for evaluating palpable masses in most patients after mastectomy. In cases where US findings are not classic, however, other modalities are useful in problem solving, including both mammography and MRI. It is imperative that radiologists are educated about benign and malignant imaging characteristics, further workup considerations, and appropriate management. In cases where findings are not characteristic across multiple imaging modalities, biopsy may be warranted.

Accuracy of Two-Dimensional Shear Wave Elastography and Attenuation Imaging for Evaluation of Patients With Nonalcoholic Steatohepatitis

We evaluated the accuracy of a multiparametric approach using attenuation imaging and 2-dimensional shear wave elastography (2D-SWE) for the detection of steatosis and fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). We studied 102 patients with increased levels of liver enzymes or suspicion of NAFLD, examined by attenuation imaging and 2D-SWE, immediately before biopsy collection and analysis (reference standard), from January 2018 to July 2019. We collected data on the attenuation coefficient (dB/cm/MHz) from attenuation imaging, liver stiffness measurements, and shear wave dispersion slope (SWDS, [m/s]/kHz) from 2D-SWE. Multivariate linear regression analysis was performed to identify factors associated with each parameter. Diagnostic performance was determined from area under the receiver operating curve (AUROC) values. The attenuation coefficient was associated with steatosis grade (P < .01) and identified patients with steatosis grades S1 or higher, S2 or higher, and S3 or higher, with AUROC values of 0.93, 0.88, and 0.83, respectively. Liver stiffness associated with fibrosis stage (P < .01) and lobular inflammatory activity was the only factor associated with SWDS (P < .01). SWDS detected inflammation grades I1 or higher, I2 or higher, and I3 or higher with AUROC values of 0.89, 0.85, and 0.78, respectively. We developed a risk scoring system to detect steatohepatitis based on the attenuation coefficient (score of 1 for 0.64 < attenuation coefficient ≤ 0.70; score of 2 for 0.70 < attenuation coefficient ≤ 0.73; and score of 3 for attenuation coefficient >0.73) and SWDS (score of 2 for 10.5 [m/s]/kHz < SWDS ≤ 11.7 [m/s]/kHz; and score of 3 for SWDS >11.7 [m/s]/kHz), using an unweighted sum of each score. Based on histopathology analysis, 55 patients had steatohepatitis. Risk scores correlated with NAFLD activity score (rho= 0.73; P < .01). Our scoring system identified patients with steatohepatitis with an AUROC of 0.93-this valuewassignificantly higher than that of other parameters (P < .05), except SWDS (AUROC, 0.89; P= .18). In the evaluation of patients with suspected NAFLD, the attenuation coefficient can identify patients with steatosis and liver stiffness can detect fibrosis accurately. SWDS was associated significantly with lobular inflammation. We developed a risk scoring system based on the attenuation coefficient and SWDS that might be used to detect steatohepatitis.

Does hyaluronic acid injection prevent the progression of knee Osteoarthritis ?

Purpose: Intra-articular injection of hyaluronic acid (HA) is performed as a conservative treatment for knee osteoarthritis (OA). HA has diverse pharmacological actions. In addition to increased lubrication of joint surfaces, its actions have been reported to include inhibition of the release of inflammatory cytokines and promotion of endogenous HA production. While many reports have suggested that injection of HA is clinically effective for knee OA, the actual improvement only seems to be modest. It has also been reported that injection of HA did not prevent the progression of knee OA, but rather promoted it. Thus, there are many unanswered questions about intra-articular HA therapy. The purpose of this study is imaging evaluation of patients who received long-term treatment with intra-articular HA for knee OA was conducted. Methods: This study was conducted in accordance with all applicable requirements of our university (including IRB approval). The subjects were 42 patients/64 knees (male: 17, female: 25) who received long-term intra-articular injection of HA for knee OA at the outpatient clinic of our university. Their mean age was 74.0 years, and the mean observation period was 4 years and 7 months. Knee radiographs were assessed by the Kellgren-Lawrence (K-L) classification, and the joint space was measured on frontal and lateral views obtained with the patient in the standing semiflexion position. In addition, the height, body weight, body mass index (BMI), frequency of HA injections, and total dose of HA were evaluated. Radiographic disease progression was defined as an annual increase of at least 1 grade in the K-L score or a decrease of > 0.2 mm in knee joint cartilage thickness annually. Results: Knee OA progression was seen in 24/64 knees (37.5%), while OA did not progress or the joint space increased in 40/64 knees (62.5%) (Fig 1). Approximately half of the knees with progression of knee OA were in K-L grade 3 or higher (45.8% * χ2 test), while all grade 1 or 2 patients who showed progression were obese with a BMI ≥27 kg/m2. On the other hand, in the group without knee OA progression, more than three-fourths of the knees were K-L grade 1 and 2 (77.5% * unpaired t-test). The interval between HA injections was shorter in patients without progression of knee OA, and the total dose was larger than in patients with progression (Table 1). Conclusions: Our previous study in OA animal models indicated that intra-articular injection of HA has both symptom-modifying and disease-modifying effects. In this study, the aim was to determine whether HA has these effects in human knees, as well as to determine the long-term treatment course with intra-articular injection of HA. In the OARSI guidelines, the strength of the recommendation for intra-articular injections of HA is 64, which is lower than for intra-articular injection of corticosteroids. In the previous research, HA treatment is well tolerated and produces statistically and clinically significant improvement of symptoms in patients with mild to moderate knee OA. In this study, 37.5% of the patients showed OA progression despite continuing HA injection. Converted to the annual OA progression ratio, 7.9% of the patients were shown to have knee disease progression annually. Comparing this ratio with the natural course of knee OA, 7% was reported by the Framingham study, with 3% reported by another study. It is difficult to compare this ratio because of the different populations and study designs. However, intra-articular injection of HA may not prevent OA progression. Approximately two-thirds of patients who received intra-articular injection of HA showed no progression or improvement of knee OA. Intra-articular injection of HA may not be effective in patients with K-L grade 3 or higher or BMI ≥27 kg/m2.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Hereditary and Sporadic Pancreatic Ductal Adenocarcinoma: Current Update on Genetics and Imaging.

Pancreatic ductal adenocarcinoma (PDAC) is a genetically heterogeneous, biologically aggressive malignancy with a uniformly poor prognosis. While most pancreatic cancers arise sporadically, a small subset of PDACs develop in patients with hereditary and familial predisposition. Detailed studies of the rare hereditary syndromes have led to identification of specific genetic abnormalities that contribute to malignancy. For example, germline mutations involving BRCA1, BRCA2, PRSS1, and mismatch repair genes predispose patients to PDAC. While patients with Lynch syndrome develop a rare "medullary" variant of adenocarcinoma, intraductal papillary mucinous tumors are observed in patients with McCune-Albright syndrome. It is now well established that PDACs originate via a multistep progression from microscopic and macroscopic precursors due to cumulative genetic abnormalities. Improved knowledge of tumor genetics and oncologic pathways has contributed to a better understanding of tumor biology with attendant implications on diagnosis, management, and prognosis. In this article, the genetic landscape of PDAC and its precursors will be described, the hereditary syndromes that predispose to PDAC will be reviewed, and the current role of imaging in screening and staging assessment, as well as the potential role of molecular tumor-targeted imaging for evaluation of patients with PDAC and its precursors, will be discussed. Keywords: Abdomen/GI, Genetic Defects, Oncology, Pancreas Supplemental material is available for this article. © RSNA, 2020.

Lung monitoring with electrical impedance tomography: technical considerations and clinical applications.

In recent years there has been substantial progress in the imaging evaluation of patients with lung disease requiring mechanical ventilatory assistance. This has been demonstrated by the inclusion of pulmonary ultrasound, positron emission tomography, electrical impedance tomography (EIT), and magnetic resonance imaging (MRI). The EIT uses electric current to evaluate the distribution of alternating current conductivity within the thoracic cavity. The advantage of the latter is that it is non-invasive, bedside radiation-free functional imaging modality for continuous monitoring of lung ventilation and perfusion. EIT can detect recruitment or derecruitment, overdistension, variation of poorly ventilated lung units (silent spaces), and pendelluft phenomenon in spontaneously breathing patients. In addition, the regional expiratory time constants have been recently explored.

Computed Tomography Perfusion Imaging in Evaluation of Patients With Acute Stroke is Not Associated With Increased Risk of Acute Kidney Injury (P5.3-051)

Computed Tomography Perfusion Imaging in Evaluation of Patients With Acute Stroke is Not Associated With Increased Risk of Acute Kidney Injury (P5.3-051)

Cranial nerve disorders: Clinical manifestations and topography

The detection of pathological conditions related to the twelve cranial pairs represents a significant challenge for both clinicians and radiologists; imaging techniques are fundamental for the management of many patients with these conditions. In addition to knowledge about the anatomy and pathological entities that can potentially affect the cranial pairs, the imaging evaluation of patients with possible cranial pair disorders requires specific examination protocols, acquisition techniques, and image processing.This article provides a review of the most common symptoms and syndromes related with the cranial pairs that might require imaging tests, together with a brief overview of the anatomy, the most common underlying processes, and the most appropriate imaging tests for different indications.

Abstract WP69: Computed Tomography Perfusion Imaging in Evaluation of Patients With Acute Stroke is Not Associated With Increased Risk of Acute Kidney Injury

Introduction: Mechanical thrombectomy has become standard of care in acute ischemic stroke with proximal arterial occlusion. For patients 6-24 hours from last known well, computed tomography perfusion (CTP) is now frequently used for assessment of endovascular therapy (EVT) eligibility. CTP requires an increased contrast load compared to computed tomographic angiography (CTA). Hypothesis: In patient assessment for EVT, CTA/CTP is not associated with higher incidence of acute kidney injury (AKI) compared to CTA alone. Methods: We reviewed data from consecutive acute stroke alerts at our institution from January-July 2018, and recorded baseline serum creatinine and creatinine at 24, 48, and 72 hours post-alert. AKI was defined by an increase in serum creatinine of 0.3, or more than a 1.5 fold increase in baseline creatinine, according to the Acute Kidney Injury Network definition. We compared patients receiving CTA/CTP versus CTA alone using independent samples t-test, including variables of age, NIHSS, baseline creatinine, and creatinine at 24, 48, and 72 hours. Chi-square testing was performed to compare incidence of AKI between groups. A binary logistic regression model was performed including covariates of age, sex, location of alert (emergency room or inpatient), NIHSS, baseline creatinine and imaging group. Significance was defined as p &lt; 0.05 for all tests. Results: Analysis included 285 patients: 210 receiving CTA alone, and 75 receiving CTA/CTP. Incidence of AKI was 4.7% in the CTA alone group versus 4% in the CTA/CTP group (χ2=0.74, p=0.786). The two groups did not differ with regard to age, NIHSS, or serum creatinine at any time point. In the binary logistic regression model, addition of CTP to CTA did not increase the odds ratio of developing AKI (OR 1.076 [95% CI 0.276-4.193]; p=0.916). Conclusions: In acute stroke assessment for EVT eligibility, the addition of CTP to CTA did not increase rates of AKI. While this retrospective analysis includes the possibility of selection bias, the two groups were similar in baseline characteristics including kidney function. These results provide Level II, Class B evidence supporting the safety of CTP in patient selection for EVT and may inform future AHA/ASA guidelines for management of acute ischemic stroke.

Role of Diffusion Weighted Magnetic Resonance Imaging in Evaluation of Patients with Salivary Glands Tumors

Role of Diffusion Weighted Magnetic Resonance Imaging in Evaluation of Patients with Salivary Glands Tumors

Role of Diffusion Weighted Magnetic Resonance Imaging in Evaluation of Patients with Salivary Glands Tumors

Background: The diffusion weighted imaging and ADC value give appreciable information about tumor cellularity with tissue contrast between the active and necrotic areas within the tumor. This would be valuable and could direct the beneficial site for interventional procedure and biopsy to be taken from the viable tumoral tissue especially in case with non-enhanced studies due to renal impairment. Objective: The aim of this study was to investigate the capacity of Diffusion MRI to predict the benign and malignant Salivary gland tumors, using ADC value and DWI. Patients and Methods: This study included 40 patients (24 male and 16 female). Sixteen patients had malignant lesions and twenty-four had benign ones. The DWI was obtained with b values including 0 and 800mm2/second. The Apparent Diffusion Coefficient (ADC) generated by measuring identical images at different b-values and represented as ADC map, from which the ADC value was calculated. Results: The absolute ADC value of lesions was significantly different between benign and malignant salivary gland tumors (p<0.001). The sensitivity of ADC in differentiating benign from malignant lesions in our study was 93.7% indicating a high true positive rate. Hence, if the average ADC is below 0.85 x 10 -3 mm2/sec, there is high probability that the mass will be malignant with high specificity of 95.8 %. Results revealed that the mean ADC value of benign and malignant salivary gland tumors were 1.33±0.46x 10-3 mm2/s and 0.65±0.21 x 10-3 mm2/s, respectively. The mean ADC value of benign was significantly higher than that of malignant lesions. Conclusion:Theuse of DWI and ADC values can provide better assessment of salivary gland tumors and predict the benign and malignant lesions.

Sintomatología derivada de los pares craneales: Clínica y topografía

The detection of pathological conditions related to the twelve cranial pairs represents a significant challenge for both clinicians and radiologists; imaging techniques are fundamental for the management of many patients with these conditions. In addition to knowledge about the anatomy and pathological entities that can potentially affect the cranial pairs, the imaging evaluation of patients with possible cranial pair disorders requires specific examination protocols, acquisition techniques, and image processing.This article provides a review of the most common symptoms and syndromes related with the cranial pairs that might require imaging tests, together with a brief overview of the anatomy, the most common underlying processes, and the most appropriate imaging tests for different indications.

Extruding Cervical Screw: A Rare Cause of Dysphagia

Complications from instrumentation of the cervical spine may affect the esophagus, as it directly overlies the cervical vertebrae; there have been reported cases of perforation, abscess, stricture, and diverticulum formation. While orthopedic surgeons and neurosurgeons are aware of these rare complications, gastroenterologists may not be familiar with them and may not consider these diagnoses when evaluating patients with oropharyngeal issues. We present a case of cervical screw extrusion leading to dysphagia and hoarseness, that underscores the importance of careful endoscopic inspection of the retropharynx during endoscopy and the early use of imaging in evaluation of patients with a history of cervical instrumentation. A 49 year old woman presented with a 4 month history of increasing difficulty and pain swallowing (right side of the throat), and significant hoarseness. Past history was significant for a motor vehicle accident 17 years prior, with cervical spine injury leading to refractory radiculopathy. She subsequently underwent anterior cervical decompression, fusion, and insertion of an integrated cage and plate system. Upper endoscopy showed a normal esophagus. Careful inspection identified a prominent bulge in the right posterior oropharynx, proximal to the piriform sinus with a superficial mucosal erosion, but no perforation (Fig. 1). A follow-up cervical CT scan confirmed a screw extending from the C4-5 level into the posterior esophagus to the right of midline at the level of the piriform sinus (Fig. 2); there was also evidence of instrumented fusion at C4-5 and C4-6 using integrated cage and plate system. The patient was then referred to neurosurgery for urgent operative removal of the screws.1742_A Figure 1. Endoscopic examination identifying a prominent bulge in the right posterior oropharynx, proximal to the piriform sinus.1742_B Figure 2. CT scan confirming a screw extending from the C4-5 level into the posterior esophagus to the right of midline at the level of the piriform sinus.Esophageal complications related to cervical fusion hardware are rare, and may present in the immediate post-operative period or years later. Slow anterior migration of the screw or cage system over time may cause extrinsic compression of the pharyngoesophageal wall leading to pressure necrosis and ultimately erosion or perforation. Gastroenterologists should have a high index of suspicion for this diagnosis when evaluating patients with history of cervical instrumentation presenting with oropharyngeal dysphagia. Endoscopic exam should focus on careful inspection of the oropharynx, as the pertinent findings may be subtle. Follow-up imaging with CT or MRI should be considered in the appropriate setting to confirm the diagnosis.