Introduction OSA is characterized by recurrent episodes of upper airway collapse and obstruction during sleep, leading to oxygen desaturations. Risk factors include obesity, age, sex, family history, craniofacial abnormalities, stroke, diabetes, polycystic ovarian syndrome. This case illustrates symptomatic and clinically proven worsening of OSA after anterior cervical discectomy and fusion (ACDF), which can lead to narrowing of the airspace and dysfunction of the pharyngeal plexus leading to upper airway collapse. Report of Cases: A 49-year-old female with cervical myelopathy was evaluated in the sleep clinic for snoring, witnessed apnea, and daytime somnolence. Her Epworth score was 11, and Mallampati score was 4, suggestive of underlying sleep-disordered breathing (SDB). A home diagnostic sleep test revealed mild OSA with AHI of 6.8/hr and was started on an Auto Continuous Positive Airway Pressure (APAP) device. She then reported worsening of her cervical pain leading to decreased use of APAP and total sleep time and underwent ACDF approximately 6 months after her diagnosis of OSA was made. Post-surgery she reported mild dysphagia, frequent nighttime awakening due to a choking sensation, and an increase in snoring. Following hospital discharge, the patient was re-evaluated in the sleep clinic for these complaints. Upon review, her BMI had decreased to 33.99 kg/m2, from 37.35 kg/m2, and the only medication change was the addition of hydrocodone-acetaminophen 5-325, 1-2 times daily as needed for pain. A repeat diagnostic home sleep study showed progression of OSA to moderate severity with an AHI of 24.5/hr, with no evidence of central sleep apnea or hypoventilation. Therefore, it was unlikely that the worsening of AHI was due to opioids. Thus, it was concluded that ACDF most likely led to the worsening of OSA. Conclusion Although there is no strong association in medical or sleep literature, this case demonstrates a strong association between ACDF and OSA. This highlights the importance of a timely diagnosis of new-onset or reassessment for worsening OSA in patients post-ACDF to improve sleep quality and prevent morbidity. Support (If Any)

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