Current status of bone graft options for anterior interbody fusion of the cervical and lumbar spine.

Anterior cervical discectomy and fusion (ACDF) and anterior lumbar interbody fusion (ALIF) are common surgical procedures for degenerative disc disease of the cervical and lumbar spine. Over the years, many bone graft options have been developed and investigated aimed at complimenting or substituting autograft bone, the traditional fusion substrate. Here, we summarise the historical context, biological basis and current best evidence for these bone graft options in ACDF and ALIF.

Timing of surgical intervention in cauda equina syndrome: a systematic critical review.

OBJECTIVE: Cauda equina syndrome (CES) is a rare but important neurosurgical emergency. Despite being a recognized clinical entity since 1934, there remains significant uncertainty in the literature regarding the urgency for surgical intervention. The past decade has seen the emergence of the much-referred-to 48-hour limit as a possible window of safety. The ramifications of this time point are significant for early patients who may subsequently have urgent treatment delayed, and for litigation cases, after which adverse decisions are more likely to occur. METHODS: A systematic principally qualitative review of the animal and human clinical literature is presented, examining the evidence for urgent surgical decompression in CES and the much-quoted 48-hour rule. RESULTS: There is significant discordance in the literature regarding whether emergency surgery improves outcomes; however, a growing consensus is the acknowledgment that biologic systems deteriorate in a continuous rather than stepwise manner. Level of neurological dysfunction at surgery (incomplete CES vs. CES with retention) is probably the most significant determinant of prognosis. Onset and duration of symptoms also are likely to have an impact, if not on overall outcome then at least on duration of neurological recovery. CONCLUSIONS: There is no strong basis to support 48 hours as a blanket safe time point to delay surgery. Both early and delayed surgery may result in improved neurological outcomes. However, it is likely that the earlier the surgical intervention, the more beneficial the effects for compressed nerves, especially with acute neurological compromise.

Blunt vs. sharp uterine expansion at lower segment cesarean section delivery: a systematic review with metaanalysis.

OBJECTIVE: Blunt vs sharp expansion of the uterine incision at cesarean delivery has been investigated as a technique primarily to reduce intraoperative blood loss. The objective of this systematic review was to compare the effects of either intervention on maternal outcomes. STUDY DESIGN: A systematic review with metaanalyses that used the DerSimonian and Laird random effects model was performed. The Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 4), MEDLINE (1948-Apr 2012), EMBASE (1947-Apr 2012), and the reference lists/citation history of articles were searched. Only randomized controlled trials were included. RESULTS: Four trials (1731 patients) were evaluated. Data from one recently completed trial (535 patients) were not yet available. Metaanalyses revealed a trend towards reduced maternal blood loss with blunt expansion of the uterine incision that was statistically significant when measured by surgeon's estimation of volume lost, but not by comparison of pre- and postoperative hematocrit and hemoglobin levels or a requirement for blood transfusion. There was a trend towards fewer unintended extensions in the blunt group and no difference in the incidence of endometritis. CONCLUSION: Blunt dissection of the uterine incision at cesarean delivery appears to be superior to sharp dissection in minimizing maternal blood loss. However, this conclusion could change when data from a new unpublished large trial are available.