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Cashew nut testa (CNT) is an underutilized cashew by-product rich in polyphenols. The applications of CNT are limited due to its astringency, less solubility, and instability of polyphenols during the processing. Nanoencapsulation was used to overcome these limitations. β-cyclodextrin alone and in combination with whey protein isolate (WPI) was used for nano-complex preparation. The WPI/CD-CNT nano-complex powder showed higher encapsulation efficiency (86.9%) and yield (70.5-80%) compared to CD-CNT powder. Both the spray-dried powders showed improved thermal stability, higher solubility (97%), less moisture content, and increased DPPH and ABTS radical scavenging activities indicating potential food and agricultural applications. In addition, the nano-complex powders showed a controlled release of core bio-actives under gastric and intestinal pH compared to the non-encapsulated CNT phenolic extract. Degradation kinetics studies of the CNT extract after thermal and light treatments were also discussed. Both the nano-complexes showed high stability under light and thermal treatment. The results suggest that valorization of CNT can be done through nano-complex preparation and WPI and β-CD are efficient carrier materials for the encapsulation of polyphenols with potential applications in food and agriculture., 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. Published by Elsevier Ltd.)

The present study aimed to assess the safety, toxicity, biodistribution, and pharmacokinetics of eugenol nanoparticles (EONs) following oral administration in Wistar rat models. In the acute toxicity study, the rats were given a fixed dose of 50, 300, and 2000 mg/kg body weight per group orally and screened for 2 weeks after administration. In the subacute study, three different doses (500, 1000, and 2000 mg/kg BW) of EON were administered for 28 days. The results indicated no significant differences in food and water consumption, bodyweight change, hematological and biochemical parameters, relative organ weights, gross findings, or histopathology compared to the control. Additionally, no significant changes were observed in the expression profiles of inflammatory cytokines such as IL-1, IL-6, and TNFα in the plasma, confirming the absence of systemic inflammation. Biodistribution analysis revealed rapid absorption of eugenol and improved bioavailability due to gradual and sustained release, leading to a maximum eugenol concentration of 15.05 μg/mL (Cmax) at approximately 8 h (Tmax) in the blood plasma. Thus, the study provides valuable insights into the utilization of EON for enhancing the stability, solubility, and sustained release of eugenol and highlights its promising safety profile in vivo.

Purpose: This study aimed to determine the diagnostic accuracy of CT and MRI in the preoperative detection of bone involvement for non-melanoma skin cancers (NMSCs) located on the scalp. This study further aimed to evaluate the predictive value of these imaging modalities in determining the need for craniectomy and to identify gaps in the existing literature., Methods: Electronic searches of the MEDLINE, Embase, Cochrane and Google Scholar databases were performed for English language studies of any type. Studies reporting detection or exclusion of histopathologically confirmed bone involvement through preoperative imaging were identified according to PRISMA guidelines. Studies reporting dural involvement, non-scalp tumours, and lacking tumour type(s) or outcome data were excluded. Outcomes were preoperative imaging result and histopathologically confirmed bone invasion. Meta-analysis was performed and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated (excluding case report and MRI data due to insufficient quality and quantity respectively)., Results: Four studies with a total of 69 patients were included in the final review, of which two studies totalling 66 patients were included in the meta-analysis. Preoperative CT had a sensitivity of 38%, specificity of 98%, PPV of 90% and NPV of 73%., Conclusions: The available data suggests that a preoperative CT finding of calvarial involvement by a scalp NMSC is likely to be real, but the absence of such a finding is unreliable. Current evidence suggests that preoperative imaging cannot exclude the necessity for craniectomy and future research is needed, particularly on the role of MRI., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Sacroiliac (SI) joint dysfunction is a common source of back pain. Recent evidence from different parts of the world suggest that cooled radiofrequency ablation of sacral nerves supplying the SI joints has superior pain alleviating properties than currently available treatment options for SI joint dysfunction., Patients and Methods: After obtaining institutional review board approval, the medical records of 81 patients who underwent cooled radiofrequency ablation in a single institution and by a single surgeon were analyzed retrospectively. The recurrence of pain, progression to fusion and functional outcomes were noted. The patients were operated on between June 2020 and December 2021, they include 59 females and 22 males, the average age was 55.4 ± 17.3. Follow up was at least 6 months postoperative., Results: 22 of the patients had previously underwent lumbar fusions. Follow up period ranged from 6 to 18 months. After radiofrequency ablation, 7 patients progressed to fusions, and 6 patients had to have the procedure done again to relieve their pain. Student t-test was used to compare between preoperative and postoperative values of NPRS (numerical pain rating score) and ODI (Oswestry disability index). It showed significance with P-value < 0.001 in both., Conclusions: Sacroiliac joint radiofrequency ablation is a good option in the treatment of SI joint pain showing good results in the short term follow up period. It is a simple procedure that can be done in less than 30 min and is capable of providing significant pain relief for patients with sacroiliac joint dysfunction., (© 2023. The Author(s).)

Curcumin, bioactive from turmeric Curcuma longa , has been known for its therapeutic properties. However, its lipophilic nature and poor bioavailability are the constraints to harnessing its properties. Encapsulation in nano-size helps to alleviate the constraints and enhance its biological properties due to its higher surface area. The study aims to encapsulate curcumin in a nanometer size range by solubilizing in lipid (milk fat) and using milk protein as a water-soluble carrier. The lipid:curcumin ratio (1:0.05, 1:0.1, 1:0.2, 1.5:0.1, 1.5:0.2, 2.0:0.1 and 2:0.2% (w/w)) produced nanoemulsion with droplets sizes 30-200 nm. The sample containing lipid: curcumin, as 1.0:0.05 resulted in an encapsulation efficiency of 92.6%, and its binding interaction with the carrier, was K D  = 4.7 µM. A high solubility of curcumin in milk fat and digestion during in vitro lipolysis increased its bioaccessibility. A simulated gastro-intestinal in vitro studies showed that cumulative release percentage of nanoencapsulated curcumin was 60% at pH 7.4 compared to 0.8% of native curcumin. The anti-microbial property of nanoencapsulated curcumin was more potent than native curcumin against food pathogenic organisms such as S. aureus, B. cereus, E. coli , B. subtilis , P. aeruginosa, P. aeruginosa , C. violaceum ., Supplementary Information: The online version contains supplementary material available at 10.1007/s13197-023-05684-5., Competing Interests: Conflict of interestAuthors declare no competing interest., (© Association of Food Scientists & Technologists (India) 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Purpose: To establish reference ranges for four most commonly used diagnostic measures of craniocervical instability (CCI) in three cervical sagittal positions. This necessitated development of a reliable measurement protocol using upright, dynamic MRI (udMRI), to determine differences in the extent of motion between positions, and whether age and sex correlate with these measures., Materials and Methods: Deidentified udMRIs of 50 adults, referred for reasons other than CCI, were captured at three positions (maximal flexion, maximal extension and neutral). Images were analyzed, providing measures of basion-axial interval, basion-axial angle, basion-dens interval (BDI) and the Grabb-Oakes line (GOL) for all three positions (12 measures per participant). All measures were independently recorded by a radiologist and neurosurgeon to determine their reliability. Descriptive statistics, correlations, paired and independent t-tests were used. Mean (± 2 SD) identified the reference range for all four measures at each craniocervical position., Results: The revised measurement protocol produced inter-rater reliability indices of 0.69-0.97 (moderate-excellent). Fifty adults' (50% male; mean age 41.2 years (± 9.7)) reference ranges for all twelve measures were reported. Except for the BDI and GOL when moving between neutral and full flexion, significant extents of movement were identified between the three craniocervical positions for all four measures (p ≤ 0.005). Only a minor effect of age was found., Conclusions: This is the first study to provide a rigorous standardized protocol for four diagnostic measures of CCI. Reference ranges are established at mid and ends of sagittal cervical range corresponding to where exacerbations of signs and symptoms are commonly reported., (© 2023. The Author(s).)

Crop yield varies considerably within agroecology depending on the genetic potential of crop cultivars and various edaphic and climatic variables. Understanding site-specific changes in crop yield and genotype × environment interaction are crucial and needs exceptional consideration in strategic breeding programs. Further, genotypic response to diverse agro-ecologies offers identification of strategic locations for evaluating traits of interest to strengthen and accelerate the national variety release program. In this study, multi-location field trial data have been used to investigate the impact of environmental conditions on crop phenological dynamics and their influence on the yield of mungbean in different agroecological regions of the Indian subcontinent. The present attempt is also intended to identify the strategic location(s) favoring higher yield and distinctiveness within mungbean genotypes. In the field trial, a total of 34 different mungbean genotypes were grown in 39 locations covering the north hill zone ( n = 4), northeastern plain zone ( n = 6), northwestern plain zone ( n = 7), central zone ( n = 11) and south zone ( n = 11). The results revealed that the effect of the environment was prominent on both the phenological dynamics and productivity of the mungbean. Noticeable variations (expressed as coefficient of variation) were observed for the parameters of days to 50% flowering (13%), days to maturity (12%), reproductive period (21%), grain yield (33%), and 1000-grain weight (14%) across the environments. The genotype, environment, and genotype × environment accounted for 3.0, 54.2, and 29.7% of the total variation in mungbean yield, respectively ( p < 0.001), suggesting an oversized significance of site-specific responses of the genotypes. Results demonstrated that a lower ambient temperature extended both flowering time and the crop period. Linear mixed model results revealed that the changes in phenological events (days to 50 % flowering, days to maturity, and reproductive period) with response to contrasting environments had no direct influence on crop yields ( p > 0.05) for all the genotypes except PM 14-11. Results revealed that the south zone environment initiated early flowering and an extended reproductive period, thus sustaining yield with good seed size. While in low rainfall areas viz ., Sriganganagar, New Delhi, Durgapura, and Sagar, the yield was comparatively low irrespective of genotypes. Correlation results and PCA indicated that rainfall during the crop season and relative humidity significantly and positively influenced grain yield. Hence, the present study suggests that the yield potential of mungbean is independent of crop phenological dynamics; rather, climatic variables like rainfall and relative humidity have considerable influence on yield. Further, HA-GGE biplot analysis identified Sagar, New Delhi, Sriganganagar, Durgapura, Warangal, Srinagar, Kanpur, and Mohanpur as the ideal testing environments, which demonstrated high efficiency in the selection of new genotypes with wider adaptability., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Parihar, Gupta, Hazra, Lamichaney, Sen Gupta, Singh, Kumar, Singh, Vaishnavi, Jaberson, Das, Dev, Yadav, Jamwal, Choudhary, Khedar, Prakash, Dikshit, Panwar, Katiyar, Kumar, Mahto, Borah, Singh, Das, Patil, Nanda, Kumar, Rajput, Chauhan, Patel, Kanwar, Kumar, Mishra, Kumar, Swarup, Mogali, Kumaresan, Manivannan, Gowda, Pandiyan, Rao, Shivani, Prusti, Mahadevu, Iyanar and Das.)

Curcumin, a major bioactive in curcuminoids and food colorant, possess therapeutic properties, however, its low water solubility, instability during processing limit its industrial applications. The nanoencapsulated curcumin (NEC) in sodium caseinate (SC) and Maillard conjugate (MC) showed >90% water solubility. Encapsulation in MC reduced particle size (150 to 120 nm) zeta potential (-34 to -45 mV) and improved encapsulation efficiency (74 to 94%) compared to SC under optimized Tween20 and salt-ions. The in-vitro bioaccessibility of NEC was 300% more than curcumin (pH 7.4). The curcumin (0.092 mmol) and spray-dried NEC (0-0.092 mmol) were incorporated in Indian Basmati rice. The UV-VIS revealed 14, 10% higher stability of NEC (0.069 mmol) incorporated rice under dark and light at 27 ± 2 °C and 43, 39% more in thermally processed limited and excess water conditions, respectively, than curcumin. The high visual appeal and anti-oxidant activity (60%) of NEC Basmati rice demonstrated application in fortified product development., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Pod borer (Helicoverpa armigera) causes the highest yield losses in pigeonpea, followed by pod fly (Melanagromyza obtusa). High levels of resistance to pod borer are not available in the cultivated genepool. Several accessions of wild Cajanus species with strong resistance, and different resistance mechanisms (antixenosis and antibiosis) to pod borer have been identified. These accessions can be utilized to improve the pod borer resistance of cultivated pigeonpea. Using pod borer resistant Cajanus scarabaeoides and Cajanus acutifolius as pollen donors and popular pigeonpea varieties as recipients, pre-breeding populations were developed following simple- and complex-cross approaches. Preliminary evaluation of four backcross populations consisting of >2300 introgression lines (ILs) under un-sprayed field conditions resulted in identifying 156 ILs with low visual damage rating scores (5.0−6.0) and low pod borer damage (<50%). Precise re-screening of these ILs over different locations and years resulted in the identification of 21 ILs having improved resistance to pod borer. Because these ILs were derived from wild Cajanus species, they may contain different alleles for different resistance components to pod borer. Hence, these ILs are ready-to-use novel and diverse sources of pod borer resistance that can be utilized for improving the pod borer resistance of cultivated pigeonpea.

The low stability of anthocyanins is a constraint in the food industry. The present work has been carried out to overcome this low stability by encapsulating fruit concentrate of underutilized plant Carissa spinarum (CS) with polyphenols in microemulsions (CSME) and nanoemulsions (CSNE). Increasing the amount of CS reduced the particle size from 1154 to 70-300 nm whereas addition of Tween 80 reduced it optimally to 5-25 nm. Degradation of anthocyanins in control and ME/NE proceeded with zero- and first-order reaction rates, respectively, at 28 °C (half-life 6, 25 and 40 days, respectively). The degradation kinetics of phenolics-flavonoids were also studied. CSNE exhibited higher anti-quorum sensing (QS) activity than CSME against Chromobacterium violaceum (73.7%); it inhibited biofilm formation by 70.1 and 64.4% in Pseudomonas aeruginosa, and Yersinia enterocolitica, respectively. This is the first report of using the more stable ME/NE to study anti-QS activity, an alternative to conventional antibiotics., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The influence of protein (sodium caseinate-SC), polysaccharide (maltodextrin-MD; pectin-PC) and their Maillard conjugates (sodium caseinate maltodextrin conjugate-SCMDC; sodium caseinate pectin conjugate-SCPCC) were studied on the physico-chemical and biological properties of eugenol nanoemulsions/powder. The chemical composition was optimized using Taguchi design. The particles size of eugenol nanoemulsions with SC, MD, PC, SCMDC and SCPCC were 104.6, 323.5, 1872, 181.7, and 454.4 nm, respectively while their zeta potentials were -31.2, -28.5, -21.4, -40.1 and -25.1 mV, respectively. Turbidity studies revealed higher stability of nanoemulsion prepared with Maillard conjugate (SCMDC) compared to protein or polysaccharides alone. The dispersion of SCMDC eugenol nanoparticles in buffer was prepared to study its stability at different pH (3.0, 5.0, and 7.0) and temperature (4°, 37°, 60 °C) range. In-vitro enzymatic release study showed 31 and 74% release of eugenol after 6 h at pH 2.4 and 7.4, respectively. In vitro antioxidant capacity of SCMDC encapsulated eugenol was higher than native eugenol, as demonstrated by free radical scavenging assays. In comparison to native eugenol, E:SCMDC eugenol showed reduced toxicity. These findings suggested that nanoencapsulated eugenol (E:SCMDC) have a huge potential in nutraceutical and therapeutic applications., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: A bacterial cause of disc degeneration has evoked several controversies and, if true, would lead to a major shift in treatment paradigm. Earlier studies analyzing the relationship of bacterial disc infection within a degenerative cohort featured prolonged cultures susceptible to contamination. The degenerate-disc infection study with contaminant control (DISC) trial aims to investigate this theory further by examining infection rates using a non-degenerative control cohort in comparison to a degenerative internal control cohort and a sham cohort (sampling only sterile paraspinal tissue). To our knowledge, the current study is the largest evaluating the growth of organisms (or possible contamination rate) in paraspinal tissue if prolonged cultures are performed. Protocols on methodology have been previously published., Purpose: (1) To investigate the infection rates across cohorts (degenerative vs. nondegenerative control; paraspinal and/or disc controls vs. combined sampling cohorts) using stringent standardized aseptic surgical technique and laboratory processing. (2) To compare our findings to that of the literature and make a statement in support and/or against a possible contamination theory to positive cultures., Study Design: Multicenter, multisurgeon case-control trial., Patient Sample: In all, 812 surgical samples were retrieved across a 3.5-year period (2013-2016) including 25 trauma controls (nondegenerative), 550 "disc and paraspinal" samples (degenerative cases with internal control), 190 disc-only samples (degenerative cases without internal control), and 46 paraspinal only controls (sham group)., Outcome Measures: Growth and/or Contamination rate (%) per cohort. Chi-square of growth in disc versus paraspinal samples as a means of examining the distribution of false positive and contaminant growth. The impact of previous injections and/or surgery on positive disc or paraspinal growth. Correlation of Modic changes with positive growth rates analyzed with the Kruskal-Wallis Test. The distribution of species in positive samples were also analyzed., Methods: The DISC trial is registered under Australian and New Zealand clinical trials registry-ACTRN12616000541404. Institutional ethics review was obtained (HREC northern sector 13/218) at the primary center and further centers (n=6) were recruited. Patients undergoing spinal surgery with discectomy were eligible for trial entry with tissue specimens obtained using strict aseptic technique for microbiological examination. All specimens were handled with sterile instruments only and by a fresh instrument to a sterile pot that was closed immediately. Separate pots were used for the disc and paraspinal tissue respectively with similar stringent processing during microbiological assessment. A cohort of the degenerative cases at one single institution also underwent an additional histopathological examination., Results: There was an expected significant difference in gender and age associated with the non-degenerative control group (due to trauma patients) compared with other cohorts. There was a higher percentage of positive-growth in the control group in comparison to the disc and paraspinal and disc only groups across positive disc growth (48% vs. 27% vs. 17%, p<.001). A similar infection rate was observed in the paraspinal samples across the equivalent controls (44% vs. 36% vs. 37%, p=.739). There was a significant difference in the proportions of positive growth with a large proportion of false positives (growth in both disc and paraspinal samples; p<.001). There was no difference in true positive growth between the case and control groups (16.0 vs. 7.7%, p=.112). These trends were preserved across all cohorts and when stratifying by spinal segment (cervical or lumbar). There was no correlation between Modic changes and positive disc culture growth (p=.398, n=144 samples). Cutibacterium (formerly Propionibacterium) acnes was the most dominant pathogen isolated, representing between 50% and 70% of positive disc and paraspinal specimens, followed by staphylococcal species., Conclusions: Our study failed to find a difference in true infection rates between the nondegenerative and degenerative disc populations. These findings are suggestive of a contamination theory and against a common infective etiology in the setting of discogenic back and neck pain. We believe the rationale for antibiotic therapy in the management of discogenic back pain warrants further evidence to establish efficacy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: Literature review., Objective: To conduct a literature review of studies reporting the incidence of pars interarticularis defects in athletes of specific sports, in order to allow more targeted prevention and treatment strategies to be implemented for the groups at highest risk., Methods: Electronic searches were performed using PubMed, Ovid Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Database of Controlled Trials from their dates of inception to September 2017, with the following keywords: "spondylolysis," "sports," "low back pain," and "pars defects.", Results: A total of 509 total articles were retrieved, of which 114 were used in the final review. The incidence of pars interarticularis defects was found to be highest in diving (35.38%), cricket (31.97%), baseball/softball (26.91%), rugby (22.22%), weightlifting (19.49%), sailing (17.18%), table tennis (15.63%), and wrestling (14.74%). Only 5 studies reported the management instituted for their participants, and these were all case reports. Of 74 players with spondylolysis in these studies, 70 (94.59%) underwent conservative treatment and 4 (5.41%) underwent surgical treatment. 61 (82.43%) returned to their previous level of play, 6 (8.11%) retired, and the disposition of the final 7 was not reported., Conclusion: The current medical literature provides good evidence that the incidence of pars interarticularis defects is higher in the athletic population, with the highest incidence in diving. There remains no gold standard protocol for the management of pars interarticularis defects. Further research is required to compare conservative therapy to surgical therapy and to compare the various surgical techniques to each other., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

Pigeonpea [ Cajanus cajan (L.) Millsp.], a multipurpose and nutritious grain legume crop, is cultivated for its protein-rich seeds mainly in South Asia and Eastern and Southern Africa. In spite of large breeding efforts for pigeonpea improvement in India and elsewhere, genetic enhancement is inadequate largely due to its narrow genetic base and crop susceptibility to stresses. Wild Cajanus species are novel source of genetic variations for the genetic upgradation of pigeonpea cultivars. In the present study, 75 introgression lines (ILs), derived from crosses involving cultivated pigeonpea variety ICPL 87119 and wild Cajanus cajanifolius and Cajanus acutifolius from the secondary gene pool, were evaluated for yield and yield-attributing traits in diverse environments across locations and years. Restricted maximum likelihood (REML) analysis revealed large genetic variations for days to 50% flower, days to maturity, plant height, primary branches per plant, pods per plant, pod weight per plant, 100-seed weight, and grain yield per plant. Superior ILs with mid-early to medium maturity duration identified in this study are useful genetic resources for use in pigeonpea breeding. Additive main effects and multiplicative interaction (AMMI) analysis unfolded large influence of environment and genotype × environment interaction for variations in yield. A few lines such as ICPL 15023 and ICPL 15072 with yield stability were identified, while a number of lines were completely resistant (0%) to sterility mosaic diseases and/or Fusarium wilt. These lines are novel genetic resources for broadening the genetic base of pigeonpea and bring yield stability and stress tolerance. High-yielding lines ICPL 15010, ICPL 15062, and ICPL 15072 have been included in the initial varietal trials (IVTs) of the All India Coordinated Research Project (AICRP) on pigeonpea for wider evaluation across different agro-ecological zones in India for possible release as variety(ies)., (Copyright © 2019 Sharma, Paul, Kumar, Rao, Prashanti, Muniswamy and Sharma.)

Recent evidence into an infectious etiology of discogenic back pain/leg pain are ongoing with contradictory data in literature. We sought to validate the clinical relevance of histopathological evidence of inflammation through a previously proposed histological grading system. In this prospective cohort study, 124 consecutive patients undergoing an elective spinal decompression and/or fusion procedure involving discectomy were selected with intraoperative tissue sampling of intervertebral disc and paraspinal tissue at a single institution. The histological domains were correlated with positive disc cultures to assist in identifying relevant positive infections. Inter-observer analysis of the scoring system was also performed. There were 124 samples (36 cervical and 88 lumbar) obtained. 29 (23.4%) disc specimens and 37 (29.8%) of ligament samples demonstrated growth of C. acnes. In total, 38/124 (30.6%) of disc specimens were positive for growth of any species. There was poor association between positive disc culture and the presence of neutrophilia (p = 0.123) or chronic inflammatory changes (p = 0.092) on histopathological assessment. There was no statistical significance noted across all histological domains examined within the finalised scoring system and positive culture across disc specimens. There was moderate agreement in between observers (kappa range: 0.41-0.60) in the assessment of inflammatory changes using the proposed scoring system. The current study suggests poor correlation between histopathological evidence of chronic or acute inflammation and positive disc cultures questioning the idea that disc infection is the root cause of acute or chronic back pain/leg pain., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Idarucizumab is the first Food and Drugs Administration (FDA) approved reversal agent for anticoagulant dabigatran, a direct thrombin inhibitor. Emerging evidence suggests idarucizumab can improve clinical outcome following dabigatran-associated hemorrhage, however, its specific use in intracranial hemorrhage has been poorly described. The aim of this study was to systematically review the available literature of idarucizumab in the setting of dabigatran-associated ICH to evaluate its efficacy in the stabilizing/resolving of the primary hemorrhage. A systematic search of 7 electronic databases from their earliest records to August 2018 was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 864 articles identified for screening against selection criteria. The search identified 9 articles to be included in our analysis, describing hemorrhage outcomes in 23 dabigatran-associated cases of ICH managed by idarucizumab. Mean overall age was 76.2 years, with 43% females, and bleeding was subdural, subarachnoid and intracerebral in 43%, 13% and 43% cases respectively. Surgical intervention was pursued in 48% of cases. During the course of the hospitalization, the hemorrhages stabilized/resolved in 87% of patients, and worsened in 13%. In-hospital complications occurred in 4% of cases, and mortality occurred in 4% of cases as well. The available literature suggests that idarucizumab can be applied in the setting of ICH, for its therapeutic effect in patients presenting with dabigatran-associated ICH appears acceptable with no compromise to clinical safety. However, currently there is a paucity of data about various aspects that are involved in other aspects of ICH treatment, including recovery, that limits the significance of the current literature. As more evidence is published relating specifically to long-term ICH outcomes that have been treated by idarucizumab, we will be better placed to establish the optimal role of idarucizumab in the setting of dabigatran-associated ICH., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Direct lateral interbody fusion (DLIF) mitigates many of the vascular complications and bony resections associated with other interbody fusion techniques. However, there are concerns regarding postoperative neural complications and that indirect decompression of the foramen has not been consistently demonstrated. This study prospectively assessed the clinical and radiological outcomes and the complication rates of the DLIF approach., Methods: A prospective review was conducted of the first 50 consecutive DLIF cases of a single neurosurgeon between 2010 and 2014. Clinical outcomes were assessed using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) surveys. Radiological outcomes, including spondylolisthesis, disc height, local disc angle, lumbar lordosis and foraminal height and width, were measured using Surgimap Spine software at the preoperative, 6 weeks, 6 months, and 12 months postoperative follow-up. Complication rates were also reported., Results: A total of 50 patients (84 levels) were treated with DLIF. The mean patient age was 68.2±9.8 years and 62.0% were female. At latest follow-up, mean VAS pain score improved from 7.7±1.5 to 1.9±0.9 (P<0.0001), mean ODI improved from 42.1±14.5 to 16.9±6.7 (P<0.0001) and mean RMDQ score improved from 12.1±5.2 to 6.2±4.7 (P<0.0001). Mean spondylolisthesis reduced from 7.5%±6.5% to 1.3%±1.1% at 6 weeks (P<0.0001), 0.95%±0.74% at 6 months (P<0.0001) and recurred to 1.9%±1.7% at 12 months postoperatively (P=0.0006). Mean anterior disc height improved from 7.3±3.2 to 11.6±2.5 mm at 6 weeks (P<0.0001), 12.2±3.3 mm at 6 months (P<0.0001) and 9.8±2.1 mm at 12 months (P=0.0032) postoperatively. Mean posterior disc height improved from 4.4±2.0 to 6.8±2.1 mm at 6 weeks (P<0.0001), 6.6±2.5 mm at 6 months (P=0.0003), and 5.9±1.4 mm at 12 months (P=0.0039) postoperatively. Mean local disc angle improved from 7.0°±3.7° to 9.2°±3.3° at 6 weeks (P=0.0072), 10.4°±3.9° at 6 months (P=0.0013) and 8.2°±2.9° at 12 months (P=0.2487) postoperatively. No significant postoperative changes in lumbar lordosis were observed. Mean foraminal height improved from 18.3±3.5 to 21.5±3.9 mm at 6 weeks (P=0.0004), 20.6±3.4 mm at 6 months (P=0.0266), and 18.7±1.9 mm at 12 months (P=0.8021) postoperatively. Mean foraminal width improved from 7.9±2.0 to 10.2±2.8 mm at 6 weeks (P=0.0001), 9.4±2.6 mm at 6 months (P=0.0219) and 8.3±1.6 mm at 12 months (P=0.5734) postoperatively. Fusion rate at 6 and 12 months was 62.2% and 89.2%, respectively. A total of 6 patients (12%) had postoperative complications. Three patients (6%) had pain-related psoas muscle weakness and 3 patients (6%) had sensory neural complications that had resolved entirely by 8 and 16 weeks postoperatively, respectively., Conclusions: The study provides encouraging short and medium-term clinical and radiological results for DLIF. In this patient series, there was a low complication rate with no permanent neural injury reported., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: To evaluate the initial outcomes of a composite cage with integral fixation using the Redmond titanium (Ti)/polyetheretherketone (PEEK) anterior cervical discectomy and fusion (ACDF) device., Methods: Data from 50 consecutive patients were prospectively collected from a single senior surgeon cohort. All cages were between 5 and 8 mm in height, and were packed with supercritical CO 2 sterilized allograft. Patients were followed up for a minimum of 6 months, and implant complications were assessed., Results: From the original cohort, three were unavailable for follow-up. Forty-seven patients with a total of 58 operative levels were observed for a mean of 7.9 months. A fusion rate of 96% was achieved. Good to excellent outcomes were seen in 92% of patients. There were no cases of implant Ti/PEEK delamination or implant failure, with excellent early fusion rates using supercritical CO 2 allograft., Conclusions: The present study demonstrates the development of a composite ACDF cage design that is a safe and effective treatment option with the potential for early osseointegration and interbody fusion. Supercritical CO 2 sterilized allograft was an effective graft material supporting fusion., (© 2019 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Background: In this study, a historical case series is reported of reaction bonded silicon nitride (Si 3 N 4 ) implants for anterior lumbar interbody fusion (ALIF) for a patient population of 30 and surgery levels L3/4, L4/5, and/or L5/S1. Before the study, the only work on Si 3 N 4 as a biomedical material was associated preliminary work, which involved animal trials using a rabbit model. The objective was to undertake the first use of Si 3 N 4 as a biomedical material for humans, as an implant for ALIF., Methods: The Si 3 N 4 implants were prepared by die-pressing silicon powder and reaction bonding in 95 N 2 /5 H 2 at ∼1400°C for ∼50 hours. The surgeries involved a retroperitoneal approach for L3/4 and L4/5 levels and a transperitoneal approach for L5/S1 level. The patient follow-up involved assessment of radiologic fusion up to 30 years and clinical outcomes to 10 years., Results: The reaction bonded Si 3 N 4 implants were found to be biologically safe and to show high fusion rates with minimal subsidence, no abnormal reaction, and no other complications. The primary outcome measure, visual analog scale back pain, improved from a preoperative mean of 8.4 (range, 6-10) to a mean of 3.7 (range, 0-9) at 5 years and a mean of 4.9 (range, 0-9) at 10 years. The Oswestry Disability Index improved from a preoperative mean of 48 (range, 26-84) to a mean of 35 (range, 4-76) at 10 years., Conclusions: This study confirms that Si 3 N 4 is biologically safe in the long-term, with capacity for excellent radiologic osseointegration., (Copyright © 2018. Published by Elsevier Inc.)

Study Design: Prospective cohort study., Objectives: To evaluate the role of magnetic resonance imaging (MRI) in evaluation of fusion status following anterior lumbar interbody fusion (ALIF) and compare agreement and confidence in assessing fusion or its absence on MRI to the current standard computed tomography (CT)., Methods: A prospective follow up of patients undergoing surgery by 2 spine surgeons between 2012 and 2015 at a single institution. Fusion was assessed at different time points in these patients by 2 independent musculoskeletal radiologists. Fusion was analyzed in coronal and sagittal planes using both imaging modalities, with confidence being attributed on a scale of 0 to 3. Assessors were blinded to patient data., Results: Fourteen patients (25 levels) with mean follow-up of 10.2 months (range 2.4-20.3 years) and age of 41 years (range 20.7-61.5 years) were assessed. MRI within the interbody cage in coronal (κ = .58) and sagittal (κ = .50) planes had the highest interobserver agreement. CT anterior to the cage in coronal (κ = .48) and sagittal (κ = .44) planes, as well as within the cage in coronal (κ = .50) and sagittal planes (κ = .44) showed moderate agreement. Confidence anterior to the interbody cage using MRI scan was reduced when compared with remaining angles and imaging modalities., Conclusions: The study demonstrates that MRI may be a useful tool in the assessment of fusion following ALIF with results comparable to CT, and that it may have a useful role in select patients especially considering marked radiation exposure reduction., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Michael Selby has received fellowship support from Depuy Synthes and LifeHealthCare. He has also consulted with Depuy Synthes, K2M, and LifeHealthCare.

Background: To analyse the relation between immediate intraoperative neurophysiological changes during decompression and clinical outcome in a series of patients with lumbar spinal stenosis (LSS) undergoing surgery., Methods: Twenty-four patients with neurogenic intermittent claudication (NIC) due to LSS undergoing decompressive surgery were prospectively studied. Intra operative trans-cranial motor evoked potentials (tcMEPs) were recorded before and immediately after surgical decompression. Lower limb normalised tcMEP improvement was used as primary neurophysiological outcome. Clinical outcome was assessed using the Zurich Claudication Questionnaire (ZCQ) self-assessment score, before surgery (baseline) and at an average of 8 and 29 months post-operatively., Results: We found a moderate positive correlation between tcMEP changes and ZCQ at early follow-up (R=0.36). At late follow-up no correlation was found between intra-operative tcMEP and ZCQ changes. Dichotomizing the data showed a statistically significant relationship between tcMEP improvement and better functional outcome at early follow-up (P=0.013) but not at later follow-up (P=1)., Conclusions: Our findings suggest that intra-operative neurophysiological improvement during decompressive surgery may predict a better clinical outcome at early follow-up although this is not applicable to late follow-up possibly due to the observed erosion of functional improvement with time., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: The role of bacterial infection in the causation of disc degeneration and its consequences is controversial. The current evidence is limited to underpowered studies, with the majority of such studies having only an internal contaminant arm, and only one study having a control arm with a non-degenerate disc population. The Degenerate-disc Infection Study with Contaminant Control (DISC) study includes a control arm and an internal contaminant control to resolve these shortcomings., Methods: The study is designed as a case-control study: cases are patients undergoing surgery for degenerated disc pathology and controls are patients undergoing surgery for non-degenerate pathology, such as trauma, scoliosis or tumor cases., Results: This study is part of a multi-centric trial involving six spine centers with 15 spine surgeons contributing. The DISC study methodology, rationale and controversies are presented here. The predominant issue is how to interpret contamination. We present our algorithm for the DISC study to address this. For disc samples that are positive concurrently with positive paraspinal tissue sample, the result will be interpreted as contamination. For positive disc samples with a negative paraspinal tissue culture result, the interpretation of this result will be infection. If cultures for both disc sample and paraspinal tissue sample are negative, then the result is interpreted as non-infected. If the disc culture is negative but paraspinal tissue culture is positive, then it is treated as a contaminant., Conclusions: Future large-scale studies are required with a good control arm, a contamination arm, and histopathological correlations., (© 2018 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Background: The complications associated with obesity have been well described for posterior lumbar spinal surgery. However, the influence of obesity on anterior lumbar interbody fusion (ALIF) is not well established. We aimed to compare complication risks, functional outcomes, and subsidence rates in normal-weight, overweight, and obese patients who underwent ALIF., Methods: A total of 137 consecutive patients undergoing ALIF surgery from 2012 to 2014 were followed prospectively. Patients were categorized into 3 groups according to their body mass index (BMI). Patients were evaluated preoperative and postoperatively. Outcome measures included Short Form-12, Oswestry Disability Index, surgical complications, and subsidence., Results: There was no significant difference between the BMI groups in terms of baseline age, proportion of men, levels operated, smoking status, diabetes status, or anterior, posterior, or average disc height. There was no difference in operative duration, blood loss, or hospital stay. At 12-month follow-up, no difference was found in terms of total complications, change in Short Form-12 mental or physical component scores, or Oswestry Disability Index scores. Average disc height was significant lower for the obese group (11.3 mm) compared with the normal-weight (14.4 mm) group. Fusion rate was also significantly lower for patients who were obese (60%) compared with normal-weight (88.2%) and overweight patients (76%) (P = 0.014). Delayed subsidence rates also were similar between normal-weight and overweight patients., Conclusions: There were no differences in functional outcomes or complications in patients with elevated BMI compared with normal-weight patients. Fusion rates were lower for patients were obese. Obesity should not be considered a contraindication to surgery in patients with appropriate indication to undergo ALIF., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Anterior lumbar interbody fusion (ALIF) is a surgical technique used to treat patients with a variety of lumbar pathologies. Identification of risk factors leading to complication following ALIF surgery may allow surgeons to better judge candidacy and optimize care for high-risk patients., Methods: A retrospective analysis was conducted on a prospectively collected database of 137 patients who all underwent ALIF surgery by a single primary spine surgeon. Patients were separated into age-based cohorts (≤49, 50-63, and ≥64 years of age). Chi-squared, Fisher exact test, and multivariate logistic regression models were used to identify independent risk factors., Results: A total of 137 patients met the inclusion criteria. Patients were divided into age-based tertiles as follows: Group 1 (<49 years old, n = 45, 32.8%), Group 2 (50-63 years old, n = 46, 33.6%), and Group 3 (64 years old, n = 46, 33.6%). Univariate analysis revealed increasing age (relative to Group 1) to be an independent risk factor for postoperative hematoma and delayed subsidence at 6 weeks and 12 weeks postoperatively compared with immediately post operation (all P < 0.05). No significant differences were found among the groups in terms of clinical outcome. Multivariate analysis also demonstrated increased age to be independently associated with greater prevalence of delayed subsidence (odds ratio 9.174, P = 0.029)., Conclusions: Increased age was not associated with adverse perioperative outcomes and complications of ALIF. However, there was an increased incidence of delayed subsidence in patients ≥64 years old., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design: Systematic review and meta-analysis., Objective: Current surgical management of degenerative spondylolisthesis (DS) involves decompression of the spinal canal followed by fusion with or without interbody. The additional functional and operative benefits derived from interbody inclusion has yet to be thoroughly established with a number of recent studies producing conflicting results. Thus, we aim to compare the functional and operative outcomes after fusion against interbody fusion in the treatment of DS., Methods: This systematic review of the literature comparing posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) outcomes in the treatment of DS was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic searches of 6 databases yielded 386 articles from database inception to July 2016, which were screening against established criteria for inclusion into this study., Results: A total of 6 studies, satisfied criteria and reported outcomes for 721 patients. Fusion alone was performed in 458 (63.5%) patients and interbody fusion was performed in 263 (36.5%) patients. Functional outcomes Oswestry Disability Index ( P = .29) and visual analog scale ( P = .13) were not statistically different between the 2 approaches. Furthermore, there was no significant inferiority between fusion alone and with interbody in terms of the operative outcomes of blood loss ( P = .38), reoperation rate ( P = .66), hospital stay ( P = .96), complication rate ( P = .78), or fusion rate ( P = .15)., Conclusions: There was no statistically significant difference in functional and operative outcomes following fusion alone versus with interbody. Additional subgroup analysis of intrinsic DS features in future large, prospective, randomized controlled trials will improve the validity of these findings., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Anterior lumbar-interbody fusion (ALIF) is a commonly performed procedure for degenerative spinal disorders with reasonable clinical and safety outcomes, although there is limited evidence regarding the impact of ALIF in patients receiving worker's compensation (WC) compared with those without. The aim of our study is to identify whether WC status affects the clinical outcome and rates of complication following ALIF surgery in a prospective cohort., Methods: We followed prospectively 114 consecutive patients undergoing ALIF surgery from 2012-2014. Patients were categorized into 2 groups: those with worker's compensation (WC) (n = 24) and those without (n = 90). Patients were evaluated preoperative and postoperatively. Outcome measures included Short Form-12 (SF-12), Oswestry Disability Index (ODI), surgical complications, and subsidence., Results: In terms of baseline traits, the WC group had a significantly higher proportion of class III/IV obesity patients, who were younger (46.3 vs. 60.2 years) compared with non-WC. There were no significant differences in fusion rates or preoperative or postoperative disk height. No significant differences were found for hospital stay, blood loss, or operation duration. Similar rates of complications were found between WC versus non-WC cohorts. No significant difference was noted in clinical improvement between the 2 cohorts with SF-12 PCS, SF-12 MCS, or ODI (P = 0.232). No significant difference was found in the proportion of patients achieving minimal clinically important difference for SF-12 PCS/MCS or ODI., Conclusions: In our prospective cohort, there were no significant differences found between WC versus non-WC patients in terms of fusion rates, complications, clinical outcomes, or proportion of patients achieving minimal clinically important difference., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Anterior lumbar interbody fusion (ALIF) is a widely used surgical technique for disorders of the lumbar spine. One potential complication is the subsidence of disc height in the post-operative period. Few studies have reported the rate of subsidence in ALIF surgery prospectively. We prospectively evaluated the rate of subsidence in adult patients undergoing ALIF., Methods: Results were obtained by reviewing scans of 147 patients. Disc heights were measured on radiographic scans taken pre-operatively in addition to post-operatively immediately, at 6 weeks and at 18 months. The anterior and posterior intervertebral disc heights were measured. Subsidence was defined as greater than or equal to 2 mm loss of height., Results: A total of 15 patients (10.2%) had subsidence, with 7 being male. Each case was of delayed cage subsidence (DCS) >6 weeks postoperatively. The mean subsidence was 4.7 mm (range, 2.4-7.8). Mean anterior disc height was 8.6±0.4 mm preoperatively, which improved to 15.1±0.5 mm at latest follow-up. Mean posterior disc height was 4.7±0.2 mm preoperatively, which improved to 8.7±0.4 mm at latest follow-up. The mean lumbar lordosis (LL) angle was 42.5°±10.8° and the mean local disc angle (LDA) was 6.7°±4.0°. The 91.2% (n=114/125) of patients with appropriate radiological follow-up demonstrated fusion by latest follow-up. There was no correlation between subsidence rate with patient reported outcomes [Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form 12 Item survey (SF-12)] and fusion rates. There was a significant negative correlation between LL and extent of subsidence (Pearson correlation =-0.754, P=0.012)., Conclusions: In conclusion, we found that the subsidence rate at follow-up was generally low following standalone ALIF for this patient series. Patient clinical outcomes and bony fusion rates were not significantly influenced by subsidence., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Study Design: A systematic review and meta-analysis., Objective: The aim of this study was to investigate the outcomes of anterior lumber interbody fusion (ALIF) with and without an "access surgeon.", Summary of Background Data: Anterior approaches for spine operations have become increasingly popular but may often involve unfamiliar anatomy and territory for spine surgeons, potentially placing the patient at risk to a greater proportion of approach-related complications. Thus, many spine surgeons require or prefer the assistance of an "access surgeon" to perform the exposure. However, there has been much debate about the necessity of an "access surgeon.", Methods: A systematic search of six databases from inception to April 2016 was performed by two independent reviewers. Meta-analysis was used to pool overall rates, and compare the outcomes of ALIF with an access surgeon and without., Results: A total of 58 (8028 patients) studies were included in this meta-analysis. The overall intraoperative complications were similar with and without an "access surgeon." The overall pooled rate of arterial injuries [no access 0.44% vs. access 1.16%, odds ratio (OR) 2.67, P < 0.001], retrograde ejaculation (0.41% vs. 0.96%, OR 2.34, P = 0.005), and ileus (1.93% vs. 2.26%, OR 2.45, P < 0.001) was higher with an "access surgeon." However, the overall pooled rates of peritoneal injury (0.44% vs. 0.16%, OR 0.36, P = 0.034) and neurological injury (0.99% vs. 0.11%, OR 0.11, P < 0.001) were lower with an "access surgeon." Total postoperative complications (5.95% vs. 4.08%, OR 0.67, P < 0.001) were lower with an "access surgeon" along with prosthesis complications (1.59% vs. 0.89%, OR 0.56, P < 0.001) and reoperation rates (2.28% vs. 1.31%, OR 0.57, P < 0.001)., Conclusion: Compared with no access surgeon, the use of an access surgeon was associated with similar intraoperative complication rates, higher arterial injuries, retrograde ejaculation, ileus, and lower prosthesis complications, reoperation rates, and postoperative complications. In cases wherein exposure may be difficult, support from an "access surgeon" should be available., Level of Evidence: 1.

Background: Tumor cells work in close coordination with stromal elements from its stage of emergence to metastasis. The study was designed to assess the presence and distribution pattern of stromal fibrocytes and myofibroblasts in oral squamous cell carcinoma (OSCC). Possibility of using these stromal cells as a marker for invasion and lymphnode metastasis was evaluated., Materials and Methods: A total of 40 cases of OSCC consisting twenty cases of each lymph node positive (pN+) and lymph node negative (pN0) samples and ten normal oral mucosa (NOM) tissues were subjected to double immunostaining using CD34 and alpha-smooth muscle actin (α-SMA) antibodies. Stained sections were evaluated semiquantitatively., Results: CD34 fibrocytes were seen in 70% of NOM and none of OSCC samples. α-SMA myofibroblasts were seen in 80% of OSCC and none of NOM samples. A statistically significant difference was found in fibrocyte values ( P < 0.001) and myofibroblast values ( P < 0.001) between NOM and OSCC study samples. No statistical significance in myofibroblast values between pN0 and pN+ study groups; however, their distribution pattern appreciably varied., Conclusions: This study suggested that fibrocytes could be used as one of the markers for early invasion. Abrupt loss of fibrocytes at the transition zone toward carcinoma and statistical significance in their values supported this inference. Heterogeneity in the distribution pattern of myofibroblasts in tumor stroma indicates that this variability may predict the tumor behavior toward nodal metastasis rather than their mere presence or absence., Competing Interests: There are no conflicts of interest.

Vertebral artery (VA) aneurysms in the paediatric population are a rare but a serious condition. However, the epidemiology of paediatric VA aneurysms is poorly understood and there is little consensus on what constitutes the appropriate treatment. Although multiple treatment options are available, including surgery, endovascular approaches, coil embolization and parent artery occlusion, there is limited clinical evidence regarding which approach is most optimal. This review outlines the current literature and evidence outlining the epidemiology, presentation, pathogenesis and treatment of paediatric VA aneurysms., (© 2017 Royal Australasian College of Surgeons.)

Purpose: The traditional surgical approach to treat multi-level cervical disc disease (mCDD) has been anterior cervical discectomy and fusion (ACDF). There has been recent development of other surgical approaches to further improve clinical outcomes. Collectively, when elements of these different approaches are combined in surgery, it is known as hybrid surgery (HS) which remains a novel treatment option. A systematic review and meta-analysis was conducted to compare the outcomes of HS versus ACDF for the treatment of mCDD., Methods: Relevant articles were identified from six electronic databases from their inception to January 2016., Results: From 8 relevant studies identified, 169 patients undergoing HS were compared with 193 ACDF procedures. Operative time was greater after HS by 42 min (p < 0.00001), with less intraoperative blood loss by 26 mL (p < 0.00001) and shorter return to work by 32 days (p < 0.00001). In terms of clinical outcomes, HS was associated with greater C2-C7 range of motion (ROM) preservation (p < 0.00001) and less functional impairment (p = 0.008) after surgery compared to ACDF. There was no significant difference between HS and ACDF with respect to postoperative pain (p = 0.12). The postoperative course following HS was not significantly different to ACDF in terms of length of stay (p = 0.24) and postoperative complication rates (p = 0.18)., Conclusions: HS is a novel surgical approach to treat mCDD, associated with a greater operative time, less intraoperative blood loss and comparable if not superior clinical outcomes compared to ACDF. While it remains a viable consideration, there is a lack of robust clinical evidence in the literature. Future large prospective registries and randomised trials are warranted to validate the findings of this study.

Objective: Facet joint cysts (FJCs) of the lumbar spine are an increasingly reported cause of radiculopathy, lower back pain, and neurologic deficits. Currently, there is a lack of conclusive evidence outlining when a particular treatment should be undertaken and what patient indications suit a particular approach. The present systematic review and meta-analysis aims to evaluate the efficacy of percutaneous treatment and surgical decompression with or without fusion., Methods: A systematic literature search of scientific databases from their inception to February 2016 was performed by 2 reviewers. Studies pertaining to percutaneous procedures, decompressive surgeries, or decompressive surgeries with fusion for the treatment of lumbar facet joint cysts were identified. Data for resolution of symptoms, repeat procedures, and subsequent fusion were extracted and analyzed., Results: Fifty studies comprising 870 patients with lumbar FJCs were identified for inclusion. Decompressive procedures were performed in 62.8% of patients, whereas 36.1% were treated by percutaneous aspiration or rupture, and only 1.1% were treated by decompression with fusion. Pooled analysis showed the rate of cyst resolution to be 90% for decompressive procedures with or without fusion and 58% for percutaneous procedures. Repeat procedures were required in 29% of percutaneous procedures, but less than 1% for all decompression operations., Conclusions: Evaluation of the literature shows surgical intervention to be advantageous over percutaneous procedures for the treatment of lumbar FJCs. There is no evidence suggesting when fusion should be undertaken because of the limited data available., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid arteries and the cavernous sinus. CCFs often present with double vision, reduced visual acuity, and conjunctivitis. Deteriorating ocular symptoms caused by abnormal fistula drainage can cause permanent blindness, and so urgent interventional treatment is necessary. Transvenous embolization of the fistula is the primary treatment option for most patients with symptomatic CCFs. Orbital approaches are considered to be risky compared with the traditional approach via the inferior petrosal sinus and are thus used as a secondary option. These approaches include embolization via the superior ophthalmic vein, inferior ophthalmic vein, and medial ophthalmic vein and direct transorbital puncture. This study aims to assess the merits and risks of orbital approaches in transvenous embolization of CCFs., Methods: A systematic review of 30 studies assessing the radiographic and clinical outcomes of this approach was conducted. Outcomes of interest included successful fistula closure, postoperative improvement of ocular symptoms, and complications from the procedure. Weighted averages were calculated for all outcomes., Results: Transvenous embolization via an orbital approach had a high success rate (89.9%). Improvement in visual acuity and proptosis was found in 93.4% and 88.1% of patients, respectively. There were no major complications. Minor complications found included subconjunctival hemorrhage (n = 4), intraorbital hemorrhage (n = 1), eyelid hematoma (n = 1), and foreign-body granuloma (n = 3)., Conclusions: All orbital approaches for transvenous embolization of CCFs are effective and safe., (Copyright © 2016 Elsevier Inc. All rights reserved.)

External ventricular drains (EVD) are crucial for the emergency management of hydrocephalus and raised intracranial pressure. Infection is the most morbid and costly cause of EVD malfunction and can cost up to $50,000 US to treat per case. In 2007, Canberra Hospital changed EVD management protocols requiring set-up of EVD transducer systems in theatre, cessation of prophylactic antibiotics after 24hours, cerebrospinal fluid (CSF) samples second or third daily and discontinuation of elective EVD changes. The current study aimed to retrospectively audit EVD inserted between 2006 and 2010 in order to determine the impact of these changes. There was a non-significant downward trend in infection rates from 20.93% to 11.50% (p=0.343) after the protocol changes. Patient age (OR=1.032, p=0.064, confidence interval (CI): 0.998-1.067) and sex (OR=1.405, p=0.595, CI: 0.401-4.917) were not significantly associated with infection. However, multiple drains were associated with a significant increase in infections rates (OR=21.96, p=0.001, CI: 6.103-79.023) and systemic perioperative antibiotic prophylaxis was associated with decreased rates of infections (OR=0.269, p=0.044, CI: 0.075-0.964). Our study showed a non-significant downwards trend in infections with introduction of changes to hospital protocol and illustrated some risk factors for infection in the Australian setting., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Endovascular coil embolization is a widely accepted and useful treatment modality for intracranial aneurysms. However, the principal limitation of this technique is the high aneurysm recurrence. The adjunct use of stents for coil embolization procedures has revolutionized the field of endovascular aneurysm management, however its safety and efficacy remains unclear. Two independent reviewers searched six databases from inception to July 2015 for trials that reported outcomes according to those who received stent-assisted coiling versus coiling-only (no stent-assistance). There were 14 observational studies involving 2698 stent-assisted coiling and 29,388 coiling-only patients. The pooled immediate occlusion rate for stent-assisted coiling was 57.7% (range: 20.2%-89.2%) and 48.7% (range: 31.7%-89.2%) for coiling-only, with no significant difference between the two (odds ratio [OR}=1.01; 95% confidence intervals [CI}: 0.68-1.49). However, progressive thrombosis was significantly more likely in stent-assisted coiling (29.9%) compared to coiling-only (17.5%) (OR=2.71; 95% CI: 1.95-3.75). Aneurysm recurrence was significantly lower in stent-assisted coiling (12.7%) compared to coiling-only (27.9%) (OR=0.43; 95% CI: 0.28-0.66). In terms of complications, there was no significant difference between the two techniques for all-complications, permanent complications or thrombotic complications. Mortality was significantly higher in the stent-assisted group 1.4% (range: 0%-27.5%) compared to the coiling-only group 0.2% (range: 0%-19.7%) (OR=2.16; 95% CI: 1.33-3.52). Based on limited evidence, stent-assisted coiling shows similar immediate occlusion rates, improved progressive thrombosis and decreased aneurysm recurrence compared to coiling-only, but is associated with a higher mortality rate. Future randomized controlled trials are warranted to clarify the safety of stent-associated coiling., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Lumbar fusion surgical intervention is often followed by bilateral pedicle screw fixation. There has been increasing support for unilateral pedicle screw fixation in an attempt to reduce complications and costs. The following study assesses the efficacy and complications of bilateral versus unilateral pedicle screw fixation in open and minimally invasive lumbar interbody fusion techniques. A systematic review with meta-analysis and trial sequential analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and recommendations. In comparison with existing meta-analyses, trial sequential analysis was implemented to reduce the potential for type I error. Of the 1310 citations screened, four observational studies and 13 randomised controlled trials were used comprising 574 bilateral cases and 549 unilateral cases. Statistical analysis showed no difference in fusion rates, total complications, dural tear rates, Visual Analogue Scale (VAS) score for back pain, VAS for leg pain, Oswestry Disability Index scores, and length of stay between bilateral and unilateral instrumentation. Unilateral instrumentation was significantly shorter in duration (P<0.00001) and led to significantly lower blood volume loss (P=0.0002). These results were the same for both open and minimally invasive surgical approaches. Unilateral pedicle screw fixation appears to have similar post-operative outcomes as bilateral fixation and improved efficacy in regards to procedure duration and blood volume loss., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Study Design: Prospective observational study., Objective: Patient-based subjective ratings of symptoms and function have traditionally been used to gauge the success and extent of recovery following spine surgery. The main drawback of this type of assessment is the inherent subjectivity involved in patient scoring. We aimed to objectively measure functional outcome in patients having lumbar spine surgery using quantitative physical activity measurements derived from accelerometers., Methods: A prospective study of 30 patients undergoing spine surgery was conducted with subjective outcome scores (visual analog scale [VAS], Oswestry Disability Index [ODI] and Short Form 12 [SF-12]) recorded; patients were given a Fitbit accelerometer (Fitbit Inc., San Francisco, California, United States) at least 7 days in advance of surgery to record physical activity (step count, distance traveled, calories burned) per day. Following surgery, postoperative activity levels were reported at 1-, 2-, and 3-month follow-up., Results: Of the 28 compliant patients who completed the full trial period, mean steps taken per day increased 58.2% (p = 0.008) and mean distance traveled per day increased 63% (p = 0.0004) at 3-month follow-up. Significant improvements were noted for mean changes in VAS back pain, VAS leg pain, ODI, and SF-12 Physical Component Summary (PCS) scores. There was no significant correlation between the improvement in steps or distance traveled per day with improvements in VAS back or leg pain, ODI, or PCS scores at follow-up., Conclusions: High compliance and statistically significant improvement in physical activity were demonstrated in patients who had lumbar decompression and lumbar fusion. There was no significant correlation between improvements in subjective clinical outcome scores with changes in physical activity measurements at follow-up. Limitations of the present study include its small sample size, and the validity of objective physical activity measurements should be assessed in future larger, prospective studies.

Back pain remains one the most prevalent types of pain and disability worldwide. Infection is estimated to be the underlying cause in approximately 0.01% of patients. Despite recent evidence demonstrating prominent infection rates, a standardised algorithm for diagnosis of disc infection is lacking. Histopathological evaluation can aid in confirming inflammatory changes and also in identifying degenerative changes. Hence, standardising practice through a clear scoring system with regards to inflammation and degeneration may have some utility in the clinical setting. To our knowledge no such systems exist specifically for intervertebral disc infection. A literature review of current methods of scoring inflammation and degeneration in spine surgery and orthopaedic surgery was performed. Based on the current evidence, a scoring system for disc inflammatory and degenerative changes was proposed. We propose four domains for consideration: (1) granulation tissue, (2) dense fibrosis, (3) chronic inflammatory cells, and (4) neutrophil count. The non-standardised nature of diagnosing infections and degeneration in the spinal surgery literature means that this scoring system is currently of particular value. Based on a literature review, our proposed method for diagnosis incorporates a combination of histopathological criteria expected to increase diagnostic sensitivity in the setting of disc infection. Overall, scoring can be applied to surgically obtained material and integrated directly into routine pathological practice., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

One of the primary strategies for the management of acute ischemic stroke is intravenous (IV) thrombolysis with tissue plasminogen activator (t-PA). Over the past decade, endovascular therapies such as the use of stent retrievers to perform mechanical thrombectomy have been found to improve functional outcomes compared to t-PA alone. We aimed to reassess the functional outcomes and complications of IV thrombolysis with and without endovascular treatment for acute ischemic stroke using conventional meta-analysis and trial sequential analysis. Pooled relative risks (RR) and 95% confidence intervals (CI) were calculated for the effect of IV thrombolysis with and without endovascular therapy on functional outcome, mortality and symptomatic intracranial hemorrhage (SICH). Trial sequential analysis was done to strengthen the meta-analysis. We analyzed six randomized controlled trials involving 1943 patients. Patients who received IV thrombolysis with endovascular treatment showed significantly higher rates of excellent functional outcomes (modified Rankin Scale [mRS] 0-1) (RR, 1.75 [95% CI, 1.29-2.39]) compared to those who received IV thrombolysis alone. A similar association was seen for good functional outcomes (mRS 0-2) (RR, 1.56 [95% CI, 1.24-1.96]). Trial sequential analysis demonstrated endovascular treatment increased the RR of a good functional outcome by at least 30% compared to IV thrombolysis alone. There was no significant difference in all-cause mortality for mechanical thrombectomy compared to IV thrombolysis alone or the incidence of SICH at 3month follow-up. Endovascular treatment is more likely to result in a better functional outcome for patients compared to IV thrombolysis alone for acute ischemic stroke., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Microvascular decompression (MVD) has been demonstrated to be an excellent surgical treatment approach in younger patients with trigeminal neuralgia (TN). However, it is not clear whether there are additional morbidity and mortality risks for MVD in the elderly population. We performed a systematic literature review using six electronic databases for studies that compared outcomes for MVD for TN in elderly (cut-off ⩾60, 65, 70years) versus younger populations. Outcomes examined included success rate, deaths, strokes, thromboembolism, meningitis, cranial nerve deficits and cerebrospinal fluid leaks. There were 1524 patients in the elderly cohort and 3488 patients in the younger cohort. There was no significant difference in success rates in elderly versus younger patients (87.5% versus 84.8%; P=0.47). However, recurrence rates were lower in the elderly (11.9% versus 15.6%; P=0.03). The number of deaths in the elderly cohort was higher (0.9% versus 0.1%; P=0.003). Rates of stroke (2.5% versus 1%) and thromboembolism (1.1% versus 0%) were also higher for elderly TN patients. No differences were found for rates of meningitis, cranial nerve deficits or cerebrospinal fluid leak. MVD remains an effective and reasonable strategy in the elderly population. There is evidence to suggest that rates of complications such as death, stroke, and thromboembolism may be significantly higher in the elderly population. The presented results may be useful in the decision-making process for MVD in elderly patients with TN., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Study Design: Prospective cohort study., Objective: To evaluate if degenerative disc-related back or neck pain and/or radicular symptoms are caused by infection with low virulent bacterial organisms., Summary of Background Data: The potential relationship between disc infection and disc degeneration-related symptoms remains controversial, with contradictory evidence available in the literature. Several studies have demonstrated the presence of infected extruded nucleus tissue from first-time disc herniation, implicating the role of disc microbial infection in disc degeneration. The current study is a pilot study evaluating if high infection rates are prevalent in the Australian degenerate disc cohort., Methods: Institutional ethics approval was obtained (HREC 13/218). The pilot project was a single spine center prospective cohort of patients undergoing spine surgery for degenerate disc disease. In each case, disc material was obtained and prolonged aerobic and anaerobic cultures performed as per methods used by Stirling et al., Results: To date, a total of 168 patients have been enrolled, with male: female = 1:1. Surgical caseload includes 17.9% anterior cervical fusion, 35.0% anterior lumbar fusion, 40.7% lumbar discectomy, and 5.7% posterior lumbar fusions; 34.1% patients presented with neck pain, 31.6% with arm pain, 59.3% with leg pain, and 64.2% with back pain, and 20.2% of the patients received transforaminal or epidural or facet joint injections prior to surgery. In this pilot study, 19.6% were culture positive, with P. acnes predominant in 50%. Disc-only cultures were positive in 27.8% of lumbar cases and 18.5% of cervical cases, with predominant organisms being P. acnes., Conclusion: Similar to the infection rates from previous studies, this Australian cohort had 19.6% infection rates when disc-only cultures are performed. P. acnes is the predominant organism followed by Streptococcus sp. It is imperative to perform contaminant controls as such high infection with skin bugs is a significant finding., Level of Evidence: 4.

With the potential of bias from subjective evaluation scores in spine surgery, there is a need for practical and accurate quantitative methods of analysing patient recovery. In recent years, technologies such as accelerometers and global positioning systems have been introduced as potential objective measures for pain and symptoms following spine surgery. Overall, this perspective article aims to discuss and critique currently utilised methods of monitoring spine surgical outcomes. After analysing current modalities it will briefly analyse new potential methods before examining the place for accelerometers in the field of spine surgery. A literature review was performed on the use of accelerometers for objective evaluation of symptoms and disability after spine surgery, and perspectives are summarised in this article. Physical activity measurement with the use of accelerometers following spine surgery patients is practical and quantitative. The currently available accelerometers have the potential to transform the way functional outcomes from spine surgery are assessed. One key advantage is the collection of standardised objective measurements across studies. Future studies should aim to validate accelerometer data in relation to traditional measures of functional recovery, patient outcomes, and physical activity., (Copyright © 2015 Elsevier Ltd. All rights reserved.)