Focus on perioperative management of anticoagulants and antiplatelet agents in spine surgery.

UNLABELLED: Perioperative management of anticoagulants and antiplatelet agents is based on a compromise between the risk of hemorrhage induced by maintaining (or substituting for) them and the risk of thrombosis if they are discontinued. The hemorrhage risk in major spinal surgery is clear (50-81% incidence of transfusion), and the incidence of postoperative symptomatic spinal hematoma varies between 0.4% and 0.2% depending on whether low-molecular-weight heparin (LMWH) is prescribed postoperatively. The French Health Authority, in 2008, published guidelines on the management of patients treated with vitamin K antagonists. Treatment may be stopped without preoperative replacement in certain cases of atrial fibrillation or venous thromboembolic disease; otherwise, preoperative replacement by curative dose unfractionated heparin (UFH) or LMWH is recommended, with withdrawal early enough to avoid peroperative bleeding. Postoperative care should take account of hemorrhagic risk following surgery. The management of patients treated with antiplatelets is delicate, as maintenance is preferable in most of the situations in which they are prescribed (bare or active stenting, or secondary prevention of myocardial infarction, stroke or peripheral ischemia), although they are liable to increase the risk of perioperative hemorrhage, especially when associated to antithrombotic prophylaxis. If surgery cannot be performed under treatment continuation, the interruption should be as short as possible. New guidelines are presently being drawn up under the auspices of the French Health Authority. In both types of treatment, the strategy should be jointly determined by surgeon, anesthesiologist and cardiologist, to optimize individualized care taking account of each party's requirements, with the patient in the central role. The selected strategy should be clearly stated in the patient's file. LEVEL OF EVIDENCE: V.

[Angioplasty of intra-stent restenosis of a saphenous graft complicated by massive embolism]. / Angioplastie d'une resténose intra-stent de greffon saphène compliquée d'embolie massive.

The main risk of angioplasty of saphenous vein aortocoronary bypass grafts is myocardial infarction by distal embolism, explaining the introduction of systems of distal protection with encouraging results. Although embolism of an atheromatous stenosis is classical, that of intra-stent restenosis is exceptional. The authors report a very unusual case of atheromatous and/or thrombotic embolism occurring during angioplasty of an intra-stent restenosis which was recovered by a micropore filter system.

[The hyoid bone and vertical dimension]. / L'os hyoïde et la dimension verticale.

Located at the center of the neck and the pharyngeal column and, thanks to its attachments, tied to the base of the skull, to the mandible, to the tongue, to the larynx, and to the scapular belt, the hyoid bone is intimately related to an extensive tendino-muscular complex. From this strategic position, the hyoid bone participates in all functional and nutritional activities of the oro-facial complex. Heavily involved in the physiology of the pharyngeal column, it appears to enjoy a remarkable stability in relation to its surrounding structures as it participates in the critical process of vertical ontogenetic development. Deceptively simple in its shape and location it is anything but. While it would be easy to scorn it as a vestigial organ of little importance, the hyoid bone is actually an ancient witness of the evolution of the first human vertebrae and a vestige of the 2nd and 3rd brachial arches. Like a toy buffeted by powerful groups of muscles and tendons, the hyoid bone occupies a crossroads position where it is solicited by many vital functions, the most critical of which is respiration. Its functional behavior seems to have evolved considerably over the course of phylogeny. By piecing together the conceptions of many authors, we can conclude that the similarities--and, later, the differences--existing between the human fetus and those of other primates, and, then between young children and young primates, are related to an essentially different status quo, which modifies the delicate equilibrium of the pharyngeal region. In metamorphosing from a sagittal equilibrium to one that is vertical, this very status quo maintains an open respiratory airway during each time frame, continuously permitting the articulation and modulation of sounds, particularly during the vertical period. The hyoid bone is unpaired, in a mid-line position, symmetrical, and located just below the mandible with which it shares, to an astonishing extent, certain morphological characteristics. Its maturation and its ossification occur slowly and late even though it migrates much more rapidly to a vertical position than does the bulk of the cervical complex. True articulations between the body and the horns of the hyoid bone persist for a very long time; and so the junction between the small horns doesn't fully calcify until about the age of 50; and, in spite of its appearance, the hyoid bone is extremely supple, a quality that allows it to make substantial contributions to functional activity. If the hyoid bone itself scarcely moves during normal respiration, modern research attributes an increasing role to it in the maintenance of the equilibrium of the pharyngeal column. It seems to be called upon to respond to a number of demands that it manages to satisfy as it helps to maintain the permeability of the pharyngeal column and thus make respiration possible. In so doing, the hyoid bone adjusts its positioning, and, perhaps most important, its orientation to the physiological requirements imposed by pharyngeal obstruction and mouth breathing. Intimately connected to the larynx, the hyoid bone plays a part in phonation that has long been recognized. Recent studies now also show that the contribution the hyoid bone makes to respiratory equilibrium is far more important than its small size would suggest.