Introduction Far lateral disc prolapse (also known as foraminal or extreme lateral prolapse) make up 10% of all disc herniations. In addition, far lateral disc prolapses tend to affect more proximal levels more frequently than do prolapses in the posterolateral location and they are often associated with greater radicular symptoms than typical posterolateral herniations, most likely due to involvement of the dorsal root ganglion. Surgery for far lateral disc protrusions has been associated with a less favourable outcome, perhaps due to delays in diagnosis, inadequate preoperative imaging, and postoperative instability as a result of excessive bony and facet resection during the surgical approach

Methods Twelve patients with far lateral disc herniations operated on by the senior author (RPW) fulfilled the criteria of having both pre- and postoperative Oswestry Disability Index (ODI) scores recorded at each clinic visit. Results of these cases and those of a cohort of age and sex matched patients undergoing standard posterolateral discectomy undertaken by the same surgeon were analyzed. The presence of radiculopathy pre- and postoperatively, workers compensation status, return to work, length of stay and complications, as well as any prior intervention in the form of nerve root sleeve blocks or surgery were recorded

Results Both groups were well matched in terms of age and sex. Follow up ranged from 4 to 18 months. Herniations at more proximal levels (L2/3 and L3/4) were seen more frequently in the far lateral group than in the posterolateral group. Six patients in the far lateral group had preoperative nerve root sleeve blocks compared with one in the posterolateral group. Two patients in each group had had previous (different level) surgery. Patients in each group had similar preoperative ODI scores. Both groups demonstrated a reduction in the preoperative ODI compared with the preoperative score. The mean improvement was 24 (range −26 to +62) for the far lateral group and 22 (range −6 to +46). There was no significant difference between the groups

Discussion The results of this study are encouraging with respect to surgical treatment of far lateral discs. Recent literature has questioned the efficacy of surgical intervention for this pathology. These results show that with carefully selected patients results are comparable with standard posterolateral discectomy

Introduction and Aims: Decreasing blood loss during total hip replacement (THR) remains a challenge for the orthopaedic surgeon. This study investigated the effects of the antifibrinolytics aprotinin and epsilon aminocaproic acid (EACA) against placebo on blood loss during primary total hip replacement. Their safety and mechanism of action was also investigated.

Method: Forty-five patients undergoing primary unilateral total hip arthroplasty were randomised to receive an infusion of either aprotinin, EACA, or placebo. Intra- and post-operative blood loss was measured, as was the rate of blood transfusion and changes in haemoglobin concentration. Clinical examination and duplex ultrasound was used in all patients to detect thrombotic events. All patients were assessed clinically six weeks post-op to detect adverse events. Platelet function was assessed using P-selectin, Platelet-monocyte aggregates (PMA) and factor V/Va levels. D-dimer activity was recorded as an indicator of fibrinolysis. Non-parametric statistical analysis was employed in the interpretation of results.

Results: There was no difference in demographics or pre-operative platelet function between the groups with the exception of the EACA group which had a lower pre-operative haemoglobin concentration. Intra-operative blood loss was significantly lower in the aprotinin group compared to placebo (p=0.01), similarly there was also a reduction in intra-operative blood loss in the EACA group but this did not reach statistical significance. Post-operative bleeding from closed suction drains was markedly reduced for both aprotinin (60%, p=< 0.01) and EACA (53%, p=< 0.001) compared to placebo. Markedly less haemoglobin was lost in drains in both antifibrinolytic groups, with aprotinin showing a 77% (p=< 0.0001) and EACA a 73% reduction (p=< 0.001) in post-operative haemoglobin loss. Despite this, no difference in the rate of blood transfusion was observed between groups. Total hip arthroplasty surgery led to the activation of platelets as evidenced by P-selectin, PMA and factor V/Va levels. However, platelet function was not affected by either aprotinin or EACA. Both antifibrinolytics showed a similar increase in D-dimer levels indicating a similar efficacy in inhibiting fibrinbolysis. There were no DVTs, PEs or infections recorded in the study, and no increase in adverse events was seen with the use of antifibrinolytics.

Conclusion: Infusion of either aprotinin or EACA reduces blood loss after primary THA. Both agents are equally effective and have a favourable safety profile. The two drugs inhibit fibrinolysis in a similar fashion, and this action appears to be independent of platelets.