OBJECTIVE Spinal fusion surgery is increasingly common; however, pseudarthrosis remains a common complication affecting as much as 15% of some patient populations. Currently, no clear consensus on the best bone graft materials to use exists. Recent advances have led to the development of cell-infused cellular bone matrices (CBMs), which contain living components such as mesenchymal stem cells (MSCs). Relatively few clinical outcome studies on the use of these grafts exist, although the number of such studies has increased in the last 5 years. In this study, the authors aimed to summarize and critically evaluate the existing clinical evidence on commercially available CBMs in spinal fusion and reported clinical outcomes. METHODS The authors performed a systematic search of the MEDLINE and PubMed electronic databases for peer-reviewed, English-language original articles (1970–2020) in which the articles’ authors studied the clinical outcomes of CBMs in spinal fusion. The US National Library of Medicine electronic clinical trials database (www.ClinicalTrials.gov) was also searched for relevant ongoing clinical trials. RESULTS Twelve published studies of 6 different CBM products met inclusion criteria: 5 studies of Osteocel Plus/Osteocel (n = 354 unique patients), 3 of Trinity Evolution (n = 114), 2 of ViviGen (n = 171), 1 of map3 (n = 41), and 1 of VIA Graft (n = 75). All studies reported high radiographic fusion success rates (range 87%–100%) using these CBMs. However, this literature was overwhelmingly limited to single-center, noncomparative studies. Seven studies disclosed industry funding or conflicts of interest (COIs). There are 4 known trials of ViviGen (3 trials) and Bio4 (1 trial) that are ongoing. CONCLUSIONS CBMs are a promising technology with the potential of improving outcome after spinal fusion. However, while the number of studies conducted in humans has tripled since 2014, there is still insufficient evidence in the literature to recommend for or against CBMs relative to cheaper alternative materials. Comparative, multicenter trials and outcome registries free from industry COIs are indicated.

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OBJECTIVE US allopathic medical schools have experienced improvements in racial and ethnic diversity among matriculants in the past decade. It is not clear, however, whether better representation of historically excluded racial and ethnic groups at medical school entry impacts subsequent stages of the medical training pipeline leading into a specific field. The aim of this study was to examine these trends as they relate to the neurosurgical medical education pipeline and consider the drivers that sustain barriers for underrepresented groups. METHODS Race and ethnicity reports from the American Association of Medical Colleges were obtained on allopathic medical school applicants, acceptees, and graduates and applicants to US neurosurgical residency programs from 2012 to 2020. The representation of groups categorized by self-reported race and ethnicity was compared with their US population counterparts to determine the representation quotient (RQ) for each group. Annual racial composition differences and changes in representation over time at each stage of medical training were evaluated by estimating incidence rate ratios (IRRs) and 95% confidence intervals (CIs) using non-Hispanic Whites as the reference group. RESULTS On average, Asian and White individuals most frequently applied and were accepted to medical school, had the highest graduation rates, and applied to neurosurgery residency programs more often than other racial groups. The medical school application and acceptance rates for Black individuals increased from 2012 to 2020 relative to Whites by 30% (95% CI 1.23–1.36) and 42% (95% CI 1.31–1.53), respectively. During this same period, however, inequities in neurosurgical residency applications grew across all non-Asian racialized groups relative to Whites. While the incidence of active Black neurosurgery residents increased from 2012 to 2020 (0.6 to 0.7/100,000 Black US inhabitants), the prevalence of White neurosurgery residents grew in the active neurosurgery resident population by 16% more. CONCLUSIONS The increased racial diversity of medical school students in recent years is not yet reflected in racial representation among neurosurgery applicants. Disproportionately fewer Black relative to White US medical students apply to neurosurgery residency, which contributes to declining racial representation among all active neurosurgery resident physicians. Hispanic individuals are becoming increasingly represented in neurosurgery residency but continue to remain underrepresented relative to the US population. Ongoing efforts to recruit medical students into neurosurgery who more accurately reflect the diversity of the general US population are necessary to ensure equitable patient care.

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