Article Reviewed Russell N, Al-Adli N, Shank C, Carey S, Ajayi O. Utility of routine type and cross for anterior cervical discectomy and fusion: A retrospective review. N Am Spine Soc J. 2023 Sep 22;16:100280. https://doi.org/10.1016/j.xnsj.2023.100280 Commentary The study by Russell et al1 critically evaluated the use of routine typing and crossmatching for patients undergoing elective anterior cervical discectomy and fusion (ACDF). The authors challenge the necessity of these practices by presenting data that demonstrate a low perioperative transfusion rate and a high crossmatch to transfusion (C/T) ratio, indicating inefficient use of blood products. While several studies have considered related questions previously, their systematic approach adds to the literature questioning this practice. The reviewed study was a retrospective analysis of all patients who underwent elective ACDF at a single tertiary medical center from January 2016 to January 2021. The primary outcome measures included the frequency of type and screen/crossmatch orders, rate of perioperative transfusion, and C/T ratio. Secondary outcomes included changes in preoperative and postoperative hemoglobin and hematocrit levels. In total 1,162 ACDF patients were identified. The cohort included patients undergoing one-level cases (26%), two-level cases (40%), three-level cases (27%), and four-level cases (8%). Patient demographics were defined. Of note, 67% of the patients were on anticoagulant or antiplatelet therapy that was discontinued one or two weeks prior to surgery. Preoperatively, laboratory studies were performed for 96% of total patients, type and screen for 83%, and crossmatching for 56%, which facilitated the crossmatching of 1,318 units of blood. 49% of patients (567 of 1,162) received preoperative complete blood counts (CBCs) within six weeks of surgery, followed by postoperative CBCs within 24 hours. Notably, no packed red blood cells were transfused, and only one patient received two units of platelets (a patient with known preoperative thrombocytopenia). Postoperatively, laboratory studies were performed for 51%, no packed red blood cells were transfused, and one patient received two units of platelets (a patient with known preoperative thrombocytopenia). They reported no intraoperative or postoperative complications necessitating emergent blood product transfusions. Overall, the results of the current study found a lack of utility for preoperative type and screen and crossmatching for the studied ACDF population. This aligns with previous studies that reported low transfusion rates in degenerative cervical spine surgery. They cite a prior study that utilized the The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database and found an overall transfusion rate of 1.47% in cervical spine surgeries, with a lower rate of 0.77% specifically in ACDF surgeries.2 Similarly, Manning et al.3 found no patients requiring intraoperative or postoperative transfusion in a retrospective analysis of 332 patients undergoing ACDF. One other study by Nùñez et al,4 evaluated the necessity for pretransfusion testing in degenerative cervical spine surgery patients and reported an overall transfusion rate of 1.9% in degenerative cervical spine surgery, with preoperative Hgb of <12 g/dL suggested to be a risk factor. One of the striking findings of currently reviewed study is the high C/T ratio of 659:1, which far exceeds the recommended efficient usage ratio of 2.5:1. This ratio is much higher than other reports in the literature, where elevated C/T ratios of 3.4 and 17.5 were reported for colorectal surgery and total knee arthroplasty, respectively. This discrepancy highlights a significant inefficiency in the use of blood products and raises questions about the necessity of routine pretransfusion testing in elective ACDF surgeries. Additionally, since there were no cases of intraoperative transfusion and only one instance of preoperative platelet transfusion, this further supports the argument that routine pretransfusion testing may be unnecessary in this context. The study's results reinforce previously raised implications for clinical practice and health care resource utilization. By challenging the status quo of centers that routinely use pretransfusion testing for patients undergoing elective ACDF, the study opens the door for the development of more targeted and efficient preoperative protocols. Essentially, the need for such testing should consider the pre-test probability of needing a transfusion. In conclusion, the study by Russell et al provides compelling evidence that challenges the routine use of pretransfusion testing in elective ACDF surgeries. While limited by the single-institution retrospective study design, the study results suggest that these practices may be unnecessary and inefficient, with a high C/T ratio indicating overuse of blood product resources. This study serves as a valuable contribution to the ongoing efforts to optimize surgical practices and improve the efficiency of health care delivery.