Bone graft substitutes for anterior lumbar interbody fusion

Clinical and Radiographic Outcomes of Anterior Lumbar Interbody Fusions Using a Titanium Cage with a Biomimetic Surface

BACKGROUND

 We analyzed clinical and radiographic outcomes in patients undergoing anterior lumbar interbody fusions (ALIFs) using a new biomimetic titanium fusion cage (Titan nanoLOCK interbody, Medtronic, Minneapolis, Minnesota, United States). This specialized cage employs precise nanotechnology to stimulate inherent biochemical and cellular osteogenic reactions to the implant, aiming to amplify the rate of fusion. To our knowledge, this is the only study to assess early clinical and radiographic results in ALIFs.

METHODS

 We conducted a retrospective review of data for patients who underwent single or multilevel ALIF using this implant between October 2016 and April 2021. Indications for treatment were spondylolisthesis, postlaminectomy syndrome, or spinal deformity. Clinical and radiographic outcome data for these patients were collected and assessed.

RESULTS

 A total of 84 patients were included. The mean clinical follow-up was 36.6 ± 14 months. At 6 months, solid fusion was seen in 97.6% of patients. At 12 months, solid fusion was seen in 98.8% of patients. Significant improvements were seen in patient-reported outcome measures (PROMs; visual analog scale and Oswestry Disability Index) at 6 and 12 months compared with the preoperative scores (p < 0.001). One patient required reoperation for broken pedicle screws 2 days after the ALIF. None of the patients required readmission within 90 days of surgery. No patients experienced an infection.

CONCLUSIONS

 ALIF using a new titanium interbody fusion implant with a biomimetic surface technology demonstrated high fusion rates (97.6%) as early as 6 months. There was significant improvement in PROMs at 6 and 12 months.

Surgical Stabilization of the Spine: A Clinical Review of Spinal Fractures, Spondylolisthesis, and Instrumentation Methods

The spine is a complex structure critical for stability, force transmission, and neural protection, with spinal fractures and spondylolisthesis posing significant challenges to its integrity and function. Spinal fractures arise from trauma, degenerative conditions, or osteoporosis, often affecting transitional zones like the thoracolumbar junction. Spondylolisthesis results from structural defects or degenerative changes, leading to vertebral displacement and potential neurological symptoms. Diagnostic and classification systems, such as AO Spine and TLICS, aid in evaluating instability and guiding treatment strategies. Advances in surgical techniques, including minimally invasive approaches, pedicle screws, interbody cages, and robotic-assisted systems, have improved precision and recovery while reducing morbidity. Vertebral augmentation techniques like vertebroplasty and kyphoplasty offer minimally invasive options for osteoporotic fractures. Despite these innovations, postoperative outcomes vary, with challenges such as persistent pain and hardware complications necessitating tailored interventions. Future directions emphasize predictive analytics and enhanced recovery strategies to optimize surgical outcomes and patient quality of life.

A study on the effect of platelet-rich plasma (PRP) to promote bone fusion in lateral interbody fusion of the lumbar spine using artificial bone

BACKGROUND

Lateral lumbar interbody fusion (LLIF) via a retroperitoneum approach has gained popularity due to minimal invasiveness, which avoids resection of the spinous process and laminae. However, as challenges in grafting autogenous bone persist, artificial bone has been tested in Japan to fill the spinal cage. Platelet-rich plasma (PRP) contains growth factors and anti-inflammatory cytokines to promote cellular proliferation and repair damaged tissues. While the effects of PRP on tendon and ligament repair are widely known, any effects on bone healing are scarcely reported. However, PRP-loaded artificial bone carries potential to improve intervertebral bone fusion.

OBJECTIVE

This study assessed whether PRP enhances intervertebral bone fusion in LLIF surgery using β-tricalcium phosphate artificial bone.

METHODS

The current study was a prospective, randomized, controlled trial. We evaluated 13 consecutive patients undergoing LLIF surgery in our hospital. Patients received artificial bone impregnated with PRP or without PRP within the same fusion cage. The primary outcome was the intervertebral bone fusion rate at 6 and 12 months postoperatively, evaluated using CT imaging. The intervertebral bone fusion rates with and without PRP loading and with and without contact part between the endplate and the artificial bone were compared. Secondary outcomes included clinical evaluations using visual analog scale scores for low back pain, buttock-leg pain, and leg numbness from the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOA-BPEQ) and the Oswestry Disability Index (ODI), plus adverse events information.

RESULTS

Of the 13 patients (29 vertebral segments) included, bone fusion was observed in 43.4% of the PRP group and 26.1% of the non-PRP group at 6 months (p = 0.216). At 12 months, fusion rates were 60.9% with PRP and 34.8% without PRP (p = 0.074). The fusion rate was significantly higher in cases with good contact between the vertebral endplate and the artificial bone (p = 0.0004). Clinical scores improved postoperatively. Adverse events were in accordance with expectations from LLIF surgery and no PRP-specific events occurred.

CONCLUSION

PRP did not significantly improve intervertebral bone fusion rates in LLIF surgeries, particularly in cases with poor contact between the vertebral endplate and artificial bone. While PRP may have a limited role in enhancing bone fusion, maintaining good contact between the vertebral endplate and artificial bone is crucial for successful outcomes. Further research is needed to explore optimal uses of PRP in spinal fusion surgeries.

Injectable bioactive poly(propylene fumarate) and polycaprolactone based click chemistry bone cement for spinal fusion in rabbits

Degenerative spinal pathology is a widespread medical issue, and spine fusion surgeries are frequently performed. In this study, we fabricated an injectable bioactive click chemistry polymer cement for use in spinal fusion and bone regrowth. Taking advantages of the bioorthogonal click reaction, this cement can be crosslinked by itself eliminating the addition of a toxic initiator or catalyst, nor any external energy sources like UV light or heat. Furthermore, nano-hydroxyapatite (nHA) and microspheres carrying recombinant human bone morphogenetic protein-2 (rhBMP-2) and recombinant human vascular endothelial growth factor (rhVEGF) were used to make the cement bioactive for vascular induction and osteointegration. After implantation into a rabbit posterolateral spinal fusion (PLF) model, the cement showed excellent induction of new bone formation and bridging bone, achieving results comparable to autograft control. This is largely due to the osteogenic properties of nano-hydroxyapatite (nHA) and the released rhBMP-2 and rhVEGF growth factors. Since the availability of autograft sources is limited in clinical settings, this injectable bioactive click chemistry cement may be a promising alternative for spine fusion applications in addressing various spinal conditions.

Bone graft substitutes used in anterior lumbar interbody fusion: a contemporary systematic review of fusion rates and complications

Background

Anterior lumbar interbody fusion (ALIF) uses a broad-footprint interbody cage designed to maximize fusion rates for treating degenerative disc disease. Bone graft substitutes are being increasingly utilized during ALIF to replace or supplement autologous iliac crest bone grafts. This approach aims to optimize fusion efficacy while minimizing associated postoperative complications. The objective of this systematic review was to examine recent studies on fusion rates and postoperative complications associated with bone graft substitutes used in ALIF.

Methods

We conducted a systematic review of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, MEDLINE, and PubMed databases, to critically examine a decade of research (January 1, 2012, to July 6, 2023) on the effectiveness and safety of various bone graft substitutes in ALIF. This timeframe was chosen to build on a previous systematic review published in 2013. The PRISMA guidelines were used.

Results

In total, 27 articles met our stringent inclusion and exclusion criteria. A substantial portion of these studies (67%) focused on recombinant human bone morphogenetic protein-2 (rhBMP-2) and highlighted its efficacy for achieving high fusion rates. However, the literature presents a dichotomy regarding the association of rhBMP-2 with increased postoperative complications. Notably, the methodologies for evaluating spinal fusion varied across studies. Only one-third of studies employed computed tomography to assess interbody fusion at 12 months postoperatively, highlighting the urgent need to establish uniform fusion criteria to facilitate more accurate comparative analyses. Moreover, there was considerable variability in the criteria used for diagnosing and detecting postoperative complications, significantly influencing the reported incidence rates.

Conclusions

This review underscores the need for continued research into bone graft substitutes, particularly focusing on assessment of long-term complications. Future research endeavors should concentrate on developing comprehensive clinical guidelines to aid in the selection of the most suitable bone graft substitutes for use in ALIF, thereby enhancing patient outcomes and surgical efficacy.

Establishing a bone bank within a hospital setting in India: early insights from a tertiary care center in Northern India-a review article

When addressing bone defects resulting from trauma, infection, or tumors, the use of allogenic bone is often necessary. While autografts are considered the standard, they have limitations and can lead to donor site morbidity. Consequently, there has been exploration into the feasibility of utilizing allogenic bone and bone graft replacements. Allogenic bone transplants are acquired from donors following rigorous procurement, sterile processing, and donor screening procedures. To ensure the safe storage and effective utilization of allograft material, a bone banking system is employed. Establishing and managing an orthopedic bone bank, entails navigating complex legal and medical organizational aspects. This paper examines the establishment and operation of bone banks in India, drawing upon our first-hand experience in managing one at a tertiary care center in Northern India.Level of evidence: Level IV.

Spinal fusion of biodegradable poly(propylene fumarate) and poly(propylene fumarate-co-caprolactone) copolymers in rabbits

Background

Autologous bone grafts are currently the standard in orthopedic surgery despite limited donor sources and the prevalence of donor site morbidity. Other alternatives such as allografts are more readily available than autografts but have lower rates of graft incorporation.

Methods

Here, we propose a novel graft alternative consisting of an injectable poly(propylene fumarate) (PPF) and poly(propylene fumarate-co-caprolactone) P(PF-co-CL) copolymer with a recombinant human bone morphogenetic protein-2 (rhBMP-2)/vascular epithelial growth factor (VEGF) release system accompanied by hydroxyapatite (HA). The efficacy of scaffold formulations was studied using a standard, bilateral, L-level (L5-L6) posterolateral transverse spinal fusion using New Zealand white rabbits. Rabbits were divided into 4 experimental groups: group I, negative control; group II, autograft (positive control); group III, injectable PPF scaffold with rhBMP-2/VEGF release system and HA; group IV, injectable P(PF-co-CL)scaffold with rhBMP-2/VEGF release system and HA. Spines were harvested at 6 weeks and 12 weeks after surgery, and spinal fusions were assessed using manual palpation, radiographic analysis, micro-computed tomography (μCT) assessment, and histologic analysis.

Results

Of the 4 experimental groups, the injectable P(PF-co-CL) scaffold displayed superior initial strength and faster degradation than scaffolds constructed from PPF alone and facilitated the fusion of lateral processes in the rabbit standard posterolateral spinal fusion model. The results obtained from manual palpation, radiology, and μCT showed no difference between the P(PF-co-CL) group and the PPF group. However, histologic sections showed more osteogenesis with the new injectable P(PF-co-CL) scaffold.

Conclusion

Injectable P(PF-co-CL) polymers showed promising spine fusion abilities in rabbits after 12 weeks of posterolateral implantation.

The safe and effective use of supercritical CO2-processed bone allografts for cervical and lumbar interbody fusion: A retrospective study

Introduction

The clinical efficacy and safety of supercritical CO₂-processed bone allografts prepared from living donors has yet to be confirmed in spinal surgery. Here we report our clinical and surgical experience of using supercritical CO₂-processed bone allografts for lumbar and cervical fusion.

Methods

Sixteen patients underwent one or two level anterior cervical discectomy and fusion and 37 patients underwent anterior retroperitoneal route lumbar fusion using bone allografts processed using supercritical CO₂ extraction combined with chemical viral inactivation. Fusion success was assessed radiographically in the immediate postoperative period and at one month, six months, one year, and three years postoperatively. Function and pain were assessed using visual analog scales, Odom's criteria, the neck disability index (NDI), and the Oswestry disability index (ODI).

Results

At a mean of 43 and 47 months postoperatively, 95.3% and 90.5% of cervical and lumbar fusion patients had radiographic evidence of bone fusion, respectively. Over 80% of patients reported good to excellent outcomes according to Odom's criteria, the perception of pain significantly decreased, and the mean NDI and ODI scores significantly improved at the last follow-up compared with before the operations. There were no safety concerns. For the cervical group, the mean NDI score improved from 26.3 ± 6.01 preoperatively to 15.00 ± 8.03 and 17.60 ± 13.95 at immediate post-op (p = 0.02) and last follow-up visits (p = 0.037) respectively. For the lumbar cases, the mean ODI score improved from 28.31 ± 6.48 preoperatively to 14.68 ± 5.49 (p < 0.0001) and 12.54 ± 10.21 (p < 00001) at immediate post-op and last follow-up visits respectively.

Conclusion

Within the limitations of this study, the use of supercritical CO₂-processed bone allografts resulted in satisfactory clinical outcomes and fusion rates with acceptable safety for both cervical and lumbar surgeries.

Early Osteogenic Marker Expression in hMSCs Cultured onto Acid Etching-Derived Micro- and Nanotopography 3D-Printed Titanium Surfaces

Polyetheretherketone (PEEK) titanium composite (PTC) is a novel interbody fusion device that combines a PEEK core with titanium alloy (Ti6Al4V) endplates. The present study aimed to investigate the in vitro biological reactivity of human bone-marrow-derived mesenchymal stem cells (hBM-MSCs) to micro- and nanotopographies produced by an acid-etching process on the surface of 3D-printed PTC endplates. Optical profilometer and scanning electron microscopy were used to assess the surface roughness and identify the nano-features of etched or unetched PTC endplates, respectively. The viability, morphology and the expression of specific osteogenic markers were examined after 7 days of culture in the seeded cells. Haralick texture analysis was carried out on the unseeded endplates to correlate surface texture features to the biological data. The acid-etching process modified the surface roughness of the 3D-printed PTC endplates, creating micro- and nano-scale structures that significantly contributed to sustaining the viability of hBM-MSCs and triggering the expression of early osteogenic markers, such as alkaline phosphatase activity and bone-ECM protein production. Finally, the topography of 3D-printed PTC endplates influenced Haralick's features, which in turn correlated with the expression of two osteogenic markers, osteopontin and osteocalcin. Overall, these data demonstrate that the acid-etching process of PTC endplates created a favourable environment for osteogenic differentiation of hBM-MSCs and may potentially have clinical benefit.

Bone marrow mesenchymal stem cells with low dose bone morphogenetic protein 2 enhances scaffold-based spinal fusion in a porcine model

High doses bone morphogenetic protein 2 (BMP-2) have resulted in a series of complications in spinal fusion. We previously established a polyelectrolyte complex (PEC) carrier system that reduces the therapeutic dose of BMP-2 in both rodent and porcine spinal fusion models. This study aimed to evaluate the safety and efficacy of the combination of bone marrow mesenchymal stem cells (BMSCs) and low dose BMP-2 delivered by PEC for bone regeneration in a porcine model of anterior lumbar interbody spinal fusion (ALIF) application. Six Yorkshire pigs underwent a tri-segmental (L2/L3; L3/L4; L4/L5) ALIF in four groups, namely: (a) BMSCs + 25 μg BMP-2/PEC (n = 9), (b) 25 μg BMP-2/PEC (n = 3), (c) BMSCs (n = 3), and (d) 50 μg BMP-2/absorbable collagen sponge (n = 3). Fusion outcomes were evaluated by radiography, biomechanical testing, and histological analysis after 12 weeks. Mean radiographic scores at 12 weeks were 2.7, 2.0, 1.0, and 1.0 for Groups 1 to 4, respectively. μ-CT scanning, biomechanical evaluation, and histological analysis demonstrated solid fusion and successful bone regeneration in Group 1. In contrast, Group 2 showed inferior quality and slow rate of fusion, and Groups 3 and 4 failed to fuse any of the interbody spaces. There was no obvious evidence of seroma formation, implant rejection, or any other complications in all groups. The results suggest that the combination of BMSCs and low dose BMP-2/PEC could further lower down the effective dose of the BMP-2 and be used as a bone graft substitute in the large animal ALIF model.

Assessment of the Defatting Efficacy of Mechanical and Chemical Treatment for Allograft Cancellous Bone and Its Effects on Biomechanics Properties of Bone

Objective

To assess the defatting efficacy of high pressure washing and gradient alcohol and biomechanical properties of defatted bone.

Methods

Fresh cancellous bone was obtained from the femoral condyle and divided into six groups according to different defatting treatments, which were: high pressure washing for 10 s (10S group), 20 s (20S group), and 30 s (30S group), gradient alcohol immersion (Alcohol group), acetone immersion (Acetone group), and non‐defatted (Fresh group). The appearance of six groups was observed, and the appearance of defatted bone and fresh bone was compared. The residual lipid content and infrared spectrum were used to compare the efficacy of defatting, the DNA content was used to compare the cell content after defatting, and the maximum stress and elastic modulus were used to compare the effects of defatting treatment on biomechanical properties.

Results

The fresh bone was yellow and the pores contained a lot of fat. The defatted bone was white and the porous network was clear. There was no difference in residual lipid content among the three groups with high pressure washing (1.45% ± 0.16%, 1.40% ± 0.13%, and 1.46% ± 0.11%, respectively) (P = 0.828). There was no difference in residual lipid content among the 10S, alcohol, and acetone groups (1.45% ± 0.16%, 1.28% ± 0.07%, and 1.13% ± 0.22%, respectively) (P = 0.125). Infrared spectra showed that the fat content of the five defatting groups was significantly lower than that of the fresh group. There was no difference in residual lipid content among the three groups with high pressure washing (4.53 ± 0.23 ug/mL, 4.61 ± 0.18 ug/mL, and 4.66 ± 0.25 ug/mL, respectively) (P = 0.645). There was no difference in residual lipid content among the 10S, alcohol, and acetone groups (4.53 ± 0.23 ug/mL, 4.29 ± 0.24 ug/mL, and 4.27 ± 0.29 ug/mL, respectively) (P = 0.247). The maximum stress of the bone decreased significantly with the increase of the washing time (9.95 ± 0.31 Mpa, 9.07 ± 0.45 Mpa, and 8.17 ± 0.35 Mpa, respectively) (P = 0.003). The elastic modulus of the bone decreased significantly with the increase of the washing time (116.40 ± 3.54 Mpa, 106.10 ± 5.29 Mpa, and 95.63 ± 4.08 Mpa, respectively) (P = 0.003). There was no statistical difference in the maximum stress between the fresh group, the 10S group, the alcohol group, and the acetone group (10.09 ± 0.67 Mpa, 9.95 ± 0.31 Mpa, 10.11 ± 0.07 Mpa, and 10.09 ± 0.39 Mpa, respectively) (P = 0.963). There was no statistical difference in the maximum stress between the fresh group, the 10S group, the alcohol group and the acetone group (119.93 ± 4.94 Mpa, 116.40 ± 3.54 Mpa, 118.27 ± 0.85 Mpa, 118.10 ± 4.52 Mpa, respectively) (P = 0.737).

Conclusion

The defatting efficiency was satisfactory at a time of 10 s under high pressure washing. In terms of defatting efficiency and its effect on biomechanical properties of bone, high pressure washing and gradient alcohol were similar to conventional acetone solvent extraction defatting.

The use of demineralised bone fibres (DBF) in conjunction with supercritical carbon dioxide (SCCO2) treated allograft in anterior lumbar interbody fusion (ALIF)

Spinal fusion is a common procedure for the treatment of various spinal pathologies. Since the early days, spinal fusion has been carried out with the use of bone grafts as interbody spacers. With the development of synthetic interbody implants, bone grafts were used to facilitate fusion. Although autograft provides the best outcomes for fusion, allografts have been sought after due to donor site morbidity and other shortcomings. Currently, a vast variety of demineralised bone matrix (DBM) products are available with their methods of processing and preparation impacting their properties and clinical outcomes. Demineralised bone fibres (DBF), a form a DBM can be easily packed into implants when mixed with other substances such as allograft bone and patient's blood providing a scaffold for the mixture. We report two cases of anterior lumbar interbody fusion (ALIF) utilising a titanium-polyetheretherketone (PEEK) interbody cage filled with DBF, allograft and patient's blood with a maximum of 12 months follow-up outcome.

Interbody options in lumbar fusion

Interbody devices have revolutionized lumbar fusion surgery by enhancing mechanical stability, optimizing sagittal parameters, and maximizing fusion potential. There are several lumbar interbody fusion approaches available for varying pathologic etiologies, surgical index levels, or due to surgeon preference. With the advancement of spinal instrumentation and interbody devices, a variety of cage materials and dimensions have been engineered to accommodate various lumbar fusion approaches. The efficacy of a fusion is dependent on the shape, size, and material makeup of that interbody device. Since there are numerous cages available in today's market, it is important to find the optimal cage to best accommodate specific lumbar fusion cases. This review will explain the properties and future advancements of various interbody devices available for lumbar fusions.

Unidirectional porous β-tricalcium phosphate induces bony fusion in lateral lumbar interbody fusion

Lateral lumbar interbody fusion (LLIF) often requires the use of allograft or artificial bone. We used β-tricalcium phosphate artificial bone with a porosity of 57% consisting of a novel unidirectional porous structure (Affinos®) in patients (5 male and 9 female) who underwent LLIF from August 2015 as a substitute for autologous bone. We evaluated 60 graft windows in the cages at 30 intervertebral levels. To evaluate interbody bony fusion, CT multi-planar reconstruction coronal and sagittal images obtained 1 year after surgery were assessed. Intra-cage bony fusion was observed in 39 of 60 graft windows and so total bony fusion rate was 65%. Intra-cage bony fusion was confirmed in 17 of 29 (58.6%) graft windows with autologous bone and 22 of 31 (70.9%) graft windows with Affinos®. There was no significant difference in the rate of bony fusion between autologous bone and Affinos® (p = 0.418). In conclusion, the rate of bony fusion using Affinos® in LLIF cages was not inferior to that using autologous bone graft. Affinos® is a candidate for graft material in LLIF surgery and further exploration is warranted.

Anterior Lumbar Interbody Fusion Using Reaction Bonded Silicon Nitride Implants: Long-Term Case Series of the First Synthetic Anterior Lumbar Interbody Fusion Spacer Implanted in Humans

BACKGROUND

In this study, a historical case series is reported of reaction bonded silicon nitride (Si₃N₄) 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 Si₃N₄ 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 Si₃N₄ as a biomedical material for humans, as an implant for ALIF.

METHODS

The Si₃N₄ implants were prepared by die-pressing silicon powder and reaction bonding in 95 N₂/5 H₂ 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 Si₃N₄ 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 Si₃N₄ is biologically safe in the long-term, with capacity for excellent radiologic osseointegration.

Heterotopic ossification following use of i-Factor for spinal fusion in Mucopolysaccharidosis 1: a case report

Mucopolysaccharidosis is a rare group of genetic disorder which results in a complex of anomalies involving various systems. In Mucopolysaccharidosis 1 progressive thoracolumbar kyphosis is a common presentation which can result in instability and neurological deficit. Posterior spinal surgery is performed to correct deformity and obtain spinal fusion. Peptide enhanced bone graft substitute (i-Factor^TM) is relatively a new component with proven efficacy to obtain early spinal fusion. An 8-year-old child with progressive high lumbar kyphosis due to Mucopolysaccharidosis 1 was admitted for Posterior spinal fusion with i-Factor bone graft substitute. Postoperatively patient had serous discharge from the wound which settled without intervention. A month after the surgery spinal radiographs revealed heterotopic ossification at the distal end of spinal construct in the paraspinal region. Patient remained asymptomatic and clinically well.

Allograft Versus Demineralized Bone Matrix in Instrumented and Noninstrumented Lumbar Fusion: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The aim was to determine the fusion efficacy of allograft and demineralized bone matrix (DBM) in lumbar instrumented and noninstrumented fusion procedures for degenerative lumbar disorders.

METHODS

A literature search was conducted using the PubMed and Cochrane databases. To be considered, publications had to meet 4 criteria: patients were treated for a degenerative lumbar disorder, a minimum group size of 10 patients, use of allograft or DBM, and at least a 2-year follow-up. Data on the study population, follow-up time, surgery type, grafting material, fusion rates, and its definition were collected.

RESULTS

The search yielded 692 citations with 17 studies meeting the criteria including 4 retrospective and 13 prospective studies. Six studies used DBM and 11 employed allograft alone or in the combination with autograft. For the allograft, fusion rates ranged from 58% to 68% for noninstrumented and from 68% to 98% for instrumented procedures. For DBM, fusion rates were 83% for noninstrumented and between 60% and 100% for instrumented lumbar fusion procedures.

CONCLUSIONS

Both allograft and DBM appeared to provide similar fusion rates in instrumented fusions. On the other hand, in noninstrumented procedures DBM was superior. However, a large variation in the type of surgery, outcomes collection, lack of control groups, and follow-up time prevented any significant conclusions. Thus, studies comparing the performance of allograft and DBM to adequate controls in large, well-defined patient populations and with a sufficient follow-up time are needed to establish the efficacy of these materials as adjuncts to fusion.

Trends Analysis of rhBMP2 Utilization in Single-Level Anterior Lumbar Interbody Fusion in the United States

STUDY DESIGN

Retrospective case study.

OBJECTIVE

To evaluate the trends and demographics of recombinant human bone morphogenetic protein 2 (rhBMP2) utilization in single-level anterior lumbar interbody fusion (ALIF) in the United States.

METHODS

Patients who underwent single-level ALIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were analyzed for each patient.

RESULTS

A total of 921 patients were identified who underwent a single-level ALIF in this study. The average rate of single-level ALIF with rhBMP2 utilization increased (35%-48%) from 2005 to 2009, but sharply decreased to 16.7% in 2010 and 15.0% in 2011. The overall incidence of single-level ALIF without rhBMP2 (0.20 cases per 100 000 patients) was more than twice of the incidence of single-level ALIF with rhBMP2 (0.09 cases per 100 000 patients). The average rate of single-level ALIF with rhBMP2 utilization is highest in West (41.4%), followed by Midwest (33.3%), South (26.5%) and Northeast (22.2%). The highest incidence of single-level ALIF with rhBMP2 was observed in the group aged less than 65 years (compared with any other age groups, P < .001), with an incidence of 0.21 per 100 000 patients.

CONCLUSIONS

The incidence of rhBMP2 utilization in single-level ALIF increased from 2006 to 2009, but decreased in 2010 and 2011. The Northeast region had the lowest incidence of rhBMP2 utilization. The group aged less than 65 years trended to have the higher incidence of single-level ALIF with rhBMP2 utilization.

Cultivation of EPC and co-cultivation with MSC on β-TCP granules in vitro is feasible without fibronectin coating but influenced by scaffolds' design

INTRODUCTION

Meanwhile, the osteoconductive properties of frequently used synthetic bone grafts can be improved by the use of osteoinductive cells and growth factors. Nevertheless, the cultivation of endothelial progenitor cells (EPC) seems to be difficult and requires a pre-conditioning of the scaffolds with fibronectin. Additionally, the influence of the scaffolds' design on cell cultivation is not fully elucidated.

METHODS

As scaffold, a commercially available β-tricalcium phosphate was used. 5 × 10⁵ EPC, or 5 × 10⁵ MSC or a combination of each 2.5 × 10⁵ cells was seeded onto the granules. We investigated seeding efficiency, cell morphology, cell metabolism, adherence, apoptosis and gene expression of EPC and MSC in this in vitro study on days 2, 6 and 10.

RESULTS

Total number of adherent cells was higher on the β-TCP without fibronectin coating. The number of cells in all approaches significantly declined when a solid β-TCP was used. Metabolic activity of MSC was comparable throughout the scaffolds and increased until day 10. Additionally, the amount of supernatants VEGF was higher for MSC than for EPC.

DISCUSSION

Our results demonstrate that a coating of the scaffold for successful cultivation of EPC in vitro is not necessary. Furthermore, our study showed that structural differences of the scaffolds significantly influenced cell adherence and metabolic activity. Thereby, the influence on EPC seems to be higher than on MSC.

Operative Management of Lumbar Degenerative Disc Disease

Lumbar degenerative disc disease is extremely common. Current evidence supports surgery in carefully selected patients who have failed non-operative treatment and do not exhibit any substantial psychosocial overlay. Fusion surgery employing the correct grafting and stabilization techniques has long-term results demonstrating successful clinical outcomes. However, the best approach for fusion remains debatable. There is some evidence supporting the more complex, technically demanding and higher risk interbody fusion techniques for the younger, active patients or patients with a higher risk of non-union. Lumbar disc arthroplasty and hybrid techniques are still relatively novel procedures despite promising short-term and mid-term outcomes. Long-term studies demonstrating superiority over fusion are required before these techniques may be recommended to replace fusion as the gold standard. Novel stem cell approaches combined with tissue engineering therapies continue to be developed in expectation of improving clinical outcomes. Results with appropriate follow-up are not yet available to indicate if such techniques are safe, cost-effective and reliable in the long-term.

Postoperative Cyst Associated with Bone Morphogenetic Protein Use in Posterior and Transforaminal Lumbar Interbody Fusion Managed Conservatively: Report of Two Cases

Bone morphogenetic protein use in spinal surgery for off-label indications continues to remain popular. One area where its use has known associated radicular complications is posterior or transforaminal lumbar interbody fusion. These complications include radiculitis, cyst development, and heterotopic ossification, amongst others. Typically, cyst development has been treated surgically. We present two cases of bone morphogenetic protein-related cysts treated medically and thus, present medical treatment as an alternative treatment option.

Anterior Lumbar Interbody Fusion as a Salvage Technique for Pseudarthrosis following Posterior Lumbar Fusion Surgery

Study Design Retrospective analysis of prospectively collected observational data. Objective To assess the safety and efficacy of anterior lumbar interbody fusion (ALIF) as a salvage option for lumbar pseudarthrosis following failed posterior lumbar fusion surgery. Methods From 2009 to 2013, patient outcome data was collected prospectively over 5 years from 327 patients undergoing ALIF performed by a single surgeon (R.J.M.) with 478 levels performed. Among these, there were 20 cases of failed prior posterior fusion that subsequently underwent ALIF. Visual analog score (VAS), Oswestry Disability Index (ODI), and Short Form 12-item health survey (SF-12) were measured pre- and postoperatively. The verification of fusion was determined by utilizing a fine-cut computed tomography scan at 12-month follow-up. Results There was a significant difference between the preoperative (7.25 ± 0.8) and postoperative (3.1 ± 2.1) VAS scores (p < 0.0001). The ODI scale also demonstrated a statistically significant reduction from preoperative (56.3 ± 16.5) and postoperative (30.4 ± 19.3) scores (p < 0.0001). The SF-12 scores were significantly improved after ALIF salvage surgery: Physical Health Composite Score (32.18 ± 5.5 versus 41.07 ± 9.67, p = 0.0003) and Mental Health Composite Score (36.62 ± 12.25 versus 50.89 ± 10.86, p = 0.0001). Overall, 19 patients (95%) achieved successful fusion. Conclusions Overall, our results suggest that the ALIF procedure results not only in radiographic improvements in bony fusion but in significant improvements in the patient's physical and mental experience of pain secondary to lumbar pseudarthrosis. Future multicenter registry studies and randomized controlled trials should be conducted to confirm the long-term benefit of ALIF as a salvage option for failed posterior lumbar fusion.

Bone marrow-derived mesenchymal stem cells assembled with low-dose BMP-2 in a three-dimensional hybrid construct enhances posterolateral spinal fusion in syngeneic rats

BACKGROUND CONTEXT

The combination of potent osteoinductive growth factor, functional osteoblastic cells, and osteoconductive materials to induce bone formation is a well-established concept in bone tissue engineering. However, supraphysiological dose of growth factor, such as recombinant human bone morphogenetic protein 2 (rhBMP-2), which is necessary in contemporary clinical application, have been reported to result in severe side effects.

PURPOSE

We hypothesize that the synergistic osteoinductive capacity of low-dose bone morphogenetic protein 2 (BMP-2) combined with undifferentiated bone marrow-derived stromal cells (BMSCs) is comparable to that of osteogenically differentiated BMSCs when used in a rodent model of posterolateral spinal fusion.

STUDY DESIGN/SETTING

A prospective study using a rodent model of posterolateral spinal fusion was carried out.

PATIENT SAMPLE

Thirty-six syngeneic Fischer rats comprised the patient sample.

METHODS

Six groups of implants were evaluated as follows (n=6): (1) 10 µg BMP-2 with undifferentiated BMSCs; (2) 10 µg BMP-2 with osteogenic-differentiated BMSCs; (3) 2.5 µg BMP-2 with undifferentiated BMSCs; (4) 2.5 µg BMP-2 with osteogenic-differentiated BMSCs; (5) 0.5 µg BMP-2 with undifferentiated BMSCs; and (6) 0.5 µg BMP-2 with osteogenic-differentiated BMSCs. Optimal in vitro osteogenic differentiation of BMSCs was determined by quantitative real-time polymerase chain reaction (qRT-PCR) gene analysis whereas in vivo bone formation capacity was evaluated by manual palpation, micro-computed tomography, and histology.

RESULTS

Rat BMSCs cultured in fibrin matrix that was loaded into the pores of medical-grade poly epsilon caprolactone tricalcium phosphate scaffolds differentiated toward osteogenic lineage by expressing osterix, runt-related transcription factor 2, and osteocalcium mRNA when supplemented with dexamethasone, ascorbic acid, and β-glycerophosphate. Whereas qRT-PCR revealed optimal increase in osteogenic genes expression after 7 days of in vitro culture, in vivo transplantation study showed that pre-differentiation of BMSCs before transplantation failed to promote posterolateral spinal fusion when co-delivered with low-dose BMP-2 (1/6 or 17% fusion rate). In contrast, combined delivery of undifferentiated BMSCs with low-dose BMP-2 (2.5 µg) demonstrated significantly higher fusion rate (4/6 or 67%) as well as significantly increased volume of new bone formation (p<.05).

CONCLUSION

In summary, this study supports the combination of undifferentiated BMSCs and low-dose rhBMP-2 for bone tissue engineering construct.

Lumbar interbody fusion with porous biphasic calcium phosphate enhanced by recombinant bone morphogenetic protein-2/silk fibroin sustained-released microsphere: an experimental study on sheep model

Biphasic calcium phosphate (BCP) has been investigated extensively as a bone substitute nowadays. However, the bone formation capacity of BCP is limited owing to lack of osteoinduction. Silk fibroin (SF) has a structure similar to type I collagen, and could be developed to a microsphere for the sustained-release of rhBMP-2. In our previous report, bioactivity of BCP could be enhanced by rhBMP-2/SF microsphere (containing 0.5 µg rhBMP-2) in vitro. However, the bone regeneration performance of the composite in vivo was not investigated. Thus, the purpose of this study was to evaluate the efficacy of BCP/rhBMP-2/SF in a sheep lumbar fusion model. A BCP and rhBMP-2/SF microsphere was developed, and then was integrated into a BCP/rhBMP-2/SF composite. BCP, BCP/rhBMP-2 and BCP/rhBMP-2/SF were implanted randomly into the disc spaces of 30 sheep at the levels of L1/2, L3/4 and L5/6. After sacrificed, the fusion segments were evaluated by manual palpation, CT scan, biomechanical testing and histology at 3 and 6 months, respectively. The composite demonstrated a burst-release of rhBMP-2 (39.1 ± 2.8 %) on the initial 4 days and a sustained-release (accumulative 81.3 ± 4.9 %) for more than 28 days. The fusion rates, semi-quantitative CT scores, fusion stiffness in bending in all directions and histologic scores of BCP/rhBMP-2/SF were significantly greater than BCP and BCP/rhBMP-2 at each time point, respectively (P < 0.05). These findings indicate that the SF microspheres containing a very low dose of rhBMP-2 improve fusion in sheep using BCP constructs.

Spine interbody implants: material selection and modification, functionalization and bioactivation of surfaces to improve osseointegration

The clinical outcome of lumbar spinal fusion is correlated with achievement of bony fusion. Improving interbody implant bone on-growth and in-growth may enhance fusion, limiting pseudoarthrosis, stress shielding, subsidence and implant failure. Polyetheretherketone (PEEK) and titanium (Ti) are commonly selected for interbody spacer construction. Although these materials have desirable biocompatibility and mechanical properties, they require further modification to support osseointegration. Reports of extensive research on this topic are available in biomaterial-centric published reports; however, there are few clinical studies concerning surface modification of interbody spinal implants. The current article focuses on surface modifications aimed at fostering osseointegration from a clinician's point of view. Surface modification of Ti by creating rougher surfaces, modifying its surface topography (macro and nano), physical and chemical treatment and creating a porous material with high interconnectivity can improve its osseointegrative potential and bioactivity. Coating the surface with osteoconductive materials like hydroxyapatite (HA) can improve osseointegration. Because PEEK spacers are relatively inert, creating a composite by adding Ti or osteoconductive materials like HA can improve osseointegration. In addition, PEEK may be coated with Ti, effectively bio-activating the coating.

Clinical outcomes and fusion rates following anterior lumbar interbody fusion with bone graft substitute i-FACTOR, an anorganic bone matrix/P-15 composite

Object

Despite limited availability and the morbidity associated with autologous iliac crest bone graft (ICBG), its use in anterior lumbar interbody fusion (ALIF) procedures remains the gold standard to achieve arthrodesis. The search for alternative grafts yielding comparable or superior fusion outcomes with fewer complications continues. In particular, i-FACTOR, a novel bone graft substitute composed of anorganic bone matrix (ABM) with P-15 small peptide, is one example currently used widely in the dental community. Although preclinical studies have documented its usefulness, the role of i-FACTOR in ALIF procedures remains unknown.

The authors' goal was to determine the safety and efficacy of i-FACTOR bone graft composite used in patients who underwent ALIF by evaluating fusion rates and clinical outcomes.

Methods

A nonblinded cohort of patients who were all referred to a single surgeon's practice was prospectively studied. One hundred ten patients with degenerative spinal disease underwent single or multilevel ALIF using the ABM/P-15 bone graft composite with a mean of 24 months (minimum 15 months) of follow-up were enrolled in the study. Patient's clinical outcomes were assessed using the Oswestry Disability Index for low-back pain, the 12-Item Short Form Health Survey, Odom's criteria, and a visual analog scale for pain. Fine-cut CT scans were used to evaluate the progression to fusion.

Results

All patients who received i-FACTOR demonstrated radiographic evidence of bony induction and early incorporation of bone graft. At a mean of 24 months of follow-up (range 15–43 months), 97.5%, 81%, and 100% of patients, respectively, who had undergone single-, double-, and triple-level surgery exhibited fusion at all treated levels. The clinical outcomes demonstrated a statistically significant (p < 0.05) difference between preoperative and postoperative Oswestry Disability Index, 12-Item Short Form Health Survey, and visual analog scores.

Conclusions

The use of i-FACTOR bone graft substitute demonstrates promising results for facilitating successful fusion and improving clinical outcomes in patients who undergo ALIF surgery for degenerative spinal pathologies.