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Patients Cannot Reliably Distinguish the Iliac Crest Bone Graft Donor Site From the Contralateral Side After Lumbar Spine Fusion

A Patient-blinded Randomized Controlled Trial

Lehr, A. Mechteld, MSc; Oner, F. Cumhur, MD, PhD; Hoebink, Eric A., MD; Kempen, Diederik H.R., MD, PhD; van Susante, Job L.C., MD, PhD§; Castelein, René M., MD, PhD; Kruyt, Moyo C., MD, PhD

doi: 10.1097/BRS.0000000000002882

Study Design. A multicenter, randomized, intrapatient controlled trial.

Objective. This study investigated whether lumbar fusion patients blinded to the harvest site (A) can identify the iliac crest used for bone harvesting and (B) whether this iliac crest is more painful than the contralateral side.

Summary of Background Data. Spinal fusion with iliac crest autograft is a frequently performed surgical procedure. A widely reported disadvantage of the harvesting procedure is potential donor site morbidity. This has driven the development of many bone graft substitutes. However, more recently the incidence and severity of donor site pain is debated, especially in lumbar fusion surgery.

Methods. Ninety-two nontraumatic adult patients underwent a posterolateral (thoraco)lumbar fusion. Iliac crest bone graft was harvested unilaterally through the primary midline incision. At 6 weeks, 3 months, 6 months, and 1 year follow-up, patients were asked to identify the donor site and to rate pain in their back, left iliac crest and right iliac crest on a Visual Analogue Scale (VAS).

Results. Ninety patients, 44 males and 46 females with a mean age of 54 years, were analyzed. The left/right distribution of the iliac crest donor site was 50/50 and 89% of the patients underwent a lumbar fusion below L3. Only 24% patients identified the harvest site correctly. Moreover, the VAS pain scores for the donor site and contralateral iliac crest did not differ and were at each timepoint lower than the scores for back pain.

Conclusion. This study showed that, during the first year after lumbar fusion surgery via a single midline incision approach, patients could not reliably identify the iliac crest used for bone graft harvesting and this iliac crest was not more painful than the untouched contralateral iliac crest. Therefore, donor site pain should not be the main reason to use bone graft alternatives for lumbar spinal fusion.

Level of Evidence: 2

Donor site pain after unilateral iliac crest bone graft harvesting for instrumented posterolateral lumbar fusion was analyzed in 90 adult patients blinded to the harvest site. Patients could not reliably identify the harvest site and this iliac crest was not more painful than the untouched contralateral iliac crest.

Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands

Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands

Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands

§Department of Orthopaedic Surgery, Rijnstate Hospital, Arnhem, The Netherlands.

Address correspondence and reprint requests to A. Mechteld Lehr, MSc, University Medical Center Utrecht, Department of Orthopaedic Surgery, HP G05.228, Postbox 85500, 3508 GA Utrecht, The Netherlands; E-mail:

Received 29 May, 2018

Revised 13 July, 2018

Accepted 31 August, 2018

The device is FDA-approved or approved by corresponding national agency for this indication.

The Department of Orthopaedic Surgery of the University Medical Center Utrecht received a restricted academic research grant from NuVasive Inc (San Diego, CA) to partially fund this investigator-initiated study.

Relevant financial activities outside the submitted work: grants.

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