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Bone Graft Substitutes in Single- or Double-Level Anterior Cervical Discectomy and Fusion

A Systematic Review

Stark, Jessica R., MD, MPH∗,†; Hsieh, Joseph, MD, MPH∗,†; Waller, Dorothy, PhD

doi: 10.1097/BRS.0000000000002925
LITERATURE REVIEW
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Study Design. Systematic review

Objective. To undertake a systematic review of published literature to evaluate efficacy of bone graft substitutes on radiographic and clinical outcomes in single- or double-level anterior cervical discectomy and fusion (ACDF) for degenerative disease.

Summary of Background Data. ACDF is one of the most common spinal surgeries completed in the United States. Today bone graft substitutes including ceramic-based synthetic bone grafts, allografts, bone morphogenetic proteins (BMPs), mesenchymal stem cells, and bone marrow aspirate are widely used to enhance fusions; even though the efficacy of these substitutes is poorly defined. Critical evaluation of these products is necessary to optimize radiographic and clinical outcomes for ACDF in degenerative disease.

Methods. A systematic literature review of 22 published articles was conducted. All articles reported results on patients who underwent a single- or double-level ACDF performed using a bone graft substitute and reported results on radiographic fusion rates at least 6 months after surgery.

Results. All studies using BMP showed 100% fusion rate despite length of the study or whether additional bone graft substitutes were used. Use of only ceramic-based synthetics had the lowest fusion rate, 80.5%. Use of only mesenchymal stem cells resulted in an average fusion rate of 87.7%. When used alone, allograft resulted in an average fusion rate of 87.3%. This was significantly influenced by one outlier, Kim et al, which when removed, increased the fusion rate to 93.5%. Clinical outcomes were improved postoperatively irrespective of the graft used, although dysphagia was significantly greater in studies using BMP (P < 0.001).

Conclusion. Allograft alone has the lowest cost with similar fusion rates and clinical outcomes compared to other bone graft substitutes. Physicians should consider this when choosing to use bone graft substitutes for routine ACDFs.

Level of Evidence: 4

Critical evaluation of bone graft substitutes is necessary to optimize radiographic and clinical outcomes for anterior cervical discectomy and fusion (ACDF) in degenerative disease. A systematic literature review of 22 published articles reporting fusion rates in ACDF procedures using bone graft substitutes was conducted. Allograft alone has the lowest cost with similar fusion rates and clinical outcomes compared to other bone graft substitutes.

Vivian Smith Department of Neurosurgery, University of Texas Medical School at Houston, Houston, TX

Mischer Neuroscience Institute, Memorial Hermann Hospital, Texas Medical Center, Houston, TX

University of Texas School of Public Health, Houston, TX.

Address correspondence and reprint requests to Jessica R. Stark, MD, MPH, Vivian Smith Department of Neurosurgery, University of Texas Medical School at Houston, 6400 Fannin St. Suite 2800, Houston, TX 77030; E-mail: Jessica.R.Stark@uth.tmc.edu

Received 8 August, 2018

Revised 12 September, 2018

Accepted 11 October, 2018

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.