Bone Graft Substitutes in Single or Double Level Anterior Cervical Discectomy and Fusion: A Systematic Review
Objective: To undertake a systematic review of published literature to determine which bone graft substitute or combination of grafts provides the best clinical outcomes in single or double level anterior cervical discectomy and fusion (ACDF). Background: Anterior cervical discectomy and fusion is one of the most common elective spinal surgeries completed in the United States. Today many different bone graft substitutes, particularly biologics, are used to enhance the fusion of the cervical vertebrae; however, the cost of bone graft substitutes varies greatly without any established differences in outcomes. With the wide range in prices and options available, insurance companies are starting to decline payment for these products. ^ Methods: A systematic literature review of 22 published articles was conducted. All articles included in this review reported results on patients who underwent a single or double level anterior cervical discectomy and fusion procedure performed using a bone graft substitute and reported results on radiographic fusion rates at least 6 months after surgery. Some studies also reported clinical outcomes. As this research is a systematic review there was no contact with study subjects or datasets. ^ Results: All studies using bone morphogenetic protein (BMP) showed a 100% fusion rate despite length of the study or whether another bone graft substitute was also used. Use of only ceramic-based synthetics had the lowest fusion rate, 80.5%. Use of only mesenchymal stem cells for bone graft resulted in an average fusion rate of 87.7%. One trial used bone marrow aspirate with allograft and ceramic-based synthetic and observed a rate of fusion of 100% in a sample of 66 patients. 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%. There was a significant difference in fusion rate between all bone grafts substitutes when compared to BMP or ceramic-based synthetics (p < 0.001), with improved fusion with BMP and worse fusion with ceramic-based synthetics. No significant difference in fusion rate was noted between other grafts (p > 0.05). Clinical outcomes were improved postoperatively irrespective of the graft used, though dysphagia was significantly greater in studies using BMP (p < 0.001). ^ Conclusions: Allograft alone is the most cost effective option with similar fusion rates and clinical outcomes compared to other bone graft substitutes. Institutions should consider this when choosing to use bone graft substitutes for routine anterior cervical discectomy and fusions.^
Stark, Jessica R, "Bone Graft Substitutes in Single or Double Level Anterior Cervical Discectomy and Fusion: A Systematic Review" (2017). Texas Medical Center Dissertations (via ProQuest). AAI10616197.