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Noh T, Zakaria H, Massie L, Ogasawara CT, Lee GA, Chedid M. Bone Marrow Aspirate in Spine Surgery: Case Series and Review of the Literature. Cureus 2021; 13:e20309. [PMID: 35028210 PMCID: PMC8748018 DOI: 10.7759/cureus.20309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background With the modernization of biotechnology, there has been a concerted effort to create novel biomaterials to promote arthrodesis for spine surgery. The novel use of the stem cells from bone marrow aspirate (BMA) to augment spine surgery is a burgeoning field because these cells are considered to be both osteoinductive and osteogenic. We sought to review the evidence behind the use of BMAs in spinal fusions and report the results of our own case series. Methods PubMed and EMBASE databases were searched for studies that investigated the use of stem cells for spine surgery. For our own case series, the medical records of 150 consecutive patients who underwent a lumbar spinal fusion with BMA were retrospectively reviewed for adverse events (AEs) for up to two years after surgery. Results In our case series, there were no AEs identified in 49% of our patients. Of the identified AEs, 61% were unrelated to the use of BMA (e.g., UTI and heart failure), with the remaining 39% likely unrelated to its use (e.g., back pain and anemia). There was a 92.8% arthrodesis rate with the use of BMA. Conclusions We reviewed the rationale, basic science, and clinical science for BMA usage in spine surgery and concluded that BMA is safe for use in spine surgery and is associated with a high rate of arthrodesis.
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Buser Z, Hsieh P, Meisel HJ, Skelly AC, Brodt ED, Brodke DS, Park JB, Yoon ST, Wang J. Use of Autologous Stem Cells in Lumbar Spinal Fusion: A Systematic Review of Current Clinical Evidence. Global Spine J 2021; 11:1281-1298. [PMID: 33203241 PMCID: PMC8453670 DOI: 10.1177/2192568220973190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES To systematically review, critically appraise and synthesize evidence on use of autologous stem cells sources for fusion in the lumbar spine. METHODS A systematic search of PubMed/MEDLINE, EMBASE and ClinicalTrials.gov through February 20, 2020 was conducted comparing autologous cell grafts to other biologics for lumbar spine fusion. The focus was on studies comparing distinct patient groups. RESULTS From 343 potentially relevant citations, 15 studies met the inclusion criteria set a priori. Seven studies compared distinct patient groups, with BMA being used in combination with allograft or autograft not as a standalone material. No economic evaluations were identified. Most observational studies were at moderately high risk of bias. When used for primary lumbar fusion, no statistical differences in outcomes or complications were seen between BMA+autograft/or +allograft compared to autograft/allograft alone. Compared with allograft, data from a RCT suggested statistically better fusion and lower complication rates with concentrated BMA+allograft. When used in revisions, no differences in outcomes were seen between BMA+allograft and either autograft or rh-BMP-2 but fusion rates were lower with BMA+allograft, leading to additional revision surgery. CONCLUSIONS There was substantial heterogeneity across studies in patient populations, sample size, biologic combinations, and surgical characteristics making direct comparisons difficult. The overall quality of evidence for fusion rates and the safety of BMA in lumbar fusion procedures was considered very low, with studies being at moderately high or high risk of bias.
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Affiliation(s)
- Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, CA, USA,Zorica Buser, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo St., HC4-5400A, Los Angeles, CA 90033, USA.
| | - Patrick Hsieh
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, CA, USA
| | | | | | | | - Darrel S. Brodke
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake, UT, USA
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijongbu St. Mary’s Hospital, The Catholic University of Korea School of Medicine, Uijongbu, Korea
| | - S. Tim Yoon
- Department of Orthopedics, Emory Spine Center, Emory University, Atlanta, GA, USA
| | - Jeffrey Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, CA, USA
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Abstract
BACKGROUND This manuscript is a review of the literature investigating the use of mesenchymal stem cells (MSCs) being applied in the setting of spinal fusion surgery. We mention the rates of pseudarthrosis, discuss current bone grafting options, and examine the preclinical and clinical outcomes of utilizing MSCs to assist in successfully fusing the spine. METHODS A thorough literature review was conducted to look at current and previous preclinical and clinical studies using stem cells for spinal fusion augmentation. Searches for PubMed/MEDLINE and ClinicalTrials.gov through January 2021 were conducted for literature mentioning stem cells and spinal fusion. RESULTS All preclinical and clinical studies investigating MSC use in spinal fusion were examined. We found 19 preclinical and 17 clinical studies. The majority of studies, both preclinical and clinical, were heterogeneous in design due to different osteoconductive scaffolds, cells, and techniques used. Preclinical studies showed promising outcomes in animal models when using appropriate osteoconductive scaffolds and factors for osteogenic differentiation. Similarly, clinical studies have promising outcomes but differ in their methodologies, surgical techniques, and materials used, making it difficult to adequately compare between the studies. CONCLUSION MSCs may be a promising option to use to augment grafting for spinal fusion surgery. MSCs must be used with appropriate osteoconductive scaffolds. Cell-based allografts and the optimization of their use have yet to be fully elucidated. Further studies are necessary to determine the efficacy of MSCs with different osteoconductive scaffolds and growth/osteogenic differentiation factors. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Stephen R Stephan
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Linda E Kanim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hyun W Bae
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Eder C, Schmidt-Bleek K, Geissler S, Sass FA, Maleitzke T, Pumberger M, Perka C, Duda GN, Winkler T. Mesenchymal stromal cell and bone marrow concentrate therapies for musculoskeletal indications: a concise review of current literature. Mol Biol Rep 2020; 47:4789-4814. [PMID: 32451926 PMCID: PMC7295724 DOI: 10.1007/s11033-020-05428-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 04/03/2020] [Indexed: 12/17/2022]
Abstract
The interest on applying mesenchymal stromal cells (MSCs) in orthopedic disorders has risen tremendously in the last years due to scientific successes in preclinical in vitro and animal model studies. In a wide range of diseases and injuries of the musculoskeletal system, MSCs are currently under evaluation, but so far have found access to clinical use only in few cases. The current assignment is to translate the acquired knowledge into clinical practice. Therefore, this review aims at presenting a synopsis of the up-to-date status of the use of MSCs and MSC related cell products in musculoskeletal indications. Clinical studies were included, whereas preclinical and animal study data not have been considered. Most studies published so far investigate the final outcome applying bone marrow derived MSCs. In fewer trials the use of adipose tissue derived MSCs and allogenic MSCs was investigated in different applications. Although the reported results are equivocal in the current literature, the vast majority of the studies shows a benefit of MSC based therapies depending on the cell sources and the indication in clinical use. In summary, the clinical use of MSCs in patients in orthopedic indications has been found to be safe. Standardized protocols and clear definitions of the mechanisms of action and the mode and timing of application as well as further coordinated research efforts will be necessary for finally adding MSC based therapies in standard operating procedures and guidelines for the clinicians treating orthopedic disorders.
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Affiliation(s)
- Christian Eder
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Katharina Schmidt-Bleek
- Julius Wolff Institute, Charité - Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sven Geissler
- Julius Wolff Institute, Charité - Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - F. Andrea Sass
- Julius Wolff Institute, Charité - Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tazio Maleitzke
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
- Berlin-Brandenburg School for Regenerative Therapies, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Georg N. Duda
- Julius Wolff Institute, Charité - Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Berlin-Brandenburg School for Regenerative Therapies, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tobias Winkler
- Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
- Julius Wolff Institute, Charité - Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Charité – Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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Abstract
There are a number of bone regeneration therapeutics available to aid spinal fusion; however, many are associated with pseudarthrosis, inflammation, and other complications. Mesenchymal stem cells for fusion has been promoted to mitigate these risks and achieve successful bony fusion. This article reviews the clinical studies available with use in spinal fusion. Preliminary results demonstrate that stem cells can provide high rates of fusion, comparable to autograft, without associated morbidity. Autologous and allogeneic stem cell sources showed similar rates of fusion in this review. Further research is required to evaluate which clinical situations are the optimum for stem cell use.
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Affiliation(s)
- Vivek P Shah
- Department of Orthopedic Surgery - Hsu Lab, Northwestern University, Chicago, IL 60611, USA.
| | - Wellington K Hsu
- Northwestern Department of Orthopedic Surgery, 259 East Erie Street 13th Floor Lavin Family Pavilion, Chicago, IL 60611, USA
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Murray IR, Robinson PG, West CC, Goudie EB, Yong LY, White TO, LaPrade RF. Reporting Standards in Clinical Studies Evaluating Bone Marrow Aspirate Concentrate: A Systematic Review. Arthroscopy 2018; 34:1366-1375. [PMID: 29395555 DOI: 10.1016/j.arthro.2017.11.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review of clinical studies evaluating bone marrow aspirate concentrate (BMAC) in the treatment of musculoskeletal pathology to compare levels of reporting with recently published minimum standards. METHODS A systematic review of the clinical literature from August 2002 to August 2017 was performed. Human clinical studies published in English and involving the administration of BMAC for musculoskeletal applications were included. Studies evaluating non-concentrated preparations of bone marrow aspirate or preparations of laboratory cultured cells were excluded. Studies evaluating the treatment of dental or maxillofacial conditions were excluded. Similarly, in vitro studies, editorials, letters to the editor, and reviews were excluded. Levels of reporting were compared with previously published minimum standards agreed on through an international Delphi consensus process. RESULTS Of 1,580 studies identified on the initial search, 46 satisfied the criteria for inclusion. Considerable deficiencies in reporting of key variables including the details of BMAC preparation and composition were noted. Studies reported information on only 42% (range, 25%-60%) of the variables included within established minimum reporting standards. No study provided adequate information to enable the precise replication of preparation protocols and accurate characterization of the BMAC formulation delivered. CONCLUSIONS We found that all existing clinical studies in the literature evaluating BMAC for orthopaedic or sports medicine applications are limited by inadequate reporting of both preparation protocols and composition. Deficient reporting of the variables that may critically influence outcomes precludes interpretation, prevents other researchers from reproducing experimental conditions, and makes comparisons across studies difficult. We encourage the adoption of emerging minimum reporting standards for clinical studies evaluating the use of mesenchymal stem cells in orthopaedics. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Iain R Murray
- University of Edinburgh, Edinburgh, Scotland; Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | | | | | | | - Li Y Yong
- University of Edinburgh, Edinburgh, Scotland
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Piuzzi NS, Hussain ZB, Chahla J, Cinque ME, Moatshe G, Mantripragada VP, Muschler GF, LaPrade RF. Variability in the Preparation, Reporting, and Use of Bone Marrow Aspirate Concentrate in Musculoskeletal Disorders: A Systematic Review of the Clinical Orthopaedic Literature. J Bone Joint Surg Am 2018; 100:517-525. [PMID: 29557869 DOI: 10.2106/jbjs.17.00451] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Interest in the therapeutic potential of bone marrow aspirate concentrate (BMAC) has grown exponentially. However, comparisons among studies and their processing methods are challenging because of inconsistent reporting of protocols, as well as poor characterization of the composition of the initial bone marrow aspirate and of the final products delivered. The purpose of this study was to perform a systematic review of the literature to evaluate the level of reporting related to the protocols used for BMAC preparation and the composition of BMAC utilized in the treatment of musculoskeletal diseases in published clinical studies. METHODS A systematic review of the literature was performed by searching PubMed, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials from 1980 to 2016. Inclusion criteria were human clinical trials, English language, and manuscripts that reported on the use of BMAC in musculoskeletal conditions. RESULTS After a comprehensive review of the 986 identified articles, 46 articles met the inclusion criteria for analysis. No study provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 14 (30%) of the studies provided quantitative metrics of the composition of the BMAC final product. CONCLUSIONS The reporting of BMAC preparation protocols in clinical studies was highly inconsistent and studies did not provide sufficient information to allow the protocol to be reproduced. Moreover, comparison of the efficacy and yield of BMAC products is precluded by deficiencies in the reporting of preparation methods and composition. Future studies should contain standardized and stepwise descriptions of the BMAC preparation protocol, and the composition of the BMAC delivered, to permit validating and rationally optimizing the role of BMAC in musculoskeletal care.
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Affiliation(s)
- Nicolas S Piuzzi
- Department of Orthopaedic Surgery and Bioengineering, Cleveland Clinic, Cleveland, Ohio.,Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado
| | - Mark E Cinque
- Steadman Philippon Research Institute, Vail, Colorado
| | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado.,Oslo University Hospital, University of Oslo, Oslo, Norway.,OSTRC, The Norwegian School of Sports Sciences, Oslo, Norway
| | | | - George F Muschler
- Department of Orthopaedic Surgery and Bioengineering, Cleveland Clinic, Cleveland, Ohio
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado.,The Steadman Clinic, Vail, Colorado
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Morris MT, Tarpada SP, Cho W. Bone graft materials for posterolateral fusion made simple: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1856-1867. [DOI: 10.1007/s00586-018-5511-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 01/24/2018] [Accepted: 02/03/2018] [Indexed: 12/30/2022]
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9
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Mesenchymal Stem Cells for the Treatment of Spinal Arthrodesis: From Preclinical Research to Clinical Scenario. Stem Cells Int 2017; 2017:3537094. [PMID: 28286524 PMCID: PMC5327761 DOI: 10.1155/2017/3537094] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/05/2017] [Indexed: 02/07/2023] Open
Abstract
The use of spinal fusion procedures has rapidly augmented over the last decades and although autogenous bone graft is the “gold standard” for these procedures, alternatives to its use have been investigated over many years. A number of emerging strategies as well as tissue engineering with mesenchymal stem cells (MSCs) have been planned to enhance spinal fusion rate. This descriptive systematic literature review summarizes the in vivo studies, dealing with the use of MSCs in spinal arthrodesis surgery and the state of the art in clinical applications. The review has yielded promising evidence supporting the use of MSCs as a cell-based therapy in spinal fusion procedures, thus representing a suitable biological approach able to reduce the high cost of osteoinductive factors as well as the high dose needed to induce bone formation. Nevertheless, despite the fact that MSCs therapy is an interesting and important opportunity of research, in this review it was detected that there are still doubts about the optimal cell concentration and delivery method as well as the ideal implantation techniques and the type of scaffolds for cell delivery. Thus, further inquiry is necessary to carefully evaluate the clinical safety and efficacy of MSCs use in spine fusion.
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Khashan M, Inoue S, Berven SH. Cell based therapies as compared to autologous bone grafts for spinal arthrodesis. Spine (Phila Pa 1976) 2013; 38:1885-91. [PMID: 23873235 DOI: 10.1097/brs.0b013e3182a3d7dc] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To compare the clinical outcome of cell based grafts combined with bone extenders to autologous bone grafts. SUMMARY OF BACKGROUND DATA Alternative graft options that combine mesenchymal stem cells (MSCs) and bone marrow aspirate (BMA) with synthetic or allograft scaffolds have been recently used in several animal and clinical studies. METHODS This systematic review of the literature addresses the following key questions (KQs): (1) Does the use of MSCs or BMA combined with synthetic or allograft extenders contribute to thoracolumbar fusion rates that are comparable with the rates achieved by the use of iliac crest graft? (2) Are these fusion rates comparable with those of local bone graft (LBG)? (3) Does the addition of MSCs or BMA to iliac crest bone graft or LBG contribute to better throracolumbar fusion rates? (4) Are the cervical spine fusion outcomes achieved by the use of SCM or BMA with synthetic or allograft scaffolds comparable with the iliac crest bone graft or LBG outcomes? (5) Was there any difference in terms of fusion rates, when MSCs were compared with BMA? RESULTS For KQ1, 4 level II, III studies used iliac crest bone graft as control. The results of these studies were inconsistent, and the overall body of evidence was found insufficient. Three, level II, III studies were identified for KQ2. Comparable fusion rates were demonstrated between LBG and BMA combined with calcium phosphate or collagen carrier. The overall body of evidence was found weak. For KQ3, one level III study was found. No significant difference was found in the fusion rates. No studies met the criteria for KQ4, 5. CONCLUSION The currently available evidence is insufficient to support the use of MSCs or BMA combined with synthetic or allograft materials as a substitute or supplementary graft to autologous bone graft. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Morsi Khashan
- *Orthopedic Surgery Department, University of California-San Francisco, San Francisco, CA †Department of Orthopedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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