Effects of direct current electrical stimulation on gene expression of osteopromotive factors in a posterolateral spinal fusion model

Integration of clinical perspective into biomimetic bioreactor design for orthopedics

The challenges to accommodate multiple tissue formation metrics in conventional bioreactors have resulted in an increased interest to explore novel bioreactor designs. Bioreactors allow researchers to isolate variables in controlled environments to quantify cell response. While current bioreactor designs can effectively provide either mechanical, electrical, or chemical stimuli to the controlled environment, these systems lack the ability to combine all these stimuli simultaneously to better recapitulate the physiological environment. Introducing a dynamic and systematic combination of biomimetic stimuli bioreactor systems could tremendously enhance its clinical relevance in research. Thus, cues from different tissue responses should be studied collectively and included in the design of a biomimetic bioreactor platform. This review begins by providing a summary on the progression of bioreactors from simple to complex designs, focusing on the major advances in bioreactor technology and the approaches employed to better simulate in vivo conditions. The current state of bioreactors in terms of their clinical relevance is also analyzed. Finally, this review provides a comprehensive overview of individual biophysical stimuli and their role in establishing a biomimetic microenvironment for tissue engineering. To date, the most advanced bioreactor designs only incorporate one or two stimuli. Thus, the cell response measured is likely unrelated to the actual clinical performance. Integrating clinically relevant stimuli in bioreactor designs to study cell response can further advance the understanding of physical phenomenon naturally occurring in the body. In the future, the clinically informed biomimetic bioreactor could yield more efficiently translatable results for improved patient care.

Changes in the extracellular microenvironment and osteogenic responses of mesenchymal stem/stromal cells induced by in vitro direct electrical stimulation

Electrical stimulation (ES) has potential to be an effective tool for bone injury treatment in clinics. However, the therapeutic mechanism associated with ES is still being discussed. This study aims to investigate the initial mechanism of action by characterising the physical and chemical changes in the extracellular environment during ES and correlate them with the responses of mesenchymal stem/stromal cells (MSCs). Computational modelling was used to estimate the electrical potentials relative to the cathode and the current density across the cell monolayer. We showed expression of phosphorylated ERK1/2, c-FOS, c-JUN, and SPP1 mRNAs, as well as the increased metabolic activities of MSCs at different time points. Moreover, the average of 2.5 μM of H₂O₂ and 34 μg/L of dissolved Pt were measured from the electrically stimulated media (ES media), which also corresponded with the increases in SPP1 mRNA expression and cell metabolic activities. The addition of sodium pyruvate to the ES media as an antioxidant did not alter the SPP1 mRNA expression, but eliminated an increase in cell metabolic activities induced by ES media treatment. These findings suggest that H₂O₂ was influencing cell metabolic activity, whereas SPP1 mRNA expression was regulated by other faradic by-products. This study reveals how different electrical stimulation regime alters cellular regenerative responses and the roles of faradic by-products, that might be used as a physical tool to guide and control cell behaviour.

Evaluating the Effectiveness of Biophysical Methods of Osteogenesis Stimulation: Review

Background. Stimulation of osteogenesis (SO) by biophysical methods has been widely used in practice to accelerate healing or stimulate the healing of fractures with non-unions, since the middle of the XIX century. SO can be carried out by direct current electrostimulation, or indirectly by low-intensity pulsed ultrasound, capacitive electrical coupling stimulation, and pulsed electromagnetic field stimulation. SO simulates natural physiological processes: in the case of electrical stimulation, it changes the electromagnetic potential of damaged cell tissues in a manner similar to normal healing processes, or in the case of low-intensity pulsed ultrasound, it produces weak mechanical effects on the fracture area. SO increases the expression of factors and signaling pathways responsible for tissue regeneration and bone mineralization and ultimately accelerates bone union.The purpose of this review was to present the most up-to-date data from laboratory and clinical studies of the effectiveness of SO.Material and Methods. The results of laboratory studies and the final results of metaanalyses for each of the four SO methods published from 1959 to 2020 in the PubMed, EMBASE, and eLibrary databases are reviewed.Conclusion. The use of SO effectively stimulates the healing of fractures with the correct location of the sensors, compliance with the intensity and time of exposure, as well as the timing of use for certain types of fractures. In case of non-union or delayed union of fractures, spondylodesis, arthrodesis, preference should be given to non-invasive methods of SO. Invasive direct current stimulation can be useful for non-union of long bones, spondylodesis with the risk of developing pseudoarthrosis.

Evaluating the Effectiveness of Biophysical Methods of Osteogenesis Stimulation: Review

Background. Stimulation of osteogenesis (SO) by biophysical methods has been widely used in practice to accelerate healing or stimulate the healing of fractures with non-unions, since the middle of the XIX century. SO can be carried out by direct current electrostimulation, or indirectly by low-intensity pulsed ultrasound, capacitive electrical coupling stimulation, and pulsed electromagnetic field stimulation. SO simulates natural physiological processes: in the case of electrical stimulation, it changes the electromagnetic potential of damaged cell tissues in a manner similar to normal healing processes, or in the case of low-intensity pulsed ultrasound, it produces weak mechanical effects on the fracture area. SO increases the expression of factors and signaling pathways responsible for tissue regeneration and bone mineralization and ultimately accelerates bone union.The purpose of this review was to present the most up-to-date data from laboratory and clinical studies of the effectiveness of SO.Material and Methods. The results of laboratory studies and the final results of metaanalyses for each of the four SO methods published from 1959 to 2020 in the PubMed, EMBASE, and eLibrary databases are reviewed.Conclusion. The use of SO effectively stimulates the healing of fractures with the correct location of the sensors, compliance with the intensity and time of exposure, as well as the timing of use for certain types of fractures. In case of non-union or delayed union of fractures, spondylodesis, arthrodesis, preference should be given to non-invasive methods of SO. Invasive direct current stimulation can be useful for non-union of long bones, spondylodesis with the risk of developing pseudoarthrosis.

The effect of electrical stimulation therapies on spinal fusion: a cross-disciplinary systematic review and meta-analysis of the preclinical and clinical data

OBJECTIVE

Nonunion is a common complication of spinal fusion surgeries. Electrical stimulation technologies (ESTs)-namely, direct current stimulation (DCS), capacitive coupling stimulation (CCS), and inductive coupling stimulation (ICS)-have been suggested to improve fusion rates. However, the evidence to support their use is based solely on small trials. Here, the authors report the results of meta-analyses of the preclinical and clinical data from the literature to provide estimates of the overall effect of these therapies at large and in subgroups.

METHODS

A systematic review of the English-language literature was performed using PubMed, Embase, and Web of Science databases. The query of these databases was designed to include all preclinical and clinical studies examining ESTs for spinal fusion. The primary endpoint was the fusion rate at the last follow-up. Meta-analyses were performed using a Freeman-Tukey double arcsine transformation followed by random-effects modeling.

RESULTS

A total of 33 articles (17 preclinical, 16 clinical) were identified, of which 11 preclinical studies (257 animals) and 13 clinical studies (2144 patients) were included in the meta-analysis. Among preclinical studies, the mean fusion rates were higher among EST-treated animals (OR 4.79, p < 0.001). Clinical studies similarly showed ESTs to increase fusion rates (OR 2.26, p < 0.001). Of EST modalities, only DCS improved fusion rates in both preclinical (OR 5.64, p < 0.001) and clinical (OR 2.13, p = 0.03) populations; ICS improved fusion in clinical studies only (OR 2.45, p = 0.014). CCS was not effective at increasing fusion, although only one clinical study was identified. A subanalysis of the clinical studies found that ESTs increased fusion rates in the following populations: patients with difficult-to-fuse spines, those who smoke, and those who underwent multilevel fusions.

CONCLUSIONS

The authors found that electrical stimulation devices may produce clinically significant increases in arthrodesis rates among patients undergoing spinal fusion. They also found that the pro-arthrodesis effects seen in preclinical studies are also found in clinical populations, suggesting that findings in animal studies are translatable. Additional research is needed to analyze the cost-effectiveness of these devices.

Functional Materials for Two-Photon Polymerization in Microfabrication

Direct laser writing methods based on two-photon polymerization (2PP) are powerful tools for the on-demand printing of precise and complex 3D architectures at the micro and nanometer scale. While much progress was made to increase the resolution and the feature size throughout the years, by carefully designing a material, one can confer specific functional properties to the printed structures thus making them appealing for peculiar and novel applications. This Review summarizes the state-of-the-art of functional resins and photoresists used in 2PP, discussing both the range of material functions available and the methods used to prepare them, highlighting advantages and disadvantages of different classes of materials in achieving certain properties.

Direct electrical stimulation enhances osteogenesis by inducing Bmp2 and Spp1 expressions from macrophages and preosteoblasts

The capability of electrical stimulation (ES) in promoting bone regeneration has already been addressed in clinical studies. However, its mechanism is still being investigated and discussed. This study aims to investigate the responses of macrophages (J774A.1) and preosteoblasts (MC3T3-E1) to ES and the faradic by-products from ES. It is found that pH of the culture media was not significantly changed, whereas the average hydrogen peroxide concentration was increased by 3.6 and 5.4 µM after 1 and 2 hr of ES, respectively. The upregulation of Bmp2 and Spp1 messenger RNAs was observed after 3 days of stimulation, which is consistent among two cell types. It is also found that Spp1 expression of macrophages was partially enhanced by faradic by-products. Osteogenic differentiation of preosteoblasts was not observed during the early stage of ES as the level of Runx2 expression remains unchanged. However, cell proliferation was impaired by the excessive current density from the electrodes, and also faradic by-products in the case of macrophages. This study shows that macrophages could respond to ES and potentially contribute to the bone formation alongside preosteoblasts. The upregulation of Bmp2 and Spp1 expressions induced by ES could be one of the mechanisms behind the electrically stimulated osteogenesis.

Physical stimulations and their osteogenesis-inducing mechanisms

Physical stimulations such as magnetic, electric and mechanical stimulation could enhance cell activity and promote bone formation in bone repair process via activating signal pathways, modulating ion channels, regulating bonerelated gene expressions, etc. In this paper, bioeffects of physical stimulations on cell activity, tissue growth and bone healing were systematically summarized, which especially focused on their osteogenesis-inducing mechanisms. Detailedly, magnetic stimulation could produce Hall effect which improved the permeability of cell membrane and promoted the migration of ions, especially accelerating the extracellular calcium ions to pass through cell membrane. Electric stimulation could induce inverse piezoelectric effect which generated electric signals, accordingly up-regulating intracellular calcium levels and growth factor synthesis. And mechanical stimulation could produce mechanical signals which were converted into corresponding biochemical signals, thus activating various signaling pathways on cell membrane and inducing a series of gene expressions. Besides, bioeffects of physical stimulations combined with bone scaffolds which fabricated using 3D printing technology on bone cells were discussed. The equipments of physical stimulation system were described. The opportunities and challenges of physical stimulations were also presented from the perspective of bone repair.

Combining electrical stimulation and tissue engineering to treat large bone defects in a rat model

Bone Tissue engineering (BTE) has recently been introduced as an alternative to conventional treatments for large non-healing bone defects. BTE approaches mimic autologous bone grafts, by combining cells, scaffold, and growth factors, and have the added benefit of being able to manipulate these constituents to optimize healing. Electrical stimulation (ES) has long been used to successfully treat non-healing fractures and has recently been shown to stimulate bone cells to migrate, proliferate, align, differentiate, and adhere to bio compatible scaffolds, all cell behaviors that could improve BTE treatment outcomes. With the above in mind we performed in vitro experiments and demonstrated that exposing Mesenchymal Stem Cells (MSC) + scaffold to ES for 3 weeks resulted in significant increases in osteogenic differentiation. Then in in vivo experiments, for the first time, we demonstrated that exposing BTE treated rat femur large defects to ES for 8 weeks, caused improved healing, as indicated by increased bone formation, strength, vessel density, and osteogenic gene expression. Our results demonstrate that ES significantly increases osteogenic differentiation in vitro and that this effect is translated into improved healing in vivo. These findings support the use of ES to help BTE treatments achieve their full therapeutic potential.

Electrical Stimulation and Bone Healing: A Review of Current Technology and Clinical Applications

Pseudarthrosis is an exceedingly common, costly, and morbid complication in the treatment of long bone fractures and after spinal fusion surgery. Electrical bone growth stimulation (EBGS) presents a unique approach to accelerate healing and promote fusion success rates. Over the past three decades, increased experience and widespread use of EBGS devices has led to significant improvements in stimulation paradigms and clinical outcomes. In this paper, we comprehensively review the literature and examine the history, scientific evidence, available technology, and clinical applications for EBGS. We summarize indications, limitations, and provide an overview of cost-effectiveness and future directions of EBGS technology. Various models of electrical stimulation have been proposed and marketed as adjuncts for spinal fusions and long bone fractures. Clinical studies show variable safety and efficacy of EBGS under different conditions and clinical scenarios. While the results of clinical trials do not support indiscriminate EBGS utilization for any bone injury, the evidence does suggest that EBGS is desirable and cost efficient for certain orthopedic indications, especially when used in combination with standard, first-line treatments. This review should serve as a reference to inform practicing clinicians of available treatment options, facilitate evidence-based decision making, and provide a platform for further research.

Novel spinal instrumentation to enhance osteogenesis and fusion: a preliminary study

OBJECTIVE Instrumented spinal fusion continues to exhibit high failure rates in patients undergoing multilevel lumbar fusion or pseudarthrosis revision; with Grade II or higher spondylolisthesis; or in those possessing risk factors such as obesity, tobacco use, or metabolic disorders. Direct current (DC) electrical stimulation of bone growth represents a unique surgical adjunct in vertebral fusion procedures, yet existing spinal fusion stimulators are not optimized to enhance interbody fusion. To develop an advanced method of applying DC electrical stimulation to promote interbody fusion, a novel osteogenic spinal system capable of routing DC through rigid instrumentation and into the vertebral bodies was fabricated. A pilot study was designed to assess the feasibility of osteogenic instrumentation and compare the ability of osteogenic instrumentation to promote successful interbody fusion in vivo to standard spinal instrumentation with autograft. METHODS Instrumented, single-level, posterior lumbar interbody fusion (PLIF) with autologous graft was performed at L4-5 in adult Toggenburg/Alpine goats, using both osteogenic spinal instrumentation (plus electrical stimulation) and standard spinal instrumentation (no electrical stimulation). At terminal time points (3 months, 6 months), animals were killed and lumbar spines were explanted for radiographic analysis using a SOMATOM Dual Source Definition CT Scanner and high-resolution Microcat II CT Scanner. Trabecular continuity, radiodensity within the fusion mass, and regional bone formation were examined to determine successful spinal fusion. RESULTS Quantitative analysis of average bone density in pedicle screw beds confirmed that electroactive pedicle screws used in the osteogenic spinal system focally enhanced bone density in instrumented vertebral bodies. Qualitative and quantitative analysis of high-resolution CT scans of explanted lumbar spines further demonstrated that the osteogenic spinal system induced solid bony fusion across the L4-5 disc space as early as 6 weeks postoperatively. In comparison, inactive spinal instrumentation with autograft was unable to promote successful interbody fusion by 6 months postoperatively. CONCLUSIONS Results of this study demonstrate that novel osteogenic spinal instrumentation supports interbody fusion through the focal delivery of DC electrical stimulation. With further technical development and scientific/clinical validation, osteogenic spinal instrumentation may offer a unique alternative to biological scaffolds and pharmaceutical adjuncts used in spinal fusion procedures.

Two-Photon Lithography of 3D Nanocomposite Piezoelectric Scaffolds for Cell Stimulation

In this letter, we report on the fabrication, the characterization, and the in vitro testing of structures suitable for cell culturing, prepared through two-photon polymerization of a nanocomposite resist. More in details, commercially available Ormocomp has been doped with piezoelectric barium titanate nanoparticles, and bioinspired 3D structures resembling trabeculae of sponge bone have been fabricated. After an extensive characterization, preliminary in vitro testing demonstrated that both the topographical and the piezoelectric cues of these scaffolds are able to enhance the differentiation process of human SaOS-2 cells.

Establishment of a novel in vitro test setup for electric and magnetic stimulation of human osteoblasts

When large defects occur, bone regeneration can be supported by bone grafting and biophysical stimuli like electric and magnetic stimulation (EMS). Clinically established EMS modes are external coils and surgical implants like an electroinductive screw system, which combines a magnetic and electric field, e.g., for the treatment of avascular bone necrosis or pseudarthrosis. For optimization of this implant system, an in vitro test setup was designed to investigate effects of EMS on human osteoblasts on different 3D scaffolds (based on calcium phosphate and collagen). Prior to the cell experiments, numerical simulations of the setup, as well as experimental validation, via measurements of the electric parameters induced by EMS were conducted. Human osteoblasts (3 × 10(5) cells) were seeded onto the scaffolds and cultivated. After 24 h, screw implants (Stryker ASNIS III s-series) were centered in the scaffolds, and EMS was applied (3 × 45 min per day at 20 Hz) for 3 days. Cell viability and collagen type 1 (Col1) synthesis were determined subsequently. Numerical simulation and validation showed an adequate distribution of the electric field within the scaffolds. Experimental measurements of the electric potential revealed only minimal deviation from the simulation. Cell response to stimulation varied with scaffold material and mode of stimulation. EMS-stimulated cells exhibited a significant decrease of metabolic activity in particular on collagen scaffolds. In contrast, the Col1/metabolic activity ratio was significantly increased on collagen and non-sintered calcium phosphate scaffolds after 3 days. Exclusive magnetic stimulation showed similar but nonsignificant tendencies in metabolic activity and Col1 synthesis. The cell tests demonstrate that the new test setup is a valuable tool for in vitro testing and parameter optimization of the clinically used electroinductive screw system. It combines magnetic and electric stimulation, allowing in vitro investigations of its influence on human osteoblasts.

Factors influencing arthrodesis rates in a rabbit posterolateral spine model with iliac crest autograft

PURPOSE

The rabbit posterolateral intertransverse spine arthrodesis model has been widely used to evaluate spinal biologics. However, to date, the validity and reproducibility of performance of iliac crest bone graft, the most common and critical control group, has not been firmly established. We evaluated original research publications that utilized this model, identified which experimental conditions affected fusion rates, and developed an algorithm to predict fusion rates for future study designs.

METHODS

A MEDLINE search was performed for publications through December, 2011 that utilized this model to evaluate fusion rates elicited by iliac crest autograft. All study parameters were recorded, and logistic regression analyses were performed to determine the effects of these variables on fusion rates as determined by either manual palpation or radiographs.

RESULTS

Seventy studies with 959 rabbits in 102 groups met the inclusion criteria. Excluding studies that measured fusion at 4 or fewer weeks or intentionally tried to decrease the fusion rate, the overall fusion rate for autograft was 58.3 ± 16.3 % (mean ± SD) as determined by manual palpation and 66.4 ± 17.8 % by plain radiographs. Regression analysis demonstrated a difference between these outcome measures with a trend towards significance (p = 0.09). Longer time points and larger volumes of autograft resulted in significantly greater reported fusion rates (p < 0.0001 and p < 0.05, respectively). Neither strain, age, weight, nor vertebral level significantly affected fusion rates.

CONCLUSIONS

Although experimental conditions varied across studies, time point evaluation and autograft volume significantly affected fusion rates. Despite some variability demonstrated across certain studies, we demonstrated that when the time point and volume of autograft were controlled for, the iliac crest control group of the rabbit posterolateral spinal arthrodesis model is both reliable and predictably affected by different experimental conditions.

An implantable electrical bioreactor for enhancement of cell viability

Low survival of injected cells which are prepared by ex-vivo culture is main obstacle in cell-based tissue regeneration. To elevate cell adaptation, we designed an implantable electrical bioreactor where human mesenchymal stromal cells (hMSCs) can be cultured and stimulated electrically. Bioreactor was composed of biocompatible cylindrical Teflon body containing a flexible polyimide electrode and implantable stimulator. The Teflon body has about 300 holes with a diameter of 300 um for effective nutrients supply inside the bioreactor and has a length of 17 mm and a diameter of 8mm for implantation. After hMSCs seeded on the collagen sponge that serves as scaffold to form a bone tissue graft, they are cultured in the bioreactor with biphasic electric current (BEC) stimulation. BEC stimulation with amplitude of 20/40 uA, duration of 100 us and a frequency of 100 Hz was applied for one week in the early stage of cultivation. Subsequently, after hMSCS were cultured for another week without electrical stimulation, cell response such as cell proliferation, cell attachment and gene expression are evaluated. In vitro and In vivo culture of hMSCs showed 19% and 22% increase in cell proliferation at stimulated groups, compared to unstimulated control. The expression of type I collagen increased significantly at stimulated group. These results suggest that the usage of implantable electrical bioreactor can be a good strategy to enhance the efficiency of stem cell-based tissue engineering.

Vertebral growth modulation by electrical current in an animal model: potential treatment for scoliosis

BACKGROUND

The concept of modulating spinal growth to correct scoliosis is intriguing, and this study proposes a new model. Inhibition of vertebral growth on the convex side of a curve would allow continued normal growth on the concave side to correct the scoliosis. In an earlier study, we induced bony bridges across the physis of the femur producing an epiphysiodesis in rabbits by using a stimulator modified to deliver a current of 50 muA. This study builds on this finding to design a model with an aim of inhibiting growth in a unilateral peripheral portion of the vertebral endplate physis, which induces asymmetric spinal growth.

METHODS

The study was conducted with 8-week-old rabbits; 6 were treated with electrical current through an implantable 4-lead device; 3 were age-matched normal rabbits. The device was implanted and delivered a constant current of 50 muA from each electrode, continuously for 6 weeks. Weekly radiograph monitoring and endpoint histology were carried out.

RESULTS

Spinal growth was modified by inducing asymmetric growth of the vertebra of young rabbits using electric stimulators delivering 50 muA of direct current through electrodes implanted in a left peripheral portion of the endplate physis.

CONCLUSIONS

This concept study, based on our earlier study, involved a method and device for inhibiting growth in one aspect of the vertebral endplate using electrical current at an amplitude that induced a hemiepiphysiodesis. Our results showed that this technique both establishes an in vivo model of scoliosis and suggests that if this technique were applied to an existing curve it could potentially induce asymmetrical growth of the spine, thereby correcting scoliosis by continuing the normal growth on the concavity of the curve.

CLINICAL RELEVANCE

A potential new method for modulating spinal growth was developed, and, with further research, this method may be useful in treating children with scoliosis by delivering a growth-inhibiting current to the physeal areas of vertebra through electrodes placed percutaneously.

Novel effect of biphasic electric current on in vitro osteogenesis and cytokine production in human mesenchymal stromal cells

Electrical stimulation (ES) can activate diverse biostimulatory responses in a range of tissues. Of various forms of ES, the application of biphasic electric current (BEC) is a new approach to bone formation. This study is to investigate the effects and mechanism of action of BEC in osteoblast differentiation and cytokine production in human mesenchymal stromal cells (hMSCs). Using an in vitro culture system with a modified version of the BEC stimulator chip used in our previous study, we exposed hMSCs to a 100 Hz ES with a magnitude of 1.5/15 muA/cm(2) for 250/25 mus. hMSCs showed increased proliferation during static BEC stimulation for 5 days. However, alkaline phosphatase activity and calcium deposition were enhanced in hMSCs 7 days after the stimulation, rather than during the period of ES. BEC induced vascular endothelial growth factor (VEGF) and BMP-2 production; the former can enhance the proliferation of human umbilical vein endothelial cells in culture using conditioned media from BEC cultures. Treatment with selective inhibitors of p38 MAPK (SB203580) or Erk (PD98059), as well as calcium channel blockers (verapamil and nifedipine), reduced the BEC-mediated increase of VEGF expression and cell proliferation. These findings reveal that BEC is involved in the osteoblast differentiation of hMSCs through enhancement of cell proliferation and modulation of the local endocrine environment through VEGF and BMP-2 induction through the activation of MAPK (Erk and p38) and the calcium channel. Thus, local stimulation using BEC might be most beneficial in promoting osteogenic differentiation of hMSCs, resulting in enhanced bone formation for bone tissue engineering.

The effect of electrical stimulation on lumbar spinal fusion in older patients: a randomized, controlled, multi-center trial: part 2: fusion rates

STUDY DESIGN

Randomized, controlled, multi-center trial.

OBJECTIVE

To investigate the effect of direct current (DC) electrical stimulation on fusion rates after lumbar spinal fusion in patients older than 60 years.

SUMMARY OF BACKGROUND DATA

Older patients have increased complication rates after spinal fusion surgery. Treatments which have the possibility of enhancing functional outcome and fusion rates without lengthening the procedure could prove beneficial. DC-stimulation of spinal fusion has proven effective in increasing fusion rates in younger and "high risk" patients, but little information exist on the effect in older patients.

METHODS

A randomized clinical trial comprising 5 orthopedic centers. The study included a total of 107 patients randomized to uninstrumented posterolateral lumbar spinal fusion with or without DC-stimulation. Fusion rate was assessed at 2 year follow-up using thin slice CT. Functional outcome was assessed using Dallas Pain Questionnaire and Low Back Pain Rating Scale pain index. RESULTS.: Available follow-up after 2 years was 89% (84 of 95 patients). Fusion rates were surprisingly low. DC-stimulation had no effect on fusion rate: 35% versus 36% in controls. Other factors associated with low fusion rates were female gender (32% vs. 42% in males, P = 0.050) and smoking (21% vs. 42% in nonsmokers, P = 0.079). Patients who achieved a solid fusion as determined by CT had superior functional outcome and pain scores at their latest follow-up.

CONCLUSION

Thin slice CT revealed very high nonunion rates after uninstrumented spinal fusion in older patients. DC-stimulation was not effective in increasing fusion rates in this patient population. The achievement of a solid fusion was associated with superior functional outcome.

Electrical stimulation therapies for spinal fusions: current concepts

Electrical stimulation therapies have been used for more than 30 years to enhance spinal fusions. Although their positive effects on spinal fusions have been widely reported, the mechanisms of action of the technologies were only recently identified. Three types of technologies are available clinically: direct current, capacitive coupling, and inductive coupling. The latter is the basis of pulsed electromagnetic fields and combined magnetic fields. This review summarizes the current concepts on the mechanisms of action, animal and clinical studies, and cost justification for the use of electrical stimulation for spinal fusions. Scientific studies support the validity of electrical stimulation treatments. The mechanisms of action of each of the three electrical stimulation therapies are different. New data demonstrates that the upregulation of several growth factors may be responsible for the clinical success seen with the use of such technologies.