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Matur AV, Plummer ZJ, Mejia-Munne JC, Tabbosha M, Virojanapa JN, Nasser R, Cheng JS. Noninvasive electrical stimulation as an adjunct to fusion procedures: a systematic review and meta-analysis. J Neurosurg Spine 2022; 37:137-148. [PMID: 35090134 DOI: 10.3171/2021.11.spine211098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Noninvasive electrical stimulation represents a distinct group of devices used to augment fusion rates. However, data regarding outcomes of noninvasive electrical stimulation have come from a small number of studies. The goal of this systematic review and meta-analysis was to determine outcomes of noninvasive electrical stimulation used as an adjunct to fusion procedures to improve rates of successful fusion. METHODS PubMed, Embase, and the Cochrane Clinical Trials database were searched according to search strategy and PRISMA guidelines. Random-effects meta-analyses of fusion rates with the three main modalities of noninvasive electrical stimulation, capacitively coupled stimulation (CCS), pulsed electromagnetic fields (PEMFs), and combined magnetic fields (CMFs), were conducted using R version 4.1.0 (The R Foundation for Statistical Computing). Both retrospective studies and clinical trials were included. Animal studies were excluded. Risk-of-bias analysis was performed with the Risk of Bias 2 (RoB 2) and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tools. RESULTS Searches of PubMed, Embase, and the Cochrane Clinical Trials database identified 8 articles with 1216 participants meeting criteria from 213 initial results. There was a high overall risk of bias identified for the majority of randomized studies. No meta-analysis could be performed for CCS as only 1 study was identified. Meta-analysis of 6 studies of fusion rates in PEMF did not find any difference between treatment and control groups (OR 1.89, 95% CI 0.36-9.80, p = 0.449). Meta-analysis of 2 studies of CMF found no difference in fusion rates between control and treatment groups (OR 0.90, 95% CI 0.07-11.93, p = 0.939). Subgroup analysis of PEMF was limited given the small number of studies and patients, although significantly increased fusion rates were seen in some subgroups. CONCLUSIONS This meta-analysis of clinical outcomes and fusion rates in noninvasive electrical stimulation compared to no stimulation did not identify any increases in fusion rates for any modality. A high degree of heterogeneity between studies was noted. Although subgroup analysis identified significant differences in fusion rates in certain groups, these findings were based on a small number of studies and further research is needed. This analysis does not support routine use of these devices to augment fusion rates, although the data are limited by a high risk of bias and a small number of available studies.
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Affiliation(s)
- Abhijith V Matur
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Zachary J Plummer
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Juan C Mejia-Munne
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Monir Tabbosha
- 2Department of Neurosurgery, The Christ Hospital, Cincinnati, Ohio
| | - Justin N Virojanapa
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Rani Nasser
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
| | - Joseph S Cheng
- 1Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati; and
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Li X, Zhou Q, Wu Y, Feng C, Yang X, Wang L, Xiao Y, Zhang K, Zhu X, Liu L, Song Y, Zhang X. Enhanced bone regenerative properties of calcium phosphate ceramic granules in rabbit posterolateral spinal fusion through a reduction of grain size. Bioact Mater 2021; 11:90-106. [PMID: 34938915 PMCID: PMC8665272 DOI: 10.1016/j.bioactmat.2021.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/02/2021] [Accepted: 10/03/2021] [Indexed: 02/05/2023] Open
Abstract
Osteoinductivity is a crucial factor to determine the success and efficiency of posterolateral spinal fusion (PLF) by employing calcium phosphate (Ca-P) bioceramics. In this study, three kinds of Ca-P ceramics with microscale to nanoscale gain size (BCP-control, BCP-micro and BCP-nano) were prepared and their physicochemical properties were characterized. BCP-nano had the spherical shape and nanoscale gain size, BCP-micro had the spherical shape and microscale gain size, and BCP-control (BAM®) had the irregular shape and microscale gain size. The obtained BCP-nano with specific nanotopography could well regulate in vitro protein adsorption and osteogenic differentiation of MC3T3 cells. In vivo rabbit PLF procedures further confirmed that nanotopography of BCP-nano might be responsible for the stronger bone regenerative ability comparing with BCP-micro and BCP-control. Collectedly, due to nanocrystal similarity with natural bone apatite, BCP-nano has excellent efficacy in guiding bone regeneration of PLF, and holds great potentials to become an alternative to standard bone grafts for future clinical applications. The nanocrystal of porous BCP ceramic spheres is similar to natural bone apatite. BCP nanoceramics is conducive to protein adsorption and osteogenic differentiation of MC3T3 cells. Osteoindutivity of BCP ceramics is a crucial factor to determine the sucess and efficiency of PLF. BCP ceramic spheres with nanotopography hold great potential in clinical PLF applications.
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Affiliation(s)
- Xiangfeng Li
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
| | - Quan Zhou
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yonghao Wu
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
| | - Cong Feng
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
| | - Xi Yang
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Linnan Wang
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yumei Xiao
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
| | - Kai Zhang
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
| | - Xiangdong Zhu
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
| | - Limin Liu
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yueming Song
- Department of Orthopaedic Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xingdong Zhang
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
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Wang J, Li Y, Xu T, Zhao J, Yuan C, Wen B. Reconstructing Nanohydroxyapatite Prosthesis Based on CT-Scanning Data and Its Application in Spinal Injury. J Biomed Nanotechnol 2021; 17:1745-1753. [PMID: 34688319 DOI: 10.1166/jbn.2021.3143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study investigated the nanohydroxyapatite (nHA) prosthesis application effect based on CT-scanning data in spinal injury. This study chose 26 spinal injury patients treated in our hospital from September 2017 to September 2018, who were randomly divided into two groups. nHA prosthesis based on CT-scanning data was implanted in the nHA group, whereas titanium mesh was implanted in the titanium mesh group. Consequently, osteoblasts were cultured to test the biological activity of nHA and titanium alloy. In cell tests, we found osteoblasts could better adhere to nHA, and proliferation and activity were higher when planted on nHA material. After surgical treatment, all patients' spinal symptoms (VAS score, JOA score, and Cobb angle) had improved and did not cause obvious inflammatory foreign body reactions. During a two-year follow-up, the fusion time and support settlement in the nHA group was lower, and the vertebral fusion rate and ASIA score were higher than those in the titanium mesh group. Thus, CT-scanning data could further improve the vertebral fusion rate in the nHA group. Consequentially, nHA prosthesis based on CT-scanning data is a better choice for spinal injury therapy.
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Affiliation(s)
- Jian Wang
- Departments of Radiology, Shanxi Provincial People's Hospital, Taiyuan 030012, Shanxi, PR China
| | - Ying Li
- Departments of Radiology, Shanxi Provincial People's Hospital, Taiyuan 030012, Shanxi, PR China
| | - Ting Xu
- Departments of Radiology, Shanxi Provincial People's Hospital, Taiyuan 030012, Shanxi, PR China
| | - Jie Zhao
- Departments of Radiology, Shanxi Provincial People's Hospital, Taiyuan 030012, Shanxi, PR China
| | - Cuihua Yuan
- Department of Orthopaedics, Affiliated Mindong Hospital of Fujian Medical University, Fuan 355000, Fujian, PR China
| | - Baojun Wen
- Department of Orthopaedics, Affiliated Mindong Hospital of Fujian Medical University, Fuan 355000, Fujian, PR China
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Cottrill E, Pennington Z, Ahmed AK, Lubelski D, Goodwin ML, Perdomo-Pantoja A, Westbroek EM, Theodore N, Witham T, Sciubba D. The effect of electrical stimulation therapies on spinal fusion: a cross-disciplinary systematic review and meta-analysis of the preclinical and clinical data. J Neurosurg Spine 2020; 32:106-126. [PMID: 31593923 DOI: 10.3171/2019.5.spine19465] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/17/2019] [Indexed: 11/06/2022]
Abstract
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.
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Hu T, Naidu M, Yang Z, Lam WM, Kumarsing RA, Ren X, Ng F, Wang M, Liu L, Tan KC, Kwok KT, Goodman SB, Goh JCH, Wong HK. Bone Regeneration by Controlled Release of Bone Morphogenetic Protein-2: A Rabbit Spinal Fusion Chamber Molecular Study. Tissue Eng Part A 2019; 25:1356-1368. [PMID: 30727849 DOI: 10.1089/ten.tea.2018.0281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been widely used in spine fusion surgery. However, high doses of rhBMP-2 delivered with absorbable collagen sponge (ACS) have led to inflammation-related adverse conditions. Polyelectrolyte complex (PEC) control release carrier can substantially reduce the rhBMP-2 dose and complication without compromising fusion. The molecular events underlying controlled release and their effects on spinal fusion remain unknown. In this study, a rabbit interbody spinal fusion chamber was designed to provide a controlled environment for profiling molecular events during the fusion process. Study groups included Group 1, PEC with 100 μg rhBMP-2; Group 2, ACS with 100 μg rhBMP-2; Group 3, ACS with 300 μg rhBMP-2; Group 4, autologous bone graft; and Group 5, empty chamber. Manual palpation, microcomputed tomography, and histological analysis showed that Group 1 and 3 achieved bone fusion, while the other groups showed no signs of fusion. Gene expression profiling showed robust induction of osteogenic markers in Groups 1 and 3, with modulated early induction of inflammatory genes in the PEC group. Delivery of 100 μg rhBMP-2 with ACS (Group 2) resulted in less upregulation of osteogenic genes, increased inflammatory genes expression, and upregulation of osteoclastic genes compared to Group 1. These results suggest that the manner of BMP-2 release at the interbody spinal defect site could dictate the balance of in-situ osteogenic and antiosteogenic activities, affecting fusion outcomes. The molecular evidence supports PEC for sustained release of BMP-2 for spinal interbody fusion, and the feasibility of employing this novel interbody spinal fusion chamber for future molecular studies. Impact Statement A radiolucent rabbit interbody spinal fusion chamber was developed to study the molecular events during spinal fusion process. The gene expression profile suggests that control release of bone morphogenetic protein-2 (BMP-2) resulted in lower inflammatory and osteoclastic activities, but elicited higher osteogenic activities, while burst release of BMP-2 resulted in predominantly inflammation and osteoclastogenesis with minimum osteogenic activity. This study provides the molecular evidence that underscores the regeneration outcomes from the two different BMP-2 delivery systems. This spinal fusion chamber could be used for future molecular studies to optimize carrier design for spinal fusion.
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Affiliation(s)
- Tao Hu
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Mathanapriya Naidu
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.,NUS Tissue Engineering Program (NUSTEP), National University of Singapore, Singapore, Singapore
| | - Zheng Yang
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.,NUS Tissue Engineering Program (NUSTEP), National University of Singapore, Singapore, Singapore
| | - Wing Moon Lam
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.,NUS Tissue Engineering Program (NUSTEP), National University of Singapore, Singapore, Singapore
| | - Ramruttun Amit Kumarsing
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Xiafei Ren
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Felly Ng
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Ming Wang
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Ling Liu
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Kim Cheng Tan
- School of Engineering, Temasek Polytechnic, Singapore, Singapore
| | - Kai Thong Kwok
- School of Engineering, Temasek Polytechnic, Singapore, Singapore
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, California
| | - James Cho-Hong Goh
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.,NUS Tissue Engineering Program (NUSTEP), National University of Singapore, Singapore, Singapore.,Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Singapore, Singapore
| | - Hee-Kit Wong
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.,NUS Tissue Engineering Program (NUSTEP), National University of Singapore, Singapore, Singapore
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