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Cabrera JP, Agarwal N, Mesregah MK, Rodrigues-Pinto R, Wu Y, Martin C, Buser Z, Wang JC, Meisel HJ. Analysis of Complications in Multilevel Anterior Cervical Discectomy and Fusion Using Osteobiologics Other than Bone Morphogenetic Protein: A Systematic Review. Global Spine J 2024; 14:86S-93S. [PMID: 38421321 PMCID: PMC10913906 DOI: 10.1177/21925682231168083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The aim of this study is to analyze the complications related to multilevel anterior cervical discectomy and fusion (ACDF) using osteobiologics other than bone morphogenetic protein (BMP). METHODS A systematic review of the literature was conducted using PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases. The search to identify studies reporting complications in multilevel ACDF surgery using osteobiologics other than bone morphogenetic protein was performed in August 2020. The study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). RESULTS A total of 584 articles were found after searching the databases and removing duplicates. Next, screening was performed in a double reviewer process, and 153 eligible articles-with 4 retrospective studies-in full-text were selected; these met all inclusion criteria. A total of 197 patients received 3-level ACDF, while 72 patients received 4-level ACDF. Osteobiologics were used in all selected articles, allograft was used in 4 studies, autologous bone graft was utilized in 3 articles, and hydroxyapatite was used in 1 article. The main complications reported were dysphagia, adjacent segment disease, and pseudarthrosis. CONCLUSIONS Given the limited evidence, no conclusions on complications in multilevel ACDF using osteobiologics other than BMP could be made. However, descriptively, the most common complications found were dysphagia, adjacent segment disease, and pseudoarthrosis. Further prospective studies separately analyzing complications in multilevel ACDF by osteobiologics and a number of treated levels are needed.
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Affiliation(s)
- Juan P Cabrera
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, Concepción, Chile
- Faculty of Medicine, University of Concepción, Concepción, Chile
| | - Neha Agarwal
- Department of Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Mohamed Kamal Mesregah
- Department of Orthopaedic Surgery, Menoufia University Faculty of Medicine, Shebin El-Kom, Menoufia, Egypt
| | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM). Department of Orthopaedics, Centro Hospitalar Universitário de Santo António; ICBAS - School of Medical and Biomedical Sciences; Hospital CUF Trindade, Porto, Portugal
| | - Yabin Wu
- Research Department, AO Spine, AO Foundation, Davos, Switzerland
| | - Christopher Martin
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Zorica Buser
- Gerling Institute, Brooklyn, NY, USA
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hans Jörg Meisel
- Department of Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Germany
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Vadalà G, Ambrosio L, De Salvatore S, Riew DK, Yoon ST, Wang JC, Meisel HJ, Buser Z, Denaro V. The Role of Osteobiologics in Augmenting Spine Fusion in Unplated Anterior Cervical Discectomy and Fusion Compared to Plated Constructs: A Systematic Review and Meta-analysis. Global Spine J 2024; 14:43S-58S. [PMID: 38421326 PMCID: PMC10913900 DOI: 10.1177/21925682231156865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To compare clinical and radiographic outcomes as well as complications of unplated vs plated anterior cervical discectomy and fusion (ACDF) surgery considering the role of osteobiologics in single- and multi-level procedures. METHODS A systematic search of PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL, Cochrane and ClinicalTrials.gov databases was performed. Briefly, we sought to identify studies comparing unplated vs. plated ACDF for cervical degenerative disc disease reporting the use of osteobiologics in terms of clinical outcomes, radiographic fusion, and complications. Data on study population, follow-up time, type of cage and plate used, type of osteobiologic employed, number of levels treated, patient-reported outcomes (PROs), radiographic outcomes and complications were collected and compared. Relevant information was pooled for meta-analyses. RESULTS Thirty-eight studies met the inclusion criteria. No significant difference was found in terms of clinical outcomes between groups. Unplated ACDF was characterized by reduced blood loss, operation time and length of hospital stay. Fusion was achieved by the majority of patients in both groups, with no evidence of any specific contribution depending on the osteobiologics used. Dysphagia was more commonly associated with anterior plating, while cage subsidence prevailed in the unplated group. CONCLUSION Unplated and plated ACDF seem to provide similar outcomes irrespective of the osteobiologic used, with minor differences with doubtful clinical significance. However, the heterogeneity and high risk of bias affecting included studies markedly prevent significant conclusions.
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Affiliation(s)
- Gianluca Vadalà
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Luca Ambrosio
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Sergio De Salvatore
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Daniel K Riew
- Department of Orthopedic Surgery, Columbia University, New York, NY, USA
| | - S Tim Yoon
- Department of Orthopaedics, Emory University, Atlanta, GA, USA
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Hans Jörg Meisel
- Department of Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Zorica Buser
- Gerling Institute, Brooklyn, NY, USA
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Vincenzo Denaro
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Buser Z, Meisel HJ, Agarwal N, Wu Y, Jain A, van Hooff M, Alini M, Yoon ST, Wang JC, Santesso N. Development of an International AO Spine Guideline for the Use of Osteobiologics in Anterior Cervical Fusion and Decompression (AO-GO). Global Spine J 2024; 14:14S-23S. [PMID: 38421327 PMCID: PMC10913912 DOI: 10.1177/21925682231201601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
STUDY DESIGN Methodological study for guideline development. OBJECTIVE AO Spine Guideline for Using Osteobiologics (AO-GO) project for spine degenerative pathologies was an international, multidisciplinary collaborative initiative to identify and evaluate evidence on existing use of osteobiologics in Anterior Cervical Fusion and Decompression (ACDF). The aim was to formulate precisely defined, clinically relevant and internationally applicable guidelines ensuring evidence-based, safe and effective use of osteobiologics, considering regional preferences and cost-effectiveness. METHODS Guideline was completed in two phases: Phase 1- evidence synthesis; Phase 2- recommendation development based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. In Phase 1, key questions identified by a panel of experts were addressed in a series of systematic reviews of randomized and non-randomized studies. In Phase 2, the GRADE approach was used to formulate a series of recommendations, including expert panel discussions via web calls and face-to-face meetings. DISCUSSION AO-GO aims to bridge an important gap between evidence and use of osteobiologics in spine fusion surgeries. Owing to differences in osteobiologics preparation and functional characteristics, regulatory requirements for approval may vary, therefore it is highly likely that these products enter market without quality clinical trials. With a holistic approach the guideline aims to facilitate evidence-based, patient-oriented decision-making processes in clinical practice, thus stimulating further evidence-based studies regarding osteobiologics usage in spine surgeries. In Phase 3, the guideline will be disseminated and validated using prospectively collected clinical data in a separate effort of the AO Spine Knowledge Forum Degenerative in a global multicenter clinical study.
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Affiliation(s)
- Zorica Buser
- Department of Orthopedic Surgery, Grossman School of Medicine, NYU, NY, USA
| | | | - Neha Agarwal
- Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Yabin Wu
- AO Foundation, Davos, Switzerland
| | - Amit Jain
- Johns Hopkins Medicine, Baltimore, MD, USA
| | - Miranda van Hooff
- Department of Orthopaedic Surgery, Radboudumc, Nijmegen, Netherlands
| | - Mauro Alini
- AO Research Institute, AO Foundation, Davos, Switzerland
| | - Sangwook Tim Yoon
- Orthopedic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey C Wang
- Department of Orthopedic Surgery, Keck School of Medicine, USC, Los Angeles, CA, USA
| | - Nancy Santesso
- McMaster University Department of Health Research Methods Evidence and Impact, Hamilton, ON, Canada
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Germscheid N, Cheung JPY, Neva MH, Öner FC, Kwon BK, Valacco M, Awwad W, Sciubba DM, Lewis SJ, Rhines LD, Yoon ST, Alini M, Grad S, Fisher CG, Samartzis D. Research Practices and Needs Among Spine Surgeons Worldwide. Global Spine J 2023; 13:1894-1908. [PMID: 34870488 PMCID: PMC10556911 DOI: 10.1177/21925682211058158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Resource allocation to research activities is challenging and there is limited evidence to justify decisions. Members of AO Spine were surveyed to understand the research practices and needs of spine surgeons worldwide. METHODS An 84-item survey was distributed to the AO Spine community in September of 2020. Respondent demographics and insights regarding research registries, training and education, mentorship, grants and financial support, and future directions were collected. Responses were anonymous and compared among regions. RESULTS A total of 333 spine surgeons representing all geographic regions responded; 52.3% were affiliated with an academic/university hospital, 91.0% conducted clinical research, and 60.9% had 5+ years of research experience. There was heterogeneity among research practices and needs across regions. North American respondents had more research experience (P = .023), began conducting research early on (P < .001), had an undergraduate science degree (P < .001), and were more likely to have access to a research coordinator or support staff (P = .042) compared to other regions. While all regions expressed having the same challenges in conducting research, Latin America, and Middle East/Northern Africa respondents were less encouraged to do research (P < .001). Despite regional differences, there was global support for research registries and research training and education. CONCLUSION To advance spine care worldwide, spine societies should establish guidelines, conduct studies on pain management, and support predictive analytic modeling. Tailoring local/regional programs according to regional needs is advised. These results can assist spine societies in developing long-term research strategies and provide justified rationale to governments and funding agencies.
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Affiliation(s)
| | - Jason P. Y. Cheung
- Department of Orthopaedics & Traumatology, The University of Hong Kong, Hong Kong
| | - Marko H. Neva
- Department of Orthopaedic and Trauma Surgery, Tampere University Hospital, Tampere, Finland
| | - F. Cumhur Öner
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Brian K. Kwon
- Division of Spine, Department of Orthopaedics, University of British Columbia,Vancouver General Hospital Vancouver, BC, Canada
| | - Marcelo Valacco
- Department of Orthopaedics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Waleed Awwad
- Department of Orthopaedics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Daniel M. Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Northwell Health, Long Island Jewish Medical Center, North Shore University Hospital, Manhasset, NY, USA
| | - Stephen J. Lewis
- Department of Orthopaedics, University of Toronto, University Health Network, Toronto Western Hospital Toronto, ON, Canada
| | - Laurence D. Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S. Tim Yoon
- Department of Orthopaedics, Emory University, Atlanta, GA, USA
| | | | | | - Charles G. Fisher
- Division of Spine, Department of Orthopaedics, University of British Columbia,Vancouver General Hospital Vancouver, BC, Canada
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Darveau SC, Leary OP, Persad-Paisley EM, Shaaya EA, Oyelese AA, Fridley JS, Sampath P, Camara-Quintana JQ, Gokaslan ZL, Niu T. Existing clinical evidence on the use of cellular bone matrix grafts in spinal fusion: updated systematic review of the literature. Neurosurg Focus 2021; 50:E12. [PMID: 34062506 DOI: 10.3171/2021.3.focus2173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal fusion surgery is increasingly common; however, pseudarthrosis remains a common complication affecting as much as 15% of some patient populations. Currently, no clear consensus on the best bone graft materials to use exists. Recent advances have led to the development of cell-infused cellular bone matrices (CBMs), which contain living components such as mesenchymal stem cells (MSCs). Relatively few clinical outcome studies on the use of these grafts exist, although the number of such studies has increased in the last 5 years. In this study, the authors aimed to summarize and critically evaluate the existing clinical evidence on commercially available CBMs in spinal fusion and reported clinical outcomes. METHODS The authors performed a systematic search of the MEDLINE and PubMed electronic databases for peer-reviewed, English-language original articles (1970-2020) in which the articles' authors studied the clinical outcomes of CBMs in spinal fusion. The US National Library of Medicine electronic clinical trials database (www.ClinicalTrials.gov) was also searched for relevant ongoing clinical trials. RESULTS Twelve published studies of 6 different CBM products met inclusion criteria: 5 studies of Osteocel Plus/Osteocel (n = 354 unique patients), 3 of Trinity Evolution (n = 114), 2 of ViviGen (n = 171), 1 of map3 (n = 41), and 1 of VIA Graft (n = 75). All studies reported high radiographic fusion success rates (range 87%-100%) using these CBMs. However, this literature was overwhelmingly limited to single-center, noncomparative studies. Seven studies disclosed industry funding or conflicts of interest (COIs). There are 4 known trials of ViviGen (3 trials) and Bio4 (1 trial) that are ongoing. CONCLUSIONS CBMs are a promising technology with the potential of improving outcome after spinal fusion. However, while the number of studies conducted in humans has tripled since 2014, there is still insufficient evidence in the literature to recommend for or against CBMs relative to cheaper alternative materials. Comparative, multicenter trials and outcome registries free from industry COIs are indicated.
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Abedi A, Formanek B, Russell N, Vizesi F, Boden SD, Wang JC, Buser Z. Examination of the Role of Cells in Commercially Available Cellular Allografts in Spine Fusion: An in Vivo Animal Study. J Bone Joint Surg Am 2020; 102:e135. [PMID: 33079897 DOI: 10.2106/jbjs.20.00330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite the extensive use of cellular bone matrices (CBMs) in spine surgery, there is little evidence to support the contribution of cells within CBMs to bone formation. The objective of this study was to determine the contribution of cells to spinal fusion by direct comparisons among viable CBMs, devitalized CBMs, and cell-free demineralized bone matrix (DBM). METHODS Three commercially available grafts were tested: a CBM containing particulate DBM (CBM-particulate), a CBM containing DBM fibers (CBM-fiber), and a cell-free product with DBM fibers only (DBM-fiber). CBMs were used in viable states (CBM-particulatev and CBM-fiberv) and devitalized (lyophilized) states (CBM-particulated and CBM-fiberd), resulting in 5 groups. Viable cell counts and bone morphogenetic protein-2 (BMP-2) content on enzyme-linked immunosorbent assay (ELISA) within each graft material were measured. A single-level posterolateral lumbar fusion was performed on 45 athymic rats with 3 lots of each product implanted into 9 animals per group. After 6 weeks, fusion was assessed using manual palpation, micro-computed tomography (μ-CT), and histological analysis. RESULTS The 2 groups with viable cells were comparable with respect to cell counts, and pairwise comparisons showed no significant differences in BMP-2 content across the 5 groups. Manual palpation demonstrated fusion rates of 9 of 9 in the DBM-fiber specimens, 9 of 9 in the CBM-fiberd specimens, 8 of 9 in the CBM-fiberv specimens, and 0 of 9 in both CBM-particulate groups. The μ-CT maturity grade was significantly higher in the DBM-fiber group (2.78 ± 0.55) compared with the other groups (p < 0.0001), while none of the CBM-particulate samples demonstrated intertransverse fusion in qualitative assessments. The viable and devitalized samples in each CBM group were comparable with regard to fusion rates, bone volume fraction, μ-CT maturity grade, and histological features. CONCLUSIONS The cellular component of 2 commercially available CBMs yielded no additional benefits in terms of spinal fusion. Meanwhile, the groups with a fiber-based DBM demonstrated significantly higher fusion outcomes compared with the CBM groups with particulate DBM, indicating that the DBM component is probably the key determinant of fusion. CLINICAL RELEVANCE Data from the current study demonstrate that cells yielded no additional benefit in spinal fusion and emphasize the need for well-designed clinical studies on cellular graft materials.
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Affiliation(s)
- Aidin Abedi
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Blake Formanek
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | - Scott D Boden
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia
| | - Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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