CHAPTER
3 John Louis-Ugbo
Bone Grafting and Spine Fusion
INTRODUCTION
Currently, more than 250,000 spine fusion procedures are carried
out each year in the United States, and nearly all of these require
bone graft material. Posterolateral lumbar fusion has been associ-
ated with the highest likelihood of failure (nonunion), ranging
from 5% to 44% of patients with single level fusion, and more
frequently when multiple levels are attempted.18 The successful
repair of such pseudarthroses is even more challenging, with fail-
ures occurring in 35% to 51% of revision attempts. Although
many biologic and biophysical factors are involved in obtaining a
successful arthrodesis, union depends in large part on proper
functioning of the bone graft material (Table 3.1).24
Traditionally, bone grafting with autologous cortical and can-
cellous bone harvested from the iliac crest is the standard against
which all other bone graft substitutes are judged. It is the only
material, which satisfies the fundamental requirements of bone
graft, but it has several drawbacks, which include the associated
morbidity of pain, infection and hematoma, fracture of the har-
vested site, nerve injury, and vascular injury. Several reports have
shown complication rates as high as 30%. Limited supply of
autograft is particularly problematic when performing long seg-
ment fusions for adult scoliosis. Because autograft is fully miner-
alized, the maximal osteoinductive benefit of its factors may not
be fully realized, and hence nonunion can still occur.3
A variety of alternative bone graft materials including alloge-
neic bone, demineralized bone matrix (DBM), calcium phos-
phatebased bone graft substitute, autologous bone marrow,
and growth factors have been developed to address the short-
comings of autograft (Table 3.1). Many of these materials, how-
ever, have not been subjected to intense scrutiny by the Food
and Drug Administration (FDA) and other regulatory agencies
because they are categorized as tissues rather than devices. The
surgeon using alternative bone graft materials must understand
the uses for which they have been proven effective, and not rely
on these materials to provide outcomes beyond those already
demonstrated. The surgeons choice of the proper graft should
also be based on what is required from the graft (structural or
bone-forming function, or both), the availability of the graft,
the recipient bed, and the cost.6
BIOLOGY OF SPINAL FUSION
Successful spinal fusion depends on a complex process influ-
enced by the type of graft material used and on many local
(biological), biomechanical, systemic, and external factors
LWBK836_Ch03_p41-48.indd 41
Scott D. Boden
affecting the healing response (Table 3.2). The precise molecu-
lar mechanisms that control bone graft incorporation in a spi-
nal fusion are not well understood owing to the fact that spinal
fusion healing is difficult to study in the clinical setting, and
there no reliable noninvasive techniques for assessing the suc-
cess or failure of an arthrodesis. Thus, an animal model is a
practical solution for studying individual factors involved in this
complex process. A reliable spinal fusion animal model should
mimic the incidence of nonunion and the surgical procedure
seen in humans. Also, it should allow for the rapid observation
of several subjects over a short period of time, and allow for the
valid extrapolation of data and results.19
The posterolateral lumbar intertransverse fusion process
has been described in rabbits using autogenous iliac crest as a
graft material.19 Formation of a fusion mass requires a charac-
teristic set of events at the microscopic level (Table 3.3)
Qualitative and quantitative analysis of histologic sections
revealed three distinct and reproducible temporal phases of
spinal fusion healing (inflammatory, reparative, and remodel-
ing). Osteoprogenitor cells must enter the fusion area by deco-
rtication of the host bone. Decortication of the posterolateral
spine elements (lateral facet, pars interarticularis, transverse pro-
cess) has been shown to be important to provide bone marrow,
vascularization, and osteoprogenitor cells to the fusion mass.15
The osteoprogenitor cells then differentiate into osteoblasts that
deposit new bone matrix. This is followed by remodeling of the
fusion mass by osteoclasts. For biosynthetic materials, new bone
formation occurs by creeping substitution, and the resorbing cell
is the foreign body giant cell and not the osteoclast.21
Advances in molecular biology have been used to investigate
the characteristic sequence of temporal and spatial gene
expression that leads to the formation of a fusion mass in postero-
lateral spinal fusion. A temporal and spatial pattern of osteoblast-
related gene expression was observed in an reverse transcriptase/
polymerase chain reaction analysis of RNA from the different
zones of the fusion mass (Table 3.4).15
It should be noted that the success of a bone graft material
in one species cannot be extrapolated to another species. For
example, a bone graft material used successfully as a bone graft
substitute in a rodent or canine fusion model may not function
successfully in primate or human fusion. It is also important to
keep in mind that a bone graft material will have different suc-
cess rates in different anatomic locations. The mechanism and
timing of bone healing may vary considerably depending on
the region of the spine under consideration. The cervical spine
is generally considered to be a more conducive environment
for fusion than is the lumbar spine. Cortical allografts have a
41
8/24/11 3:21:20 PM
 42 Section I General Considerations

Bone Graft and Graft Factors Affecting Spinal

TABLE 3.2
TABLE 3.1 Alternatives Used in Fusion Healing
Spinal Fusion
Bone graft or graft substitute related
Bone graft materials Graft source or type of graft (cortical or cancellous)
Autogenous bone grafts Quantity of graft
Cancellous Preparation or handling technique of graft material
Cortical Fusion bed related
Corticocancellous Preparation of fusion site
Vascularized and nonvascularized cortical Peculiarities of blood supply of soft tissues and fusion bed
Allogeneic bone grafts Irradiation of fusion site
Fresh Previous surgery
Fresh-frozen Local bone disease (infection, tumor, marrow infiltrative
Freeze-dried disease)
Cell-based autogenous grafts Bone homeostasis (age-related factors)
Unfractionated fresh bone marrow Biomechanics of the fusion mass
Mesenchymal stem cells Stability of the fusion segment
Genetically modified cells Loading and impaction of fusion segment
Differentiated osteoblasts and chondrocytes Location of fusion along the spine (cervical, thoracic,
Demineralized bone matrix (DBM) lumbosacral)
Bone graft osteoconductive matrices Number of levels fused
Mineralized bone matrices Efficacy of spinal immobilization (internal or external)
Ceramics (calcium phosphate, tricalcium phosphate, Specific type of fusion (ALIF, PLIF, posterolateral
calcium sulfate) intertransverse process)
Collagen Systemic factors
Composite grafts (e.g., Collagraft) Metabolic bone disease, for example, osteoporosis, diabetes
Bioactive glass mellitus
Synthetic polymers Hormonal (growth hormone, anabolic hormones)
Growth factors and cytokines Nutritional status
Transforming growth factor-beta Drugs (NSAIDs, dexamethasone, chemotherapeutic agents,
Bone morphogenetic proteins biphosphonates, corticosteroids)
Alpha and beta fibroblast growth factors Infections
Platelet-derived growth factors Cigarette smoking and nicotine
Insulin-like growth factors Severe trauma
Growth differentiation factors
Gene-based therapy ALIF, anterior lumbar interbody fusion; NSAID, nonsteroidal
Ex vivo and in vivo anti-inflammatory drug; PLIF, posterior lumbar interbody fusion.

high success rate in anterior cervical discectomy and fusion
procedures, achieving fusion rates of 90% or higher.6,21 Similar
grafts used in anterior lumbar fusions have not been as success-
ful, with fusion rates of approximately 60% reported in the lit-
erature. The anterior spine, typically loaded in compression,
may be a better environment for fusion than does the posterior
spine, which is under relative tension. An anterior fusion bed
between two decorticated vertebral bodies contains a very large
cancellous surface area for healing. In contrast, the posterior
intertransverse region has a relatively smaller surface area. If a
laminectomy is not performed, the posterior interlaminar area
provides a much larger surface area for fusion than does the
intertransverse region alone. While the anterior fusion bed is
typically not surrounded by paraspinal musculature, extensor
muscles envelop both the posterolateral and posterior fusion
beds, which may impair healing of the fusion mass. Also the
stability of the spinal fusion construct and contact between host
bone and the graft determines the incidence and speed of
union between bone grafts and the adjacent host bone more
than the characteristics of the grafts themselves.9,21
SELECTING A GRAFT MATERIAL
A bone graft material is any implanted material that, alone
or in combination with other materials, promotes a bone
healing response by providing osteogenic, osteoconductive,
or osteoinductive activity at a local site (Table 3.5).21 Osteogenic
graft materials contain viable cells that are capable of forming
bone (i.e., differentiated osteogenic precursor cells) or have
the potential to differentiate into bone-forming cells (induc-
ible osteogenic precursor cells). Surface cells on both cortical
and cancellous grafts that are properly handled can survive
and produce new bone. This potential to produce bone is
characteristic only of fresh autogenous bone and marrow
cells.9
Osteoinduction is the process by which some graft-derived fac-
tors stimulate recruitment from the surrounding bed of unde-
termined mesenchymal-type cells, which then differentiate into
cartilage-forming and bone-forming cells. The osteoinductivity
of mineralized grafts is minimal or absent, but the osteoinduc-
tive capacity of DBM has been well characterized. Bone matrix
contains several bone-promoting cytokines, including bone
morphogenetic proteins (BMPs), which are capable of inducing
or influencing the differentiation of mesenchymal cells into
bone-forming cells. In addition to DBM and the above growth
factors, autogenous and allograft bones are known to possess
osteoinductive properties.18
A purely osteoconductive graft material transfers neither osteo-
genic cells nor inductive stimuli, but it acts as a nonviable scaffold
or trellis that supports the healing process. Osteoconduction
is often determined by the structure of the graft, the

LWBK836_Ch03_p41-48.indd 42 8/24/11 3:21:20 PM


Stages of Spine Fusion
TABLE 3.3 Healing (Histologic Stages
of Spinal Fusion)
Stage 1 early No solid fusions observed. Hematoma
(inflammatory) surrounds the graft material. Influx of
phase weeks 13 inflammatory cells.
Neovascularization and formation of
fibrovascular stroma. Recruitment of
pluripotential cells from marrow cavity
and transplanted autograft bone.
Primary membranous ossification and
osteoid seams appear over transverse
process (corticocancellous ratio 1.4).
Minimal endochondral ossification
seen between graft fragments.
Stage 2 middle Solidification of fusion and
(reparative) phase remodeling occurs over transverse
weeks 4 and 5 processes.
Increased revascularization, resorption
of necrotic tissue and graft fragments,
and differentiation of osteoblastic and
chondroblastic cells.
Membranous bone extends toward
central zone of fusion mass.
Cartilaginous interface zone centrally.
Endochondral ossification unites
upper and lower halves of the fusion.
Stage 3 late Solid fusion. No cartilage present.
(remodeling) Corticocancellous ratio 1.
phase weeks 610 Remodeling proceeds.
Extension of trabecular bone from
peripheral cortical rim toward center
of fusion.
Increased secondary spongiosa and
bone marrow formation.
Progressive resorption of graft
material in the center of fusion mass.
Data taken from Boden SD, Titus L, Hair G, et al. 1998 Volvo
Award in Basic Sciences: lumbar spine fusion by local gene
therapy with a cDNA encoding a novel osteoinductive protein
(LMP-1). Spine 1998;23:24862492.
vascular supply from the surrounding soft tissue, and the
mechanical environment of the graft and surrounding structures.
Osteoconductive materials include autogenous and allograft
bone, bone matrix, collagen, and ceramics.18
An osteopromotive material possesses the ability to accelerate
or improve bone healing when it is already taking place, but it
is incapable of initiating and mediating bone formation from
scratch in an ectopic location (e.g., not osteoinductive). Some
examples might be parathyroid hormone, statins, vascular
endothelial growth factor, basic fibroblast growth factor, etc.
This term is not yet universally accepted, but the number of
agents in this category is increasing and should be distinguished
from osteoinductive proteins.
Currently available bone graft substitutes can be used as a
(1) bone graft extenderthat is, a material that allows the use of
less autogenous bone graft with the same end result, or one
that allows a given amount of autogenous bone to be stretched
over a greater area with the same success rate; (2) bone graft
enhancerthat is, a substance that, when added to autogenous
LWBK836_Ch03_p41-48.indd 43
Chapter 3 Bone Grafting and Spine Fusion 43
BMP Gene Expression and
TABLE 3.4 Bone Protein Expression
During Spine Fusion Healing
Stage 1 early Characterized by increased gene
(inflammatory) expression in outer zones.
phase weeks 13 Increased expression of BMP-6 and
BMP-4 mRNA in week 1.
Increased alkaline phosphatase
levels.
Increased type I and type II collagen.
Increased osteopontin and
osteonectin mRNA.
Peak expression of BMP-2 mRNA
occurs in week 3.
Stage 2 middle Characterized by increased activity
(reparative) phase in central zone.
weeks 4 and 5 Peak expression of osteopontin,
osteonectin, and osteocalcin.
Second increase in BMP-6 mRNA
level in central zone.
Increased BMP-4 and BMP-2 mRNA
in central zone.
Stage 3 late Return of gene expression to
(remodeling) baseline levels.
phase weeks 610 Persistent BMP-6 mRNA expression.
Data taken from Morone MA, Boden SD, Martin G, Hair G, Titus
L. Gene expression during autograft lumbar spine fusion and the
effect of bone morphogenetic protein-2. Clin Orthop 1998;351:
252265.
bone graft, increases the successful healing rate above that
reported for autograft alone (70% to 90%); or (3) bone graft
substitute that is, a material that may be used entirely in place
of autogenous bone graft to achieve the same or a better fusion
success rate.18
TABLE 3.5 Properties of Graft Materials
Properties Description
Osteogenic Contain cells capable of directly
forming bone
Osteoinductive Ability to stimulate and support
mitogenesis of undifferentiated
perivascular cells to form
osteoprogenitor
Osteoconductive The ability to support growth of bone
over its surface
Osteopromotive Ability to accelerate or improve bone
healing when it is already taking
place but incapable of initiating
and mediating bone formation
from scratch in an ectopic location.
Osteointegrative The ability to chemically bond to
the surface of bone without an
intervening layer of fibrous tissue
Biocompatible Elicit minimal or no immunologic
reaction
Biomechanically stable Allow loading and impaction early to
induce bone formation
Bioresorbable Undergo remodeling
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 44 Section I General Considerations
CURRENT BONE GRAFT ALTERNATIVES
FOR SPINAL FUSION
AUTOGENOUS BONE GRAFT IN SPINAL FUSION
Autogenous bone graft is the most successful bone graft or the
gold standard for grafting material in spinal fusion. It has
osteogenic properties (numerous differentiated and undeter-
mined stromal cells within the cavity lining), osteoinductive
properties (noncollagenous bone matrix proteins, including
growth factors), and osteoconductive properties (hydroxyapa-
tite [HA] and collagen). Also, it is histocompatible, osteointe-
grative, and does not pose the risk of disease transmission or
immune rejection. Drawbacks in the use autogenous bone graft
include paucity of supply, donor site morbidity, and periopera-
tive complications. Commonly used sites for autograft harvest
include the posterior iliac crest, anterior iliac crest, fibula, and,
rarely, proximal tibia, which are used in decreasing order of
frequency.6,18 Available autologous grafts include cancellous
chips; corticocancellous strips or morcellized fragments; corti-
cal (strut); and vascularized or nonvascularized struts.
Cancellous bone grafts contain a greater proportion of osteo-
conductive, osteoinductive, and osteogenic properties com-
pared with cortical autograft. It does not provide substantial
structural support. Some osteoblasts and osteocytes of the graft
survive and are capable of producing early bone. Cancellous
bone permits more rapid ingrowth of new blood vessels, which
allow for the influx of osteoblast precursors. Osteoinductive
factors released from the graft during the resorptive process as
well as cytokines released during the inflammatory phase may
also contribute to healing of the graft.21
Corticocancellous bone graft is the most common graft material
used in a clinical setting for spinal fusion. The cancellous com-
ponent provides greater osteogenic potential because of the
large number of surviving cells in marrow, a trabecular environ-
ment favoring vascular ingrowth, and the accessibility of
osteoinductive proteins. The cortical component provides
mechanical strength and is useful for structural support.
Cortical (strut) grafts are commonly used in situations where
structural support is needed early. They are structurally dense,
more compact than cancellous bone, and are resistant to vascu-
lar ingrowth and remodeling. This slows the incorporation of
the graft into the host spine. Despite their initial strength, corti-
cal grafts still must be supported by internal or external fixa-
tion to protect them from fracture while they hypertrophy in
response to mechanical loading. Cortical bone has less osteo-
genic potential with fewer than 5% of cortical bone cells surviv-
ing transplantation. The graft loses about a third of its initial
strength before consolidation begins. Cortical grafts are almost
never completely remodeled and contain a combination of
nonviable and living bone.6,18,21
Free vascularized and nonvascularized cortical grafts can be har-
vested from the fibula, ribs, or iliac crest. The vascularized graft
remains viable through its arterial supply and does not undergo
significant cell necrosis. It unites directly with the host site with-
out needing to be revascularized and replaced by creeping sub-
stitution. The length of the soft tissue pedicle may greatly limit
the usefulness of the graft. It is preferred in situations in which
avascular graft healing is poor, such as in areas of radiation-
induced fibrosis or when radiation and/or chemotherapy is to
be given preoperatively. Vascularized bone grafts are superior
to nonvascularized bone grafts in the initial period; however,
LWBK836_Ch03_p41-48.indd 44
after the initial 6 months no difference in biomechanical
strength is observed. Vascularized bone grafts are associated
with increased donor site morbidity, increased surgical time,
and a greater utilization of resources.21
The use of autograft in uninstrumented posterolateral lum-
bar fusion has been associated with the highest likelihood of
failure (pseudoarthrosis ranging from 5% to 44%). The addi-
tion of spinal instrumentation has reduced this rate of non-
union; however, the incidence still remains at 10% to 15%.26
Bone Marrow Use in Spinal Fusion
Bone marrow is a form of autograft; it contains osteoprogenitor
cells and has been used clinically as an adjunct to some graft
materials for spinal fusion. The number of the stem cells in the
marrow is limited. Marrow contains stem cells of the order of 1
per 50,000 nucleated cells in young individuals and 1 per 2 mil-
lion in the elderly.8 The number of osteoprogenitor cells
obtained from an aspirate and delivered to a fusion site can be
increased by centrifugation or by passage through allograft
bone matrix. Clinical use of bone marrow in spinal fusion is
often done in combination with autograft and allograft bone,
or in composites of ceramic or other bone extenders. The use
of bone marrow in spinal fusion stand-alone or with ceramics
has produced quite variable results.12 Cons of bone marrow use
include the added morbidity of bone marrow harvest, difficulty
in obtaining enough bone marrow with the requisite number
of osteoprogenitor cells, and aging or disease that is accompa-
nied by a reduction in healthy bone marrow cells, especially the
osteogenic precursors, which represent approximately 0.001%
of the nucleated cells in healthy adult marrow. Therefore, tech-
niques capable of selecting, expanding, and administering the
progenitor cell fraction would be of great clinical benefit.12
MESENCHYMAL STEM CELLS OR
MSCS IN SPINAL FUSION
Mesenchymal stem cells (MSCs) have the capacity for extensive
replication and can differentiate into several tissue types includ-
ing bone, cartilage, tendon, muscle, fat, and marrow stroma.
Using culture systems, MSCs from a small marrow aspirate can
be expanded more than 1 billion fold. This expansion makes
MSCs a clinically useful source of osteoprogenitor cells for
fusion procedures. Recent animal studies have demonstrated the
efficacy of these cultured cells in the induction of spinal fusion.14
Also, the addition of growth factors has been shown to enhance
the bone-forming properties of these cells; however, a very high
(50 million) number of MSCs per side/level were needed to
achieve a posterolateral spine fusion in rabbits and this is many
more progenitor cells than are available with any of the current
strategies available for use in humans. MSCs are often not very
responsive to BMPs and thus just the presence of MSCs without
and osteogenic stimulus may not be enough to form bone.14
ALLOGRAFT
Allograft is the most widely used graft alternative, and it is available
as fresh, frozen, and freeze dried. Processing of allograft often
affects the properties of the graft including the osteoinductivity,
osteoconductivity, and immunogenicity of the material. These
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materials are highly osteoconductive, weakly osteoinductive (if
demineralized), and not osteogenic because the cells do not sur-
vive transplantation. It is available in many preparations: DBM,
morselized and cancellous chips, corticocancellous and cortical
grafts, and osteochondral and whole-bone segments.6,20,21
Fresh allografts are generally not used because of greater immu-
nogenicity, inflammatory response, and the possibility of disease
transmission. Fresh-frozen allograft: The freezing process dimin-
ishes immunogenicity compared with fresh allograft and preserves
mechanical properties better than freeze drying. Fresh-frozen
allograft must be stored at 70C. Freeze-dried allograft: These grafts
are lyophilized (water removed through vacuum processing) and
sterilized chemically or by irradiation. These processes produce
the least immunogenic allograft but also cause it to be structurally
weaker. Freeze-dried allografts can be stored at room tempera-
ture. The mechanical strength of freeze-dried implants is reduced
by close to 50% compared with frozen grafts. Cancellous bone
seems to be less affected by sterilization. Heating and autoclaving
destroys the matrix proteins and is not commonly used.
Pros of allograft use include its availability in unlimited quan-
tities, in various formulations, and avoidance of donor site mor-
bidity associated with autograft. Depending on the application,
structural and nonstructural allografts can be used. Structural
allografts are particularly useful in interbody fusions and recon-
struction of corpectomy defects. Composites can be created by
filling cortical shafts (e.g., humerus, femur) with local bone,
iliac autograft, or other bone graft material, such as DBM.
Nonstructural allografts may be crushed and used to augment
cancellous autograft. It is an excellent graft substitute especially
in the anterior cervical spine fusion.
Cons of allograft use: The risk of disease transmission, espe-
cially human immunodeficiency virus (HIV) and hepatitis
viruses B and C, is a major concern. However, the only known
cases of disease transmission in allografts to date have involved
frozen, unprocessed grafts. A decision to use allograft for spinal
surgery depends on the underlying disease condition, the
region of spine where the graft is placed, the surgical goals, the
types of graft available, the state of the host bed, and the prefer-
ences of the patient and surgeon. Fresh allografts elicit the
greatest immune reaction and rejection, and it has a greater
potential for disease transfer. Allograft incorporation is often
limited by fractures of the graft, infection, and nonunion.
Structural allograft bone has a minimal ability to remodel and
depends on internal fixation devices for clinical function.16,20
The clinical use of allograft with or without autograft for
posterior lumbar fusion in adults has produced mixed results.
Allografts are used most successfully as structural grafts for
anterior interbody fusions. The most favorable data for allograft
use in human spinal fusion have been reported for interbody
fusion in the cervical spine. The most suitable indication for
nonstructural (morcellized) allografts appears to be in the ado-
lescent patient undergoing scoliosis correction and fusion.
Allograft has shown good success in instrumented posterior spi-
nal fusion for adolescent idiopathic scoliosis, although its use
is controversial. In the adult posterolateral spine, however,
allograft has not performed well as an autograft substitute.11
DEMINERALIZED BONE MATRIX
DBM is a less immunogenic form of allograft bone, which is
produced by the acid decalcification of cortical bone. DBM
LWBK836_Ch03_p41-48.indd 45
Chapter 3 Bone Grafting and Spine Fusion 45
consists of collagens, growth factors, and noncollagenous
proteins. The osteoinductive capacity of DBM was first described
by Urist. The demineralization of bone allows these osteoin-
ductive growth factors contained within the matrix to become
locally accessible. DBM provides no structural strength, and its
primary use should be in a structurally stable environment.
Although DBM primarily functions as an osteoinductive agent,
the osteoconductivity is also important and this can vary
depending on the final product formulation.13 The absolute
amount of osteoinductive growth factors in DBM is extremely
low, due to the naturally low amounts in bone matrix. The
American Association of Tissue Banks and the U.S. FDA require
each package of DBM to be obtained from a single human
donor, thus pooling of tissue from multiple donors is not per-
mitted. The processing of DBM and its combination with a car-
rier can have negative effects on its osteoinductive capacity.
Storage of bone at room temperature for more than 24 hours
before processing, or sterilization by ethylene oxide under cer-
tain conditions and 2.5 Mrad of gamma irradiation all substan-
tially reduce osteoinductive and osteoconductive capacity of
DBM. DBM is available from many commercial sources as a
freeze-dried powder, as crushed granules or chips, and as a gel
or paste or wafer. The osteoinductivity is highly variable between
different processing methods and formulations so generaliza-
tions about DBM are not possible.6
Experimental studies using some brands of DBM alone or in
combination with autogenous bone marrow, autograft, or graft
substitutes have reported spinal fusion rates comparable to
autograft alone in rats, rabbits, and dogs. Newer formulations
containing fibers (rather than particles) of DBM have demon-
strated improved osteoconductivity and better fusion rates in
animal studies. Although the results in the animal studies are
encouraging, care must be taken when extrapolating results
from small animal models to humans because of the increased
difficulty of initiating osteoinduction in primates. One disad-
vantage of DBM is the theoretical potential to transmit infec-
tious disease; however, this risk is exceedingly low with modern
viral inactivation and tissue processing protocols. Grafton DBM
(Osteotech, Eatontown, NJ) was the original commercially
available brand and has been the most studied in animals and
human studies. DBM is typically used in the anterior spine in
conjunction with a structural autograft, allograft, or cage. An
early report on the use of Grafton DBM in conjunction with
freeze-dried allograft for nonplated anterior cervical discec-
tomy and fusion demonstrated higher pseudoarthrosis rates for
the DBM patients than for patients who received autograft iliac
bone (46% vs. 26%). Use of Grafton DBM gel in the posterolat-
eral spine has been shown in one human study to be an effec-
tive bone graft extender, allowing the use of less autologous
bone with no difference in fusion rates.2,6,13
BIOSYNTHETIC GRAFT MATERIALS
CERAMICS
Ceramics are inorganic, ionically bonded materials that mimic
the mineral phase of bone. Examples include HA, tricalcium
phosphate (TCP), calcium sulfate cements, and coralline HA.
Ceramics have been used solely as osteoconductive bone graft
substitutes. The calcium phosphates, particularly HA and TCP,
or a combination of the two, are the most commonly used
8/24/11 3:21:20 PM
 46 Section I General Considerations
ceramics in orthopedic surgery. Because of their architecture
and pore structure, ceramics used as osteoconductive agents
create an environment for osteogenic cell migration, adhesion,
differentiation, and proliferation. Ceramics alone are neither
osteoinductive nor osteogenic. They tend to function best as
bone graft extenders or carriers for an osteoinductive bone
growth factor rather than as a stand-alone bone graft substitute
in nonstructural clinical applications.4
Advantages of ceramics include the following: they are bio-
degradable, biocompatible, pose little or no risk for disease
transmission, provide structural support, are available in unlim-
ited quantities, and have no added risk of donor site complica-
tions that accompany the use of autograft. Optimal remodeling
of the fusion mass depends on the biodegradability of the
ceramic. Potential disadvantages in the use of ceramics include
incitement of sterile inflammatory reaction, difficulty assessing
fusion because of the radiopacity of ceramics (even when using
computed tomography [CT]), delay in remodeling or incorpo-
ration into bone, and the fact that they are structurally brittle
and prone to crack or fracture.6,12
Calcium phosphate composites differ with regard to their
bioresorbability properties. The optimal osteoconductive pore
size for ceramics appears to be between 150 and 500 m. The
chemical composition, porosity, and surface area of the ceramic
affect its rate of bioresorption. TCP is a porous ceramic that
undergoes partial conversion to HA once it is implanted into
the body. TCP is more porous and is resorbed 10 to 20 times
faster than HA, making it mechanically weaker in compression.
After conversion, the HA is resorbed slowly and, therefore,
large segments of HA remain in place for years. Because TCP
has an unpredictable biodegradation profile, it has not been
popular as a bone graft substitute.12
Coralline HA is processed by a hydrothermal exchange
method that converts the coral calcium phosphate to crystal-
line HA with pore diameters between 200 and 500 m and has
a structure very similar to that of human trabecular bone. It
is extremely biocompatible and has yielded promising results
when used to replace or augment autogenous bone graft or as
part of a composite with an osteoinductive protein. Calcium
sulfate (plaster of Paris) has also been used as a synthetic graft
material in bone voids, although with limited documented suc-
cess in posterolateral spine fusion. Another ceramic bone graft
substitute currently in clinical use is a calciumcollagen graft
material. This osteoconductive composite of HA, TCP, and type
I and III collagen is mixed with autologous bone marrow to
provide osteoprogenitor cells and other growth factors. The
composite does not provide structural support, but it serves as
an effective bone graft substitute or bone graft expander to
augment acute fracture healing.12
The best human clinical experience with ceramic materials
in spinal fusion exists for anterior interbody fusion of the
cervical spine. Successful fusion rates in the anterior and poste-
rior cervical spine approach 100% in most series reported.
Synthetic ceramics, however, have been reported to function
comparable to autograft in instrumented posterior fusion for
adolescent idiopathic scoliosis.17 It is important to note that
adolescent patients tend to fuse quite readily compared with
adult patients with degenerative conditions, in whom fusion is
more difficult to achieve. Also, the thoracic posterior (inter-
laminar) area is far less challenging than the lumbar posterolat-
eral environment for generating new bone. With adult patients,
successful use of ceramics in the posterior lumbar spine has
LWBK836_Ch03_p41-48.indd 46
been reported in conjunction with local autograft during poste-
rior lumbar interbody fusion or when ceramics are combined
with autograft and DBM in instrumented posterolateral fusions.
Neither study, however, included a control group without
the ceramic. Thus, the true contribution of the ceramic to the
fusion cannot be assessed. Using a ceramic as a stand-alone
bone graft in the adult posterolateral lumbar spine is not rec-
ommended. The ultimate role of ceramic implants in spinal
fusion procedures remains to be defined.17,22
COMPOSITE GRAFTS
Composite grafts incorporate all the favorable properties of the
various materials and have been used with success clinically in
spinal fusion procedures. Composite grafts offer potential for
the design of bone graft substitutes that are specific for the
structural and biologic demands of the host, and it is likely that
very different composites will be used for anterior interbody
arthrodesis than for long-instrumented posterior fusion. Ceramic
composites, which consist of the osteoconductive ceramic com-
bined with an osteoinductive agent such as DBM, bone marrow,
extracted bone matrix proteins, or osteogenic growth factors
such as recombinant BMP, have shown promising results as
graft extenders in animal studies. The ceramic implant main-
tains soft-tissue position and provides an osteoconductive
matrix, and the proteins stimulate osteoinduction.4,6
OSTEOINDUCTIVE GROWTH FACTORS
Urist (1965) discovered an osteoinductive agent within bone,
which he named BMP. BMPs are osteoinductive factors capable of
promoting differentiation of osteoprogenitor cells into the osteo-
blastic lineage, thus promoting bone fusion. These factors are not
mitogenic, and therefore are not growth factors but differentia-
tion factors. Although other growth factors, including transform-
ing growth factor-beta (TGF-b), fibroblast growth factor (FGF),
insulin-like growth factor (IGF), and platelet-derived growth fac-
tor (PDGF) are involved in bone formation, only BMPs are capa-
ble of initiating the entire bone formation process on their own.
BMPs can also induce cartilage formation under certain condi-
tions and are involved in a number of normal physiologic roles,
including limb development and fracture healing.25
Bone Morphogenetic Proteins
Semipurified human BMP extracts prepared in the laboratory of
Marshall Urist, and a commercially available extract of a bovine
BMP mixture known as NeOsteo (Sulzer Orthopedics Biologics,
Denver, CO) have been used in the treatment of nonunions and
spinal fusion. The bovine extract has shown successful osteoinduc-
tion in ectopic locations in rats and nonhuman primates. Also it
has been used as a bone graft substitute for posterolateral spinal
fusion in rabbits and nonhuman primates. Although proven effec-
tive, at present no mixtures or extracts of BMPs are still being
actively developed commercially. At present, highly pure single
BMPs, such as recombinant human (rh) BMP-2 and BMP-7 are
produced through recombinant DNA synthesis technology and
are the two BMPs most readily available to clinicians.6,25
Mechanism of Action of BMPs
BMPs are known to bind to specific receptors on a variety of
different cell types, including MSCs, osteoblasts, and osteoclasts.
8/24/11 3:21:20 PM

These receptors subsequently activate second messenger sys-
tems within the cytoplasm, which in turn affect the expression
of BMP response genes in the nucleus. Within the cell, a set of
signal-modulating proteins called SMADs then further modu-
late the BMP signal. These secondary messengers comprise a
family of small signal transducing molecules within the intracel-
lular domain that can be either negative or positive modulators
of a BMP signal. Subsequently, BMP receptor stimulation leads,
either directly or indirectly, to cellular chemotaxis, prolifera-
tion, and differentiation. With lower concentrations and dimin-
ished oxygen tension, BMPs promote the differentiation of
MSCs into chondrocytes, which lay down a cartilaginous matrix.
This matrix then calcifies, is invaded by blood vessels, and
remodels into mature bone, a process termed endochondral
bone formation. At higher concentrations when there is better
tissue oxygen tension, BMPs can induce direct bone formation,
recapitulating normal intramembranous bone formation.
There is a sizeable gap between the physiologic concentration
of BMP found in bone and the pharmacologic concentration
required to achieve spinal fusion in animals and humans. Sev-
eral potential explanations for this discrepancy are considered.
Much of the rhBMP diffuses away from the site of implantation
and is rapidly degraded. Natural inhibitors of BMP activity,
such as chordin and noggin, exist in vivo and limit the activity of
BMP to regions that are physiologically usefulthese inhibi-
tors may need to be overcome for a spinal fusion to occur.
BMPs naturally exist as homodimers, which consist of two iden-
tical subunits and heterodimers that are made up of two differ-
ent subunits. Heterodimeric BMP-2/BMP-7 has been shown to
be at least 20 times more potent than homodimers in induction
of osteoblast differentiation in vivo and in vitro. Current recom-
binant formulations contain only homodimers because of dif-
ficulty in preparation of heterodimers.10,25
RECOMBINANT HUMAN BONE
MORPHOGENETIC PROTEINS
There is adequate evidence that rhBMP-2 when used in phar-
macologic doses in various animal models are efficacious and
superior to autogenous grafts in achieving spinal fusion.
RhBMP-2 has been used extensively for in-vitro and in-vivo
safety and efficacy studies. Recent results reported in nonhu-
man primates and in pilot human clinical trials have been very
encouraging. There is a dose-dependent increase in the amount
and quality of bone formed when rhBMP-2 is used in a nonhu-
man primate posterolateral spinal fusion using a ceramic car-
rier. RhBMP-2, when added to autograft, significantly increased
the volume and the maturity of the resulting fusion mass.
RhBMP-2 has been shown to overcome the inhibitory effect of
nicotine, chemotherapy, and a nonsteroidal anti-inflammatory
drug in preclinical and clinical studies. Several animal studies
evaluating the efficacy of various carrier molecules have been
performed. Inorganic carriers of BMP that have demonstrated
efficacy in promoting spinal arthrodesis include true bone
ceramic (TBC) derived from sintered bovine bone, and
HA-TCP. Organic carriers include polylactic acid (PLA) poly-
mers, collagen and noncollagenous protein carriers, mineral-
ized bone matrix or DBM, and autograft.4,6,12
Based on the highly promising results of the preclinical
investigations, several pilot human trials were initiated. Recently
published studies examining the osteoinductive capacity of
rhBMP-2 for a human spinal fusion application have shown
LWBK836_Ch03_p41-48.indd 47
Chapter 3 Bone Grafting and Spine Fusion 47
definitive evidence of osteoinduction in humans. The FDA has
approved the use of rhBMP-2 on an absorbable collagen sponge
(InFuse Bone Graft, Medtronic, Memphis, TN) as an autograft
substitute in anterior lumbar interbody fusions (ALIFs) when
placed inside cylindrical fusion cages. The use of rhBMP-2 in
physician-directed (off-label) applications has demonstrated
the potential for local side effects including edema, sterile fluid
collections, local bone extension, and transient local bone
resorption. BMP-2 when used in higher than recommended
doses or overstuffed into defects has been associated with cervi-
cal edema after anterior cervical fusion and graft subsidence
due to end plate resorption after ALIF. These issues highlight
the importance of limiting the use of potent biologics in
untested healing environments until the dose and carrier
(release kinetics) can be safely optimized.6,7,12
The FDA has approved the use of rhBMP-7 (OP-1, Stryker
Biologics, Hopkinton, MA) for humanitarian device exemption
as an autograft alternative in compromised patients requiring
revision posterolateral lumbar fusion, for which autologous bone
and bone marrow harvest are not feasible or are not expected to
promote fusion. Pilot studies done to determine the efficacy of
rhBMP-7 in human spinal fusion procedures have been less
encouraging. A recent multicenter clinical trial to demonstrate
the safety and efficacy of OP-1 Putty as a replacement for autog-
enous bone graft in the posterolateral fusion environment with a
minimum of 4-year follow-up showed that OP-1 Putty was able to
achieve osteoinduction leading to a radiographically solid fusion
in the absence of autogenous iliac crest bone graft.23 The clinical
and preclinical results for bone formation with rhBMP-7 have
not been as consistent as those seen with rhBMP-2. Possible
explanations include differences in dose/carrier as well as differ-
ences in the relative potency of the two BMPs.
GENE THERAPY IN SPINAL FUSION
Gene therapy, which involves delivery of the DNA encoding a
growth factor rather than delivery of the protein itself, is a
novel approach for enhancing spinal fusion. Gene therapy
allows for more physiologic concentrations of factors to be
expressed in cells for longer periods of time and may direct
bone formation more naturally by prolonged expression of
growth factor rather than single boluses of a large dose. Gene
therapy options include systemic or regional delivery of cDNA
encoding for growth factors; ex vivo transduction of cells with
the BMP gene followed by the implantation of the transduced
cells into the host animal, or direct injection of a BMP vector,
which inserts the BMP transgene directly into host cells; and
using a vector (viral and nonviral) for gene delivery.1
For ex vivo gene transfer, cells are harvested from the
patient, and DNA is transferred to cells in tissue culture. The
genetically modified cells are subsequently administered to the
patient. In addition to providing an osteoinductive gene to a
desired site, the ex vivo approach has the additional advantage
of supplying cells (e.g., bone marrow cells) that are capable of
participating in osteoinduction. In vivo gene transfer involves
the introduction of the specific gene directly into the body with
the expectation that it will reach the target cell. To initiate gene
expression, exogenous DNA must penetrate the cell and enter
the nucleus where the transcriptional machinery resides. Cells
can be genetically modified to overexpress the protein, turning
them into a biologic BMP-2 factory, which can be implanted
into the site of spine fusion.
8/24/11 3:21:20 PM
 48 Section I General Considerations
Several direct and ex vivo BMP gene therapy studies have
been used to fuse the spine successfully in animals. LIM miner-
alization protein-1 (LMP-1) cDNA, a novel intracellular pro-
tein, initiates membranous bone formation in vitro and in vivo
when transfected into buffy coat white blood cells and has been
shown to be effective in inducing spinal fusion in vivo. Although
LMP-1 is an intracellular protein, it is thought to act via induc-
tion of secreted osteoinductive factors that subsequently induce
expression of other BMPs and increase cell response to BMPs.
Ex-vivo transfection of LMP-1 cDNA into bone marrow or
peripheral blood buffy coat cells is able to induce intertrans-
verse process fusion when delivered by a replication incompe-
tent type 5 adenovirus in immunocompetent rabbits. Sites
implanted with cells containing the LMP-1 gene fused solidly,
whereas control cells had no fusion. This work validated the
feasibility of local gene therapy to induce bone and spinal
fusion in a mammal. In-vivo therapy using a rodent model
transfected with an adenovirus vector containing the growth
factor of rhBMP-9 into the paraspinal musculature resulted in
solid posterior fusions. The potential benefit of regional gene
therapy for spinal fusion applications is significant, and consid-
erable work in this area is ongoing. The potential risks of gene
therapy include the possibility of immune response to the viral
vector leading to an inflammatory reaction, toxicity, and even
organ failure; the possibility of viral spread and infection of
cells beyond the site of implantation leading to damage to
healthy cells; and the possibility of reversion of the virus to its
original form thus causing disease.1,5
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