Autograft/Allograft/Cage/Bone Morphogenetic Protein

Autograft

Autograft is defined as the use of the patient’s own bone as a graft. This has been traditionally achieved through the use of iliac crest bone graft (ICBG), which is considered the “gold standard” for arthrodesis. Autograft harvested from the iliac crest has distinct advantages in achieving successful arthrodesis. It is harvested at the time of surgery and contains pluripotent stem cells with osteoinductive and osteoconductive growth factors. In addition, the cancellous portion of the ICBG contains channels for vascularization with excellent osteogenic properties that facilitate incorporation at the host site. Furthermore, owing to its tricortical surface, graft harvested from the iliac crest provides immediate structural support and optimal stability when used as a posterior lumbar interbody graft until fusion occurs. Another advantage is that it can be harvested from posteriorly while the patient is prone thus obviating the need for repositioning the patient in the operating room.

However, ICBG is limited in its supply and is associated with donor-site complications such as neuralgic pain and paresthesia when the lateral femoral cutaneous nerve is injured (particularly at risk through an anterior harvest), hematomas that can be life-threatening when large vessels are injured, infections, pelvic fracture, and chronic pain. In fact, donor-site chronic pain can be a major limiting factor in patients’ daily activities, which may negatively impact their overall surgical outcomes. Alternative autograft options to ICBG include the rib, fibula, and vertebral body, but they all have donor-site morbidity, increased blood loss, and increased operating time in common. Therefore autograft use has been mainly reserved for patients who are at risk for pseudarthrosis, for example, those with a prior failed fusion, obesity, diabetes, tobacco use, steroid use, or history of malignancy.