Patients Cannot Reliably Distinguish the Iliac Crest Bone Graft Donor Site From the Contralateral Side After Lumbar Spine Fusion

Abstract

Study Design. A multicenter, randomized, intrapatient controlled trial. Objective. This study investigated whether lumbar fusion patients blinded to the harvest site (A) can identify the iliac crest used for bone harvesting and (B) whether this iliac crest is more painful than the contralateral side. Summary of Background Data. Spinal fusion with iliac crest autograft is a frequently performed surgical procedure. A widely reported disadvantage of the harvesting procedure is potential donor site morbidity. This has driven the development of many bone graft substitutes. However, more recently the incidence and severity of donor site pain is debated, especially in lumbar fusion surgery. Methods. Ninety-two nontraumatic adult patients underwent a posterolateral (thoraco)lumbar fusion. Iliac crest bone graft was harvested unilaterally through the primary midline incision. At 6 weeks, 3 months, 6 months, and 1 year follow-up, patients were asked to identify the donor site and to rate pain in their back, left iliac crest and right iliac crest on a Visual Analogue Scale (VAS). Results. Ninety patients, 44 males and 46 females with a mean age of 54 years, were analyzed. The left/right distribution of the iliac crest donor site was 50/50 and 89% of the patients underwent a lumbar fusion below L3. Only 24% patients identified the harvest site correctly. Moreover, the VAS pain scores for the donor site and contralateral iliac crest did not differ and were at each timepoint lower than the scores for back pain. Conclusion. This study showed that, during the first year after lumbar fusion surgery via a single midline incision approach, patients could not reliably identify the iliac crest used for bone graft harvesting and this iliac crest was not more painful than the untouched contralateral iliac crest. Therefore, donor site pain should not be the main reason to use bone graft alternatives for lumbar spinal fusion. Level of Evidence: 2

Recombinant human bone morphogenetic protein-2 in spine surgery: recommendations for use and alternative bone substitutes—a narrative review

“…Similarly, other minimally invasive ICBG techniques have been introduced and demonstrated to reduce donor site morbidity ( 18 - 20 ). Small prospective studies of patients receiving ICBG for elective lumbar fusion found no significant differences in reported pain between donor and non-donor sides ( 21 , 22 ), and a retrospective chart review reported no donor site complications ( 23 ).…”

Efficacy of a Standalone Microporous Ceramic Versus Autograft in Instrumented Posterolateral Spinal Fusion

“…For autografting, corticocancellous bone was harvested from a single posterior iliac crest. 17 Both local decompression bone and iliac crest bone were morselized. To match the unilateral use of 10 cc of AttraX ® Putty, a volume of 8 to 10 cc autograft per fusion level was intended.…”

Bone Graft and Bone Graft Substitute Options in Metastatic Spine Surgery

“…Interestingly, a recent randomized control trial showed that, when using a single incision, patients undergoing iliac crest autograft for lumbar spinal fusion were unable to identify which side the iliac crest was harvested from, suggesting that the risk of donor site morbidity may be overstated. 3 The use of vascularized bone grafts has been well described for the reconstruction of large spinal defects. 4 Although the use of vascularized bone grafts after intralesional resection of tumor is controversial due to the theoretical risk of "perfusing" tumor, they have been safely used after en bloc resection.…”