This study aims to evaluate the influence of bone harvesting on postoperative pain and fusion rates. Group 1 patients received iliac crest bone graft (ICBG) either alone or augmented with local bone. Group 2 received only local bone. No statistical significance was found in radiological union or in the Oswestry Disability Index scores. Visual Analogue Scale scores showed less pain in group 2. Logistic regression showed no correlation between residual pain and occurrence of fusion. Harvesting ICBG did not appear to increase fusion rates and no relation was found between radiological non-union and pai

Kosmopoulos, Victor

Schizas, Constantin

Stafylas, Kosmas

Triantafyllopoulos, Dimitrios

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ORIGINAL PAPERImpact of iliac crest bone graft harvesting on fusion ratesand postoperative pain during instrumentedposterolateral lumbar fusionConstantin Schizas & Dimitrios Triantafyllopoulos &Victor Kosmopoulos & Kosmas StafylasReceived: 27 June 2007 /Revised: 21 July 2007 /Accepted: 28 July 2007 / Published online: 28 August 2007# Springer-Verlag 2007Abstract This study aims to evaluate the influence of boneharvesting on postoperative pain and fusion rates. Group 1patients received iliac crest bone graft (ICBG) either aloneor augmented with local bone. Group 2 received only localbone. No statistical significance was found in radiologicalunion or in the Oswestry Disability Index scores. VisualAnalogue Scale scores showed less pain in group 2.Logistic regression showed no correlation between residualpain and occurrence of fusion. Harvesting ICBG did notappear to increase fusion rates and no relation was foundbetween radiological non-union and pain.Résumé Le but de cette étude est d’évaluer l’influence duprélèvement de greffe sur la douleur post-opératoire et letaux de fusion vertébrale. Matériel et méthode : dans legroupe I, les patients ont reçu une greffe de crête iliaque(ICBG) soit isolée, soit en association avec de l’os prélevéin situ, le groupe II ne recevant que de l’os prélevé in situ.Résultats : il n’y a pas de différence significative du pointde vue fusion radiologique et du score d’Oswestry, de mêmeen ce qui concerne la douleur évaluée par échelle visuelleanalogique. Deuxièmement, il n’y a pas de corrélation entrela douleur et la fusion. Discussion : le prélèvement de greffesne paraît pas augmenter les chances d’une meilleure fusion etnous n’avons pas trouvé de relation entre une pseudarthroseet la douleur.IntroductionAutologous iliac crest bone grafting (ICBG) is consideredthe gold standard in lumbar spinal fusion. Its harvesting isnevertheless linked with potential complications (e.g.,blood loss, vascular injury, hernia, pelvic fracture, ureteralinjury and neuropathy) [2, 4, 5, 8, 14]. Serious complica-tions are nevertheless rare. Lasting pain is the mostcommon side effect, reported in as many as 38% of cases[7].Although donor site pain has been studied in caseswhere ICBG is harvested at a distance from the mainprocedure [13], cases in which harvesting through the sameincision during posterior lumbar surgery have rarely beenthe main subject in studies. In addition, retrospective datais available on the use of ICBG during spinal procedures[7]; however to our knowledge no study has lookedprospectively at the influence of bone harvesting onpostoperative pain and fusion rates in a controlled manner.This study aims to address this issue in patients undergoingonly one- or two-level posterolateral lumbar instrumentedfusion.Materials and methodsThis study included a prospective cohort of patientsoperated upon at a single academic unit by a single surgeonover a 36-month period. A total of 59 consecutive patientsundergoing one- or two-level posterolateral lumbar orlumbosacral spinal fusion were included. From these patients,34 (group 1) received ICBG either alone (n=25) or augmentedwith local bone (n=9), and 25 (group 2) received only localbone. Group 1 patients had an average age of 63 years andgroup 2 of 60 years. Ten patients in group 1 and four in groupInternational Orthopaedics (SICOT) (2009) 33:187–189DOI 10.1007/s00264-007-0446-2C. Schizas (*) :D. Triantafyllopoulos :V. KosmopoulosHôpital Orthopédique de la Suisse Romande, Centre HospitalierUniversitaire Vaudois and The University of Lausanne,Lausanne, Switzerlande-mail: cschizas@hotmail.comK. StafylasOrthopaedic Department, University Hospital of Ioannina,Ioannina, Greece2 were regular smokers. Preoperative diagnosis was spinalstenosis with degenerative spondylolisthesis (n=37), degen-erative disc disease (n=11), lumbar fracture (n=2) and isthmicspondylolisthesis (n=9).The operation included posterolateral instrumented fu-sion either as the primary procedure or as an adjunct tospinal canal decompression. No randomisation was carriedout as far as graft harvesting was concerned. When nodecompression was performed or when the amount of localbone obtained from decompression material was deemednot of sufficient quantity (i.e., less than 20 ml for one-leveland 40 ml for two-level fusion), ICBG was harvested (n=34, group 1). The remaining 25 patients (group 2) did notrequire harvesting of ICBG as local bone was used.Additionally, 17 patients from group 1 and 16 from group2 had bone substitutes with the aim of increasing the totalvolume of graft material. The graft material was harvestedthrough the same posterior incision from the outer table ofthe ilium and laid between the transverse processes of thevertebrae to be fused. Suction drains were used. In allpatients titanium poly-axial pedicle screws were employed(Expedium, DePuy Spine, Inc., Raynham, MA). Operatingtime was prospectively recorded for all cases. Non-steroidalanti-inflammatory drugs (NSAIDs) were proscribed in theperioperative period until the third postoperative month. Inthe postoperative period a soft lumbar support wasprescribed for 3 months and active physiotherapy fromthe third postoperative month onwards for 6 weeks.Patients were followed up clinically and radiologically for1 year postoperatively. Statistical analyses were performedusing Fisher’s exact test, two-tailed unpaired t-test and alogistic regression. Radiological fusion was assessed usingpublished radiological criteria [3] at 1 year by an independentobserver, blinded to the type of graft used. Clinical outcomemeasures included the Visual Analogue Scale (VAS) andOswestry Disability Index (ODI) [6], both of which wererecorded at 3 months and at 1 year.ResultsRadiological union at 1 year was present in 23 out of the 34(68%) cases in group 1 and 19 out of the 25 (76%) cases ingroup 2. This observed difference in fusion between groupswas not statistically significant (p=0.8). One haematomaoccurred in a single patient in group 1, and one seromaoccurred in a group 2 patient. Two patients, both in group1, suffered symptomatic pulmonary emboli during theimmediate postoperative period. All four of the aforemen-tioned cases had otherwise uneventful recoveries.The average preoperative ODI was 50 and 55 for group1 and 2, respectively, while the average preoperative VASwas 8 for both group 1 and 2 (p=0.3 and p=0.9,respectively). The average ODI at 3 months was 25 in group1 and 30 in group 2. This difference between ODI scores wasnot statistically significant (p=0.3). There was also nostatistically significant difference (p=0.3) between the aver-age VAS score reported at 3 months for group 1 (VAS=3.9) ascompared to group 2 (VAS=4). The average ODI at 1 yearwas 28 in group 1 and 23 in group 2. This difference wasonce again not statistically significant (p=0.3). The averagedifference in VAS scores reported at 1 year, however,between patients in group 1 (VAS=4.5) and those in group2 (VAS=2.8) was statistically significant (p=0.03).A mean operating time of 250 and 255 min was recordedfor group 1 and group 2, respectively. No statisticallysignificant difference was found comparing these operativetime means (p=0.82). A logistic regression showed nocorrelation between residual pain and preoperative diagno-sis or occurrence of fusion. At 1 year only seven and fourpatients from group 1 and group 2, respectively, reportedhaving no pain at all on the VAS (p=0.7). Twelve patientsin group 1 and five in group 2 failed to improve their ODIby more than 15 points at 1 year. This difference was notstatistically significant (p=0.3).DiscussionIn general, pain in relation with harvesting ICBG has beenreported in several series. These include not only spinalpatients, but also oral surgery and other orthopaedicreconstructive procedures [9]. Such studies report anincidence ranging from as little as 2.5% [15] to as muchas 38% [7].In a large retrospective study evaluating the morbidityof ICBG harvesting for several orthopaedic procedures,67% of cases underwent posterior crest harvestingthrough the same incision as for lumbar spine surgery[7]. Pain was reported in 38% of these patients in the first6 months after surgery, including those who underwentnon-spinal procedures, and in 18% at a 2-year follow-up.Interestingly, 50% of the patients reporting lasting painwere those who underwent a spinal procedure. At both the6-month (42% vs. 18%) and 2-year (21% vs. 6%) follow-up intervals the proportion of patients reporting pain at thegraft site was greater for the spinal group. Nevertheless,no quantification of the pain was attempted in their study.In another study looking at donor site morbidity followinganterior spinal fusion, the authors noted that chronic pain at theanterior iliac crest occurred in 25% of patients [13]. Lookinginto this in more detail, the authors report that the incidenceof donor site pain was substantially higher in patients whofelt that the fusion procedure had not relieved their back pain.The authors suggest the presence of a possible psychologicalelement in the perception of donor site pain.188 International Orthopaedics (SICOT) (2009) 33:187–189Only a few studies have looked at the contribution ofposterior graft harvesting to persistent pain followinglumbar spine surgery. A study comparing harvesting usingthe same or a separate posterior incision in posterior lumbarsurgery found that the patients in the same incision groupreported less donor site pain [1]. A separate study lookingat the bone harvesting technique, comparing outer table andintracortical harvesting, found that the technique itself didnot appear to play a role in the overall clinical result [10].One other study compared in a non-randomised mannerclinical and radiological results of two groups of postero-lateral fusion of which the first group had ICBG harvestedand the other only local bone issued from the decompres-sion material. Even though no difference was noted in theODI, fusion rates in multilevel cases were lower in the localbone group [12], but not in single level cases. Only onestudy has looked prospectively at ICBG morbidity, butcervical and thoracic cases were also included along withlumbar procedures [11]. Furthermore no control group wasavailable, and fusion rates were not studied.In our study we found that the functional outcome wassimilar for both groups at 3 and 12 months. Although theperceived pain was similar at 3 months, it remainedsignificantly higher in the ICBG group at 1 year. Thehypothesis that more patients in the ICBG group could havemore pain because they failed to improve their functionmore than the minimal clinical significant difference in ODI(widely accepted now as 15 points) [16] was also tested inour study. The results suggest that this does not appear to bethe case since there was no difference in the number of‘failed surgery’ cases between the two groups. It is difficulthowever to differentiate low back pain as a result of failedsurgery from donor site pain. A larger scale prospectiverandomised trial would be needed to test the hypothesis thatICBG harvesting alone results in significantly higher painlevels. It is nevertheless accepted that ICBG harvesting isrelated to morbidity and possibly lasting pain. Effortsshould be made to either improve harvesting techniquesor generalise the use of bone substitutes following adequateclinical testing proving their equivalence to autologousbone.In summary, the results from this study suggest thatharvesting ICBG does not appear to increase fusion rates,but is probably linked to lasting pain. Furthermore in ourresults no relation was observed between radiological non-union and pain.References1. Bezer M, Kocaoglu B, Aydin N, Guven O (2004) Comparison oftraditional and intrafascial iliac crest bone-graft harvesting inlumbar spinal surgery. Int Orthop 28:325–3282. Catinella FP, De Laria GA, De Wald RL (1990) False aneurysm ofthe superior gluteal artery. A complication of iliac crest bonegrafting. Spine 15:1360–13623. Christensen FB, Laursen M, Gelineck J, Eiskjaer SP, Thomsen K,Bunger CE (2001) Interobserver and intraobserver agreement ofradiograph interpretation with and without pedicle screw implants:the need for a detailed classification system in posterolateralspinal fusion. Spine 26:538–5434. Coventry MB, Tapper EM (1972) Pelvic instability: a conse-quence of removing iliac bone for grafting. J Bone Jt Surg, AmVol 54:83–1015. Escalas F, DeWald RL (1977) Combined traumatic arteriovenousfistula and ureteral injury: a complication of iliac bone-grafting. JBone Jt Surg, Am Vol 59:270–2716. Fairbank JC, Couper J, Davies JB, O’Brien JP (1980) TheOswestry low back pain disability questionnaire. Physiotherapy66:271–2737. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML (1997)Autogenous iliac crest bone graft. Complications and functionalassessment. Clin Orthop Relat Res 339:76–818. Hamad MM, Majeed SA (1989) Incisional hernia through iliac crestdefects. A report of three cases with a review of the literature.[Review] [12 refs]. Arch Orthop Trauma Surg 108:383–3859. Joshi A, Kostakis GC (2004) An investigation of post-operativemorbidity following iliac crest graft harvesting.[see comment]. BrDent J 196:167–17110. Mirovsky Y, Neuwirth MG (2000) Comparison between the outertable and intracortical methods of obtaining autogenous bone graftfrom the iliac crest. Spine 25:1722–172511. Robertson PA, Wray AC (2001) Natural history of posterior iliaccrest bone graft donation for spinal surgery: a prospective analysisof morbidity. Spine 26:1473–147612. Sengupta DK, Truumees E, Patel CK, Kazmierczak C, Hughes B,Elders G, Herkowitz HN (2006) Outcome of local bone versusautogenous iliac crest bone graft in the instrumented posterolateralfusion of the lumbar spine. Spine 31:985–99113. Summers BN, Eisenstein SM (1989) Donor site pain from theilium. A complication of lumbar spine fusion. J Bone Jt Surg, BrVol 71:677–68014. Ubhi CS, Morris DL (1984) Fracture and herniation of bowel atbone graft donor site in the iliac crest. Injury 16:202–20315. Younger EM, Chapman MW (1989) Morbidity at bone graftdonor sites. J Orthop Trauma 3:192–19516. Zigler J, Delamarter R, Spivak JM, Linovitz RJ, Danielson GOIII, Haider TT, Cammisa F, Zuchermann J, Balderston R, KitchelS, Foley K, Watkins R, Bradford D, Yue J, Yuan H, Herkowitz H,Geiger D, Bendo J, Peppers T, Sachs B, Girardi F, Kropf M,Goldstein J (2007) Results of the prospective, randomized,multicenter Food and Drug Administration investigational deviceexemption study of the ProDisc-L total disc replacement versuscircumferential fusion for the treatment of 1-level degenerativedisc disease. Spine 32:1155–1162International Orthopaedics (SICOT) (2009) 33:187–189 189

Impact of iliac crest bone graft harvesting on fusion rates and postoperative pain during instrumented posterolateral lumbar fusion

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Impact of iliac crest bone graft harvesting on fusion rates and postoperative pain during instrumented posterolateral lumbar fusion

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