Bone graft options for spinal fusion following resection of spinal column tumors: systematic review and meta-analysis

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>With the advent of new adjunctive therapy, the overall survival of patients harboring spinal column tumors has improved. However, there is limited knowledge regarding the optimal bone graft options following resection of spinal column tumors, due to their relative rarity and because fusion outcomes in this cohort are affected by various factors, such as radiation therapy (RT) and chemotherapy. Furthermore, bone graft options are often limited following tumor resection because the use of local bone grafts and bone morphogenetic proteins (BMPs) are usually avoided in light of microscopic infiltration of tumors into local bone and potential carcinogenicity of BMP. The objective of this study was to review and meta-analyze the relevant clinical literature to provide further clinical insight regarding bone graft options.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A web-based MEDLINE search was conducted in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines, which yielded 27 articles with 383 patients. Information on baseline characteristics, tumor histology, adjunctive treatments, reconstruction methods, bone graft options, fusion rates, and time to fusion were collected. Pooled fusion rates (PFRs) and I<jats:sup>2</jats:sup> values were calculated in meta-analysis. Meta-regression analyses were also performed if each variable appeared to affect fusion outcomes. Furthermore, data on 272 individual patients were available, which were additionally reviewed and statistically analyzed.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Overall, fusion rates varied widely from 36.0% to 100.0% due to both inter- and intrastudy heterogeneity, with a PFR of 85.7% (I<jats:sup>2</jats:sup> = 36.4). The studies in which cages were filled with morselized iliac crest autogenic bone graft (ICABG) and/or other bone graft options were used for anterior fusion showed a significantly higher PFR of 92.8, compared with the other studies (83.3%, p = 0.04). In per-patient analysis, anterior plus posterior fusion resulted in a higher fusion rate than anterior fusion only (98.8% vs 86.4%, p &lt; 0.001). Although unmodifiable, RT (90.3% vs 98.6%, p = 0.03) and lumbosacral tumors (74.6% vs 97.9%, p &lt; 0.001) were associated with lower fusion rates in univariate analysis. The mean time to fusion was 5.4 ± 1.4 months (range 3–9 months), whereas 16 of 272 patients died before the confirmation of solid fusion with a mean survival of 3.1 ± 2.1 months (range 0.5–6 months). The average time to fusion of patients who received RT and chemotherapy were significantly longer than those who did not receive these adjunctive treatments (RT: 6.1 months vs 4.3 months, p &lt; 0.001; chemotherapy: 6.0 months vs 4.3 months, p = 0.02).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Due to inter- and intrastudy heterogeneity in patient, disease, fusion criteria, and treatment characteristics, the optimal surgical techniques and factors predictive of fusion remain unclear. Clearly, future prospective, randomized studies will be necessary to better understand the issues surrounding bone graft selection following resection of spinal column tumors.</jats:p></jats:sec>

Hybrid Therapy for Metastatic Epidural Spinal Cord Compression: Technique for Separation Surgery and Spine Radiosurgery

“…Variable fusion rates in this population are reported (36%-100%) and various options for bone graft are used according to surgeon's preference. 42 (7) Lastly, the authors routinely use intraoperative electrophysiological monitoring, which offers valuable intraoperative knowledge of the integrity of the motor and sensory tracts. 43 There is no level 1 evidence to support the routine use of INM and in case of urgent need of spinal cord decompression; the absence of INM should not delay surgery.…”

Posterior occiput-cervical fixation for metastasis to upper cervical spine

“…Graft material is matter of debate in cancer surgeries. [51] Fusion mass often suffers from overall poor healing potential, an effect of radiation and chemotherapy. We used only DBM in all cases reported here.…”

“…[1718] In general, autologous bone graft should be avoided in cancer surgeries unless the graft material has been treated. [51] Coumans et al . used liquid nitrogen to treat the autologous bone graft before using.…”

“…suggested that the attempt to achieve fusion should be based on the survival estimate. [51] Oda et al . reported 12 months, while Coumans et al .…”

Anterior cervical corpectomy and fusion in a 7-year-old boy: a case report

“…Another previous study reported that the time to fusion ranged from 3 to 9 months. 19 Instead of removing the plate at 1 year after the first (primary) surgery, 18 the authors removed the plate at 2 years after the first surgery (at the age of 9 years) to ensure that the fusion had occurred and the C-spine could continue its growth. It is believed that by the time a child reaches 8-10 years of age, the cervical spine reaches adult proportions.…”