Introduction and backgroundTissue and mineral grafts in the spine perform mechanical and biologic functions. Their capacity for each function is dependent upon the structural, cellular, and biochemical properties of the particular graft chosen. Autogenous bone offers an optimal balance of osteogenic, osteoinductive, and osteoconductive capacities, structural stability, and biocompatibility. However, the availability of autogenous bone graft is clearly limited, and the complications of autogenous harvest are well known [6, 16, 17, 19, 23, 29, 30, 36, 46,78,95]. In choosing bone graft substitutes for clinical application, the spine surgeon's decision generally involves a compromise of mechanical and biological functional considerations. This article will address the clinical applications of mineralized and demineralized bone graft preparations in spinal surgery, reviewing the basic science and clinical experience supporting the use of these substitutes.A bone graft material is any implanted material that alone or in combination with other materials promotes a bone healing response by osteogenic, osteoconductive, or osteoinductive activity at a local site [56]. Graft material that is osteogenic contains viable cells at some stage of osteoblastic differentiation and is capable of forming new bone directly. Osteoinductive graft materials contain cytokines capable of inducing differentiation of host cells into bone forming cells. Osteoconductive graft materials provide a biocompatible matrix that supports new bone formation. Substitutes for autogenous bone graft may have variable capacities for each of these functions. In spinal surgery, the ideal bone graft substitute should be osteogenic, biocompatible, bioabsorbable, easy to use, and cost effective and should provide structural support. However, the success of a particular material in achieving these goals depends upon the material and biologic properties of the grafting material as well as the particular host environment in which it is placed. Abstract Bone graft substitutes may be broadly classified as mineralized and demineralized preparations. This article reviews the basic science and biology underlying each preparation. A review of the clinical and experimental applications of each preparation follows. The text concludes with a review of growth factors as biological supplements.