Spine Journal - 2026-06-12 - Journal Article
Comparison of Posterior Cellular Bonegraft Options for Single Level Lumbar Spinal Fusion: A Randomized Trial.
Buttermann GR
Topics
Key Takeaway
Posterior fusion rates for single-level ASF/PSF were 98% for iliac bone autograft, 94% for BMP, 85% for BMA, and 50–67% for cellular allograft options, yet clinical outcomes improved equivalently across all groups when anterior interbody fusion was solid.
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Summary
This single-blinded RCT randomized 175 patients undergoing single-level anterior-posterior lumbar fusion to one of six posterior graft types—IBG, BMP, BMA, or three cellular allograft constructs—plus a historical morcelized allograft control. Posterior fusion rates ranged from 98% (IBG) to 50% (allograft alone), with cellular allografts clustering at 62–67%. Despite these radiographic differences, VAS, ODI, and pain medication outcomes improved significantly and equivalently across all groups, with the exception of marginally greater back pain improvement in the cAlloFat group at 1–2 years.
Key Limitation
The historical allograft control group rather than a concurrent randomized arm compromises the integrity of the negative control comparison and may confound cost-effectiveness conclusions.
Original Abstract
BACKGROUND
Iliac bone autograft (IBG) is osteoinductive/osteogenic/osteoconductive but requires an additional harvesting procedure with known morbidities. Bone morphogenic protein (BMP) is osteoinductive and effective in obtaining fusion but is used off label for posterior fusion, has multiple side effects, and is expensive. Stem cell bone products, both auto- and allograft are attractive osteoinductive alternatives that avoid morbidity related to the graft donor site and may have a better safety profile than BMP. Morcelized allograft bone is osteoconductive but not osteoinductive or osteogenic.
PURPOSE
Evaluate and compare the effectiveness of 6 types of viable or osteoinductive bone graft material in obtaining a solid posterior spinal fusion (PSF) for single level anterior/posterior lumbar spinal fusion. The bone grafts were IBG, BMP, autogenous stem cells (MSC) from concentrated bone marrow aspirate (BMA), allograft MSC from bone marrow, adipose tissue, or amniotic fluid, combined with inert cancellous allograft (Allo).
STUDY DESIGN/SETTING
Prospective, single-blinded randomized study of 6 cohorts and inert historical control.
PATIENT SAMPLE
Elective anterior-posterior lumbar spinal fusion of 175 patients.
OUTCOME MEASURES
Assessments included pre- and postoperative back and leg pain (VAS) scores, Pain Drawing, disability (ODI) scores, pain medication usage, and 1-year postoperative thin-cut CT scans (read by blinded radiologists).
METHODS
Patients who were surgical candidates for a one-level anterior/posterior lumbar fusion were randomized to one of 6 types of posterior bone graft alternatives: IBG, BMP, BMA, allograft MSC derived from bone marrow combined with morcelized Allo (cAlloBone), adipose derived MSC combined with morcelized Allo (cAlloFat), or amnion derived MSC combined with morcelized Allo (cAlloAm). Historical Allo patients served as a negative control group. Each group (n = 27) had prospective outcomes and were followed for a minimum of 2 years. Fusion rate and outcomes were compared and referenced to Allo group.
RESULTS
All but 5 patients had a solid ASF. The posterior fusion rates were 98% for IBG, 94% for BMP, 85% for BMA, 67% for cAlloBone, 64% for cAlloFat, 62% for cAlloAm, and 50% for Allo. Outcomes were significantly improved for all measures for all groups and there was no difference between groups except cAlloFat had slightly greater improvement in back pain in the 1-2 year follow-up period. BMP was the most expensive graft material; cellular allografts had a high-cost relative to fusion rate.
CONCLUSIONS
For single level ASF/PSF, the PSF fusion rate was significantly greater for IBG and BMP followed by BMA. Various allograft MSC bone graft options resulted in lower fusion rates but may be greater than Allo. Outcomes were uniformly improved regardless of the type of graft used or the fusion status of the posterior fusion as long as the interbody fusion was solid. If bone graft cost savings is a consideration for PSF, then IBG has the greatest radiographic value, and Allo the greatest clinical value as long as the anterior interbody fusion is solid.