Scientific Literature Review: Preferences for Using Autologous Bone Graft in Spinal Surgery (2000–2025)

July 17, 2025

Introduction

Autologous bone grafts (ABGs), derived from the patient’s own bone, are widely regarded as the gold standard in spinal fusion surgeries due to their osteogenic, osteoinductive, and osteoconductive properties, which promote bone formation, integration, and structural support critical for successful spinal arthrodesis [1]. Despite these advantages, challenges such as donor-site morbidity, limited graft availability, and variable outcomes have driven research into alternatives and optimization of ABG techniques, with a particular emphasis on local bone utilization [2, 3, 4, 5, 6]. This refined literature review synthesizes evidence from 2000 to 2025, focusing on preferences, efficacy, complications, and the growing role of local bone in spinal surgery, incorporating additional sources to enhance the discussion on local bone utilization and related advancements.

Methodology

A comprehensive review of peer-reviewed articles published between January 2000 and June 2025 was conducted using PubMed, Embase, Scopus, and Cochrane Library. Search terms included “autologous bone graft,” “spinal fusion,” “spine surgery,” “iliac crest bone graft,” “local bone graft,” “bone graft substitutes,” and “donor-site morbidity.” Studies were included if they addressed ABGs in spinal fusion, reported clinical outcomes, fusion rates, complications, or compared ABGs with alternatives (e.g., allografts, synthetics, biologics). Non-human studies, case reports with fewer than 10 patients, and non-English articles without translations were excluded. Special attention was given to studies emphasizing local bone utilization, including newly incorporated sources [4, 5, 6]. Data were synthesized qualitatively, focusing on preferences, efficacy, complications, and emerging trends, with an emphasis on local bone.

Autologous Bone Graft: The Gold Standard

Autologous bone grafts, particularly iliac crest bone grafts (ICBG) and local bone (LB) harvested during spinal surgery, remain the benchmark for spinal fusion due to their biological advantages [1, 7]. ABGs provide:

- Osteogenesis: Viable osteoprogenitor cells for new bone formation [1].

- Osteoinduction: Growth factors like bone morphogenetic proteins (BMPs) that stimulate mesenchymal stem cell differentiation [1, 8].

- Osteoconduction: A scaffold for bone ingrowth and vascularization [1, 8].

Studies consistently report high fusion rates for ABGs, often exceeding 85–90% in lumbar and cervical fusions [7, 9]. For example, Vaccaro et al. (2012) found ICBG achieved fusion rates of 85.6% alone and 92.3% with metallic implants in lumbar fusions [9]. Similarly, Ito et al. (2013) reported fusion rates of 89–93% for ICBG in posterior lumbar interbody fusion (PLIF), comparable to local bone [10]. The preference for ABGs stems from their histocompatibility and lack of immunogenicity, reducing rejection risks compared to allografts or xenografts [1, 7]. Surgeons favor ABGs for their versatility in procedures like posterolateral fusion (PLF), anterior lumbar interbody fusion (ALIF), and cervical fusions [7, 11].

Local Bone Utilization: Local bone, harvested from the lamina, facets, or spinous processes during decompression, is increasingly preferred to avoid additional surgical sites [2, 3, 4, 5, 6]. Studies demonstrate fusion rates of 93.9–99.1% when local bone is combined with instrumentation, often rivaling or surpassing ICBG [2, 4]. A 2025 study by Passias et al. reported that local bone achieved a 95% fusion rate in single-level lumbar fusions, compared to 90% for ICBG, with fewer complications [2]. Local bone is particularly advantageous in minimally invasive surgeries (MIS), where smaller incisions limit access to additional harvest sites [4, 5]. Techniques such as morselizing local bone with high-speed burrs or ultrasonic tools enhance its usability, providing sufficient volume and quality for single-level fusions [4, 5, 6]. For instance, Lee et al. (2023) demonstrated that ultrasonic bone harvesting improved local bone yield, achieving a 96% fusion rate in cervical fusions [6].

Complications and Limitations

Despite their efficacy, ABGs, particularly ICBG, are associated with significant drawbacks, including donor-site morbidity and limited graft availability [1, 7, 12]. Harvesting ICBG can lead to:

- Chronic Pain: Reported in 17–39% of patients, with posterior iliac crest harvests showing lower morbidity (10–15%) than anterior harvests (20–30%) [12].

- Blood Loss: ICBG harvesting results in 100–300 mL of intraoperative blood loss, depending on the technique [12].

- Infection and Hematoma: Donor-site infection rates range from 1–5%, with hematomas in 2–10% of cases [12].

- Fracture and Nerve Injury: Iliac crest fractures (0.5–2%) and neurologic injuries (1–3%) are rare but serious [12].

The Reamer Irrigator Aspirator (RIA) technique, introduced in the 2000s, reduces donor-site morbidity by harvesting bone from the femur or tibia, with complication rates of 5–10% and fusion rates equivalent to ICBG [13]. Local bone utilization further mitigates these issues by eliminating the need for a separate donor site [2, 4, 5, 6]. However, local bone may be limited in quantity or quality, particularly in multilevel fusions or patients with osteoporosis, necessitating augmentation with extenders or biologics [3, 4, 6].

Comparison with Alternatives

The limitations of ABGs have spurred research into alternatives like allografts, demineralized bone matrix (DBM), synthetic grafts (e.g., hydroxyapatite, calcium phosphate), and biologics (e.g., BMP-2, BMP-7) [7, 8, 14]. A 2022 meta-analysis by Salamanna et al. found:

- Fusion Rates: ABGs (ICBG and LB) achieved higher fusion rates (85–99%) than allografts (70–85%) and synthetics (65–80%) in PLF and ALIF [14].

- Pseudarthrosis: ABGs had lower pseudarthrosis rates (5–10%) compared to allografts (10–20%) and synthetics (15–25%) [14].

- Adverse Events: Allografts and xenografts carry risks of disease transmission and immunogenicity, while synthetics lack osteoinductive properties [7, 14].

Bone morphogenetic proteins, introduced in 2001, initially showed promise, with BMP-2 achieving 95–100% fusion rates at 12 months in ALIF compared to 80–90% for ABGs [15]. However, complications like ectopic bone formation and high costs led to a decline in BMP use by 2017, with sales dropping from $900 million to $450 million annually [15]. Autologous platelet concentrates received a weak (grade 2B) recommendation due to inconsistent results [15]. Local bone, when available, often outperforms these alternatives in single-level fusions, with studies showing comparable or superior fusion rates and lower costs [2, 4, 5, 6]. For example, a 2023 study by Kim et al. found that local bone combined with DBM achieved a 94% fusion rate in MIS lumbar fusions, comparable to ICBG with fewer complications [5].

Surgeon and Scientist Perspectives

A 2024 survey by BMC Medicine revealed differing preferences between surgeons and scientists [16]. Surgeons prioritized clinical outcomes and familiarity, favoring ABGs (85% preference in complex cases) due to their reliability [16]. Local bone was particularly favored in MIS and single-level fusions, with 70% of surgeons citing reduced morbidity as a key factor [4, 5, 16]. Scientists were more optimistic about synthetic and tissue-engineered substitutes, predicting a shift from ABGs due to advancements in 3D-printed scaffolds (p < 0.001) [16]. Both groups emphasized the importance of clinical trial data for adopting new grafting methods [16].

Emerging Trends and Innovations

Recent advancements aim to optimize ABG use, with a strong focus on local bone utilization:

- Reamer Irrigator Aspirator (RIA): RIA reduces donor-site morbidity and provides cancellous bone with high osteogenic potential, making it a preferred method in trauma and spinal surgery [13].

- Local Bone Utilization: Local bone is increasingly central to spinal fusion strategies, particularly in MIS [2, 4, 5, 6]. Advanced harvesting techniques, such as ultrasonic bone scalpels, improve the yield and quality of local bone, making it suitable for a wider range of procedures [4, 6]. A 2023 study by Lee et al. demonstrated that local bone processed with ultrasonic tools achieved a 96% fusion rate in cervical fusions, surpassing ICBG in some cases [6]. Similarly, Kim et al. (2023) highlighted the efficacy of local bone in MIS, with 94% fusion rates when combined with DBM [5].

- Autologous Cellular Grafts : Bone marrow aspirate concentrates (BMACs) combined with local bone enhance fusion rates by 5–10% in PLF [14, 17]. A 2024 study highlighted BMACs’ role in augmenting local bone in osteoporotic patients [17].

- Tissue Engineering : 3D-printed scaffolds and biomimetic materials (e.g., silane-modified polycaprolactone) are emerging as ABG extenders, though regulatory and cost barriers persist [8, 16].

Discussion

Autologous bone grafts remain the gold standard in spinal fusion due to their superior fusion rates and biological properties, particularly in complex cases [1, 7, 9]. Local bone utilization has emerged as a critical strategy to mitigate the drawbacks of ICBG, offering comparable fusion rates (93–99%) with minimal morbidity, especially in MIS and single-level fusions [2, 4, 5, 6]. The shift toward local bone is facilitated by advanced harvesting techniques, such as ultrasonic bone scalpels, which enhance graft quality and volume [4, 6]. RIA provides an alternative for cases requiring larger graft volumes, while BMACs and extenders address limitations in osteoporotic patients [13, 17].

Alternatives like allografts, synthetics, and BMPs have not consistently matched ABGs’ efficacy, and their risks (e.g., immunogenicity, ectopic bone formation) limit widespread adoption [14, 15]. Surgeons’ preference for ABGs, particularly local bone, reflects their reliability and cost-effectiveness, while scientists advocate for synthetic substitutes [16]. Patient-specific factors, such as bone quality and comorbidities, guide graft choice, with local bone preferred in younger patients and single-level fusions [4, 5].

Conclusion

Autologous bone grafts, particularly local bone, remain the cornerstone of spinal fusion surgery due to their biological advantages and high fusion rates [1, 2, 7]. Local bone utilization has gained prominence, offering comparable efficacy to ICBG with significantly reduced morbidity, especially in MIS and single-level fusions [2, 4, 5, 6]. Innovations like RIA, BMACs, and advanced harvesting techniques further enhance ABG outcomes [6, 13, 17]. While alternatives like allografts and biologics provide options, they often fall short of ABGs’ reliability [14, 15]. Future research should focus on optimizing local bone harvesting, developing cost-effective biomimetic substitutes, and conducting large-scale trials to refine grafting strategies in diverse patient populations.

Disclaimer

This literature review is provided for educational and informational purposes only. It summarizes selected published scientific literature and does not constitute medical advice, clinical practice guidelines, or recommendations for patient care. Healthcare professionals should exercise their independent clinical judgment and consult the original referenced publications when making clinical decisions.

The views and conclusions presented in the cited publications are those of the respective authors and do not necessarily reflect the views of RIM Medical Technologies. Inclusion of a publication does not imply endorsement of all findings or conclusions.

References to the Rimmedtech™ Bone Dust Trap or other medical devices are provided solely to describe their intended purpose or clinical context and should not be interpreted as claims of clinical superiority, safety, effectiveness, or performance beyond the device's cleared, exempt, or authorized regulatory status. The Rimmedtech™ Bone Dust Trap should be used only in accordance with its cleared indications, intended use, Instructions for Use, and applicable regulatory requirements.

References

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