J Korean Neurosurg Soc.  2017 Feb;60(2):225-231. 10.3340/jkns.2017.0101.006.

Demineralized Bone Matrix (DBM) as a Bone Void Filler in Lumbar Interbody Fusion: A Prospective Pilot Study of Simultaneous DBM and Autologous Bone Grafts

• Kim BJ
• Kim SH
• Lee H
• Lee SH
• Kim WH
• Jin SW

• KMID: 2374885
• DOI: http://doi.org/10.3340/jkns.2017.0101.006

Abstract

OBJECTIVE
Solid bone fusion is an essential process in spinal stabilization surgery. Recently, as several minimally invasive spinal surgeries have developed, a need of artificial bone substitutes such as demineralized bone matrix (DBM), has arisen. We investigated the in vivo bone growth rate of DBM as a bone void filler compared to a local autologous bone grafts.
METHODS
From April 2014 to August 2015, 20 patients with a one or two-level spinal stenosis were included. A posterior lumbar interbody fusion using two cages and pedicle screw fixation was performed for every patient, and each cage was packed with autologous local bone and DBM. Clinical outcomes were assessed using the Numeric Rating Scale (NRS) of leg pain and back pain and the Korean Oswestry Disability Index (K-ODI). Clinical outcome parameters and range of motion (ROM) of the operated level were collected preoperatively and at 3 months, 6 months, and 1 year postoperatively. Computed tomography was performed 1 year after fusion surgery and bone growth of the autologous bone grafts and DBM were analyzed by ImageJ software.
RESULTS
Eighteen patients completed 1 year of follow-up, including 10 men and 8 women, and the mean age was 56.4 (32-71). The operated level ranged from L3/4 to L5/S1. Eleven patients had single level and 7 patients had two-level repairs. The mean back pain NRS improved from 4.61 to 2.78 (p=0.003) and the leg pain NRS improved from 6.89 to 2.39 (p<0.001). The mean K-ODI score also improved from 27.33 to 13.83 (p<0.001). The ROM decreased below 2.0 degrees at the 3-month assessment, and remained less than 2 degrees through the 1 year postoperative assessment. Every local autologous bone graft and DBM packed cage showed bone bridge formation. On the quantitative analysis of bone growth, the autologous bone grafts showed significantly higher bone growth compared to DBM on both coronal and sagittal images (p<0.001 and p=0.028, respectively). Osteoporotic patients showed less bone growth on sagittal images.
CONCLUSION
Though DBM alone can induce favorable bone bridging in lumbar interbody fusion, it is still inferior to autologous bone grafts. Therefore, DBM is recommended as a bone graft extender rather than bone void filler, particularly in patients with osteoporosis.

Keyword

Arthrodesis; Autograft; Bone substitutes; CT scan; Osteoporosis; Spinal fusion

MeSH Terms

Arthrodesis
Autografts
Back Pain
Bone Development
Bone Matrix*
Bone Substitutes
Female
Follow-Up Studies
Humans
Leg
Male
Osteoporosis
Pedicle Screws
Pilot Projects*
Prospective Studies*
Range of Motion, Articular
Spinal Fusion
Spinal Stenosis
Tomography, X-Ray Computed
Transplants*
Bone Substitutes

Figure

• 

  Fig. 1 Representative computed tomography of patient included in this study. A: A coronal view shows hyperdense bony bridges connecting the cranial and caudal vertebral bodies. The polyetheretherketone (PEEK) cage on the right side is packed with autologous bone grafts (arrow) and the cage on the left side is packed with demineralized bone matrix (arrowhead). The dotted rectangular area was used for densitometric analysis of the bone bridges. B: A sagittal view of each mid-cage section shows the bone growth area occupying the cage. The graft area inside the PEEK cage (dotted rectangle) was cut and the number of pixels of the white colored areas was calculated.

• 

  Fig. 2 Line chart of clinical outcomes and range of motion (ROM). A: Numeric rating scale (NRS) of back pain. B: NRS of leg pain. C: Korean Oswestry Disability Index (K-ODI ). D: ROM at the operated level.

• 

  Fig. 3 Histogram of comparative analysis of bone growth between autologous bone grafts and demineralized bone matrix (DBM). A: Densitometric analysis of bone growth on coronal view. B: Measurement of bone growth area on sagittal view. C: Comparison of bone growth with osteoporosis group on coronal view. D: Comparison of bone growth with osteoporosis group on sagittal view. * Indicate statistically significant difference with p<0.05.

Reference

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