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BMC Therapy in Atlanta
– What evidence is there to support its use in spine surgery?
Bone marrow concentrate has been used successfully in a number of studies involving spinal fusion. As such, bone marrow concentrate used alongside an allograft (donor graft) is increasingly seen as a useful alternative to autologous grafts that require bone to be harvested from the patient themselves.
In one study, researchers looked at the outcomes of spinal fusion surgery in 25 patients whose treatment either involved fusion using BMC alongside a bone graft from a donor (allograft), or fusion using a portion of the patients’ own bone harvested from their hip (autograft). After a year, there was no discernable difference between the two techniques in terms of successful fusion (Johnson, 2014).
Similar success was seen with the use of bone marrow aspirate in another study involving 46 patients who underwent 1-segment, 2-segment, or 3-segment instrumented posterolateral fusions (PLF) using autograft, bone marrow aspirate (BMA), and a nanocrystalline hydroxyapatite bone void filler (nHA). The results were comparable to rates for autograft using iliac crest autograft, with bridging bone seen in 88%, 93%, and 100%, respectively for 1-segment, 2-segment, and 3-segment fusion procedures (Robbins et al., 2014).
Typically, an autograft is favored for spinal fusion as harvesting the patients’ own bone helps to avoid the risk of immune reactivity to donor bone. However, the harvesting procedure can be painful and pose a risk of infection and issues caused by prolonged sedation and anesthesia, meaning that use of other bone graft materials may be preferred for some patients.
The use of BMC as a bone graft material appears to hold promise, especially as studies in animals show that it can provide increased biomechanical behavior compared to other grafts, thereby significantly strengthening the vertebral body (Manrique et al., 2014).
BMC injections may also be useful in conditions such as osteoradionecrosis (ORN), a potential complication of radiotherapy, including in the treatment of head and neck cancers. In one case study, injections of BMC into the mandible of a patient with this noninfectious, necrotic condition resulted in complete bone remodeling 1 year after treatment and no further symptoms in the patient (Manimaran et al., 2014).
Scientists have long known that there is an age-related decline in the population of mesenchymal stem cells in bone marrow, and in the efficacy of these stem cells (Ajiboye et al., 2015). What this means for anyone undergoing spinal fusion surgery is that the older you are the more difficult it is for your body to effectively build bridging bone between a bone graft and existing tissue.
In addition, the use of bone marrow aspirate from an older patient may be less effective as an aid for achieving spinal fusion in that patient. However, the use of bone marrow concentrate in older patients undergoing spinal fusion has been associated with successful outcomes.
In one study, 31 elderly patients (65 and older) underwent posterolateral and interbody lumbar fusion using bone marrow concentrate with an allograft (donor bone or graft material) and demineralized bone matrix. In 83.9% of cases, patients had evidence of a successful fusion, with 96.8% of interbody fusions successful. None of the patients had complications related to hardware or morbidity at the graft donor site, and excellent or good results were seen for 83.9% of patients (Ajiboye et al., 2015).
Ajiboye, R.M., Hamamoto, J.T., Eckardt, M.A., Wang, J.C. (2015). Clinical and radiographic outcomes of concentrated bone marrow aspirate with allograft and demineralized bone matrix for posterolateral and interbody lumbar fusion in elderly patients. Eur Spine J, Nov;24(11):2567-72.
Badrinath, R., Bohl, D.D., Hustedt, J.W., Webb, M.L., Grauer, J.N. (2014). Only prolonged time from abstraction found to affect viable nucleated cell concentrations in vertebral body bone marrow aspirate. Spine J, Jun 1;14(6):990-5.
Hustedt, J.W., Jegede, K.A., Badrinath, R., Bohl, D.D., Blizzard, D.J., Grauer, J.N. (2013). Optimal aspiration volume of vertebral bone marrow for use in spinal fusion. Spine J, Oct;13(10):1217-22.
Johnson, R.G. (2014). Bone marrow concentrate with allograft equivalent to autograft in lumbar fusions. Spine (Phila Pa 1976), Apr 20;39(9):695-700.
Manimaran, K., Sankaranarayanan, S., Ravi, V.R., Elangovan, S., Chandramohan, M., Perumal, S.M. (2014). Treatment of osteoradionecrosis of mandible with bone marrow concentrate and with dental pulp stem cells. Ann Maxillofac Surg, Jul-Dec;4(2):189-92.
Robbins, S., Lauryssen, C., Songer, M.N. (2014). Use of Nanocrystalline Hydroxyapatite With Autologous BMA and Local Bone in the Lumbar Spine: A Retrospective CT Analysis of Posterolateral Fusion Results. J Spinal Disord Tech. Feb 27.
Manrique, E., Chaparro, D., Cebrián, J.L., López-Durán, L. (2014). In vivo tricalcium phosphate, bone morphogenetic protein and autologous bone marrow biomechanical enhancement in vertebral fractures in a porcine model. Int Orthop, Sep;38(9):1993-9.
Sampson, S., Botto-van Bemden, A., Aufiero, D. (2013). Autologous bone marrow concentrate: review and application of a novel intra-articular orthobiologic for cartilage disease. Phys Sportsmed, Sep;41(3):7-18.