Allograft Versus Autograft in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis

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Abstract

Objective

To compare the 30-day complication rate associated with allograft versus autograft in anterior cervical discectomy and fusion (ACDF) and to determine preoperative factors that may influence complication rate.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried from 2014 to 2017 for all procedures with CPT codes for ACDF (22551). Patients undergoing ACDF with either autograft or allograft were matched by propensity scores based on age, sex, body mass index, and comorbidities. The incidence of adverse events in the 30-day postoperative period was compared.

Results

A total of 21,588 patients met the inclusion and exclusion criteria. Following the 10:1 propensity match, 17,061 remained in the study (1,551 autograft and 15,510 allograft). The overall adverse event rate was 3.18%; 3.48% for autograft and 3.15% for allograft (P=0.494). Autograft had a significantly greater incidence of extended length of stay (>2 d) (LOS) (48.9% vs 34.8%; P<0.001). Multivariate analysis suggested that autograft selection was associated with extended LOS (OR 1.4; 95% CI 1.3-1.5).

Conclusion

The results of this study provide information regarding how graft selection can relate to extended hospital LOS and influence postoperative complications. Extended LOS may be associated with worse patient outcomes and increase the overall cost of care. Further study should be performed to determine which patients would benefit from autograft versus allograft with regards to long-term outcomes, in consideration of these increased short-term complications.

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Most cited references 20

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Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion.

J Martin Leland, Alan Hilibrand, Alexander Vaccaro … (2003)

This retrospective, questionnaire-based investigation evaluated iliac crest bone graft (ICBG) site morbidity in patients having undergone a single-level anterior cervical discectomy and fusion (ACDF) procedure performed by a single surgeon (T.J.A.). To evaluate acute and chronic problems associated with anterior ICBG donation, particularly long-term functional outcomes and impairments caused by graft donation. Anterior cervical discectomy and fusion procedures frequently use autologous anterior ICBG to facilitate osseous union. Although autologous ICBG offers several advantages over alternative grafting materials, donor site morbidity can be significant. Acute and chronic complications of donor sites have been reported, yet there are currently no reports of long-term functional outcomes after autologous anterior ICBG donation after single-level ACDF. A questionnaire was mailed to 187 consecutive patients who were retrospectively identified to have undergone autologous anterior ICBG harvest for single-level ACDF between 1994 and 1998. The questionnaire divided items into symptomatic (acute and chronic) and functional assessments. Patients answered yes, no, or not applicable; pain was assessed with a Visual Analogue Scale (VAS). Surveys were completed either by mail or follow-up telephone interview by 134 patients (71.6%). Average follow-up was 48 months (range, 24-72 months). Acute symptoms were reported at the following rates: ambulation difficulty, 50.7%; extended antibiotic usage, 7.5%; persistent drainage, 3.7%; wound dehiscence, 2.2%; and incision and drainage, 1.5%. The chronic symptom questionnaire demonstrated a high degree of satisfaction with the cosmetic result (92.5%). Pain at the donor site was reported by 26.1% of patients with a mean VAS score of 3.8 in 10, and 11.2% chronically use pain medication. Twenty-one patients (15.7%) reported abnormal sensations at the donor site, but only 5.2% reported discomfort with clothing. A unique functional assessment revealed current impairments at the following rates: ambulation, 12.7%; recreational activities, 11.9%; work activities, 9.7%; activities of daily living, 8.2%; sexual activity, 7.5%; and household chores, 6.7%. A large percentage of patients report chronic donor site pain after anterior ICBG donation, even when only a single-level ACDF procedure is performed. Moreover, long-term functional impairment can also be significant. Patients should be counseled regarding these potential problems, and alternative sources of graft material should be considered.

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Trends in resource utilization and rate of cervical disc arthroplasty and anterior cervical discectomy and fusion throughout the United States from 2006 to 2013

Comron Saifi, Arielle Fein, Alejandro S Cazzulino … (2018)

The typically accepted surgical procedure for cervical disc pathology has been the anterior cervical discectomy and fusion (ACDF), although recent trials have demonstrated equivalent or improved outcomes with cervical disc arthroplasty (CDA). Trends for these two procedures regarding utilization, revision procedures, and other demographic information have not been sufficiently explored.

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Comparison between allograft plus demineralized bone matrix versus autograft in anterior cervical fusion. A prospective multicenter study.

S. Sandy An, Matthew Simpson, Jason Stephany … (1995)

This study analyzed the fusion results of an allograft-demineralized bone matrix composite versus autograft in a prospective series of patients undergoing surgery for cervical disc disease. To determine the fusion rates of allograft-demineralized bone matrix composite in anterior cervical fusion as compared with the gold standard autograft. For the anterior cervical fusion, the use of freeze-dried allograft is well documented in the literature, citing its effectiveness and inferior fusion rates. The use of demineralized bone matrix in conjunction with freeze-dried allograft in anterior cervical fusion has not been reported. This study was done in a prospective fashion in two medical centers. One group received autograft from the anterior iliac crest, whereas others received freeze-dried allograft augmented with demineralized bone matrix (Grafton, Osteotech, Inc., Shrewsbury, New Jersey). For the autograft group, the standard Smith-Robinson grafting technique was used. For the allograft composite group, demineralized bone matrix was pasted onto the freeze-dried allograft and into the disc space before graft insertion. The autograft group consisted of 38 patients with age ranging 26-71 years (mean, 46.1 years) and follow-up periods of 12-33 months (mean, 18.4 months). There were 19 one-level, 17 two-level, and two three-level fusions. Similarly, the allograft group consisted of 39 patients with age ranging 28-80 years (mean, 48.0 years) with follow-up period of 12-31 months (mean, 17.5 months). There were 19 one-level, 16 two-level, and four three-level fusions. Clinical and radiographic follow-up evaluations were completed at 3-month intervals. Radiographs taken 12 months after surgery were analyzed blindly. Pseudarthrosis developed in 46.2% of patients (33.3% of levels) in the allograft-demineralized bone matrix group compared with 26.3% (22% of levels) in the autograft group (P = 0.11 for patients, P = 0.23 for levels). For patients undergoing two-level fusions, 37.5% of allograft-demineralized bone matrix failed compared with 23.5% of autografts. For single-level fusions, 47.4% of allograft patients developed a pseudarthrosis compared with 26.3% in the autograft group. Graft collapse of > or = 3 mm was noted in 11% of the autograft group versus 19% in the allograft-demineralized bone matrix group (P = 0.32). Graft collapse of > or = 2 mm occurred in 24.4% of autograft patients compared with 39.7% of the allograft-demineralized bone matrix group (P = 0.09). Smokers had an increased rate of pseudarthrosis (47.1%) compared with nonsmokers (27.9%, P = 0.13). The study revealed that the allograft-demineralized bone matrix construct gives a higher rate of graft collapse and pseudarthrosis when compared with autograft in a prospective series, although the differences were not statistically significant. The pseudarthrosis rate in the series may be high because of the large percentage of smokers and radiographic evaluation techniques. For the purpose of solid radiographic fusion, the use of autograft is recommended in anterior cervical surgery until other acceptable osteoinductive materials are developed.

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Author and article information

Journal

Journal ID (nlm-ta): Cureus

Journal ID (iso-abbrev): Cureus

Journal ID (issn): 2168-8184

Title: Cureus

Publisher: Cureus (Palo Alto (CA) )

ISSN (Electronic): 2168-8184

Publication date (Electronic, pub): 22 February 2022

Publication date (Electronic, collection): February 2022

Volume: 14

Issue: 2

Electronic Location Identifier: e22497

Affiliations

[1 ] Orthopedic Surgery, Loma Linda University School of Medicine, Loma Linda, USA

[2 ] Orthopedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, USA

[3 ] Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, USA

[4 ] Spine Surgery, Texas Back Institute, Plano, USA

[5 ] Orthopedics, Jerry L. Pettis VA Medical Center, Loma Linda, USA

[6 ] Orthopedic Spine, Loma Linda University Medical Center, Loma Linda, USA

[7 ] Orthopedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, USA

Author notes

Joseph N. Liu joseph.liu@ 123456med.usc.edu

Article

DOI: 10.7759/cureus.22497

PMC ID: 8956488

PubMed ID: 35345686

SO-VID: 954cbf2d-f8c6-4aa2-9817-9a331e0bab68

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Allograft Versus Autograft in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis

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Most cited references 20

Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion.

Trends in resource utilization and rate of cervical disc arthroplasty and anterior cervical discectomy and fusion throughout the United States from 2006 to 2013

Comparison between allograft plus demineralized bone matrix versus autograft in anterior cervical fusion. A prospective multicenter study.

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