Use of Osteobiologics in Anterior Cervical Discectomy and Fusion for Spinal Degenerative Cases: AO Spine Guideline

The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence was collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus.

• In primary ACDF surgery for degenerative conditions, we suggest that either structural iliac crest autograft or a cage with an osteobiologic (such as tricalcium phosphate, demineralised bone matrix, hydroxyapatite or allograft) can be used with similar outcomes.

• We suggest either allograft or a cage with an osteobiologic depending on factors such as availability, costs and resources.

• When using a cage with osteobiologic in ACDF surgery, we suggest osteobiologics other than BMP in common clinical situations.

• We suggest that an osteobiologic can be used in single- or multi-level primary ACDF surgery for degenerative conditions.

• In ACDF–TDR hybrid construct surgery for degenerative conditions, we suggest for the fusion level using either structural iliac crest autograft or allograft or a cage with osteobiologic (such as DBM, bovine bone or BMP-2) to achieve similar outcomes.

• No recommendation was made for the use of osteobiologics in revision surgery because evidence was not identified.

The authors concluded – ‘Despite the comprehensive review of evidence, there were often few studies with small sample sizes and primarily nonrandomised studies and case series with inherent risks of bias, and therefore, the certainty of the evidence for the benefits and harms, and the costs was low or very low. Additionally, no information on comorbidities or risk factors was available. Although our certainty in the evidence will likely increase over time with new studies, at present, we do have some evidence that harms are not increased with the use of osteobiologics in common clinical situations. For this reason, the guideline group suggested the use of autograft, allograft, or cage with an osteobiologic. This means that surgeons can choose to use 1 graft over another or 1 osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. In such cases, surgeons will need to be informed of their local situation when making decisions. The development of this guideline also has implications for future research with well-controlled study groups and defined outcomes. As the evidence on osteobiologics grows, the AOGO will update this guideline to reflect new advancements and evidence. KF Degenerative is leading a separate effort on a global prospective clinical study and collecting the evidence on the use and effects of osteobiologic in ACDF and other spine surgeries.’

Further reading:

AO Spine Guideline for the Use of Osteobiologics (AOGO) in Anterior Cervical Discectomy and Fusion for Spinal Degenerative Cases

Hans Jorg Meiselet al

Global Spine Journal 2024, Vol. 14(2S) 6S–13S

DOI: 10.1177/21925682231178204