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Bone Grafts and Implants in Spine Surgery

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Bone Grafts and Implants in Spine Surgery CHAPTER 39 BONE GRAFTS AND IMPLANTS IN SPINE SURGERY Ken Hsu James F. Zucherman Arthur H. White Recent advances in both fusion tech of scaffolds, bridges, spacers, fillers of J • niques and instrumentation have defects, and replacements of bone lost. markedly facilitated the treatment of Immobilization of multiple motion seg spinaldisorders. Yet asignificantnumber ments is frequently necessary in the spine; of patients exist who continue to have great demands arc made on bone grafts. pseudarthroses. Despite the surgical ad In the lumbosacral spine, body weight vances the essentials ofa successful spinal and muscular forcesimpart loads equal to fusion still appear to be the effective ap three or four times body weight. It is plication of sound bone grafting princi not surprising that the highest rate of ples. These principles, along with the bone graft failure is seen in the lumbo techniques, problems, and complications sacral spine. Hence, the following is a associated with bone grafting, arc re discussion of technical problems, bio- viewed in this chapter. mechanical and physiologic character The loss ofbone in the spine often pre istics of bone grafts, and implants. sents serious difficulties not seen in other areas. The most favorable replacement THE AUTOGRAFT would still be a bone graft that fills the Autograft, or bone graft transplanted defect and becomes incorporated into the from one site to another in the same indi spine. However, the availability of ap vidual, is considered to be the most bio propriate bone to replace the loss is a logically suitable. Its advantages include: significant problem. Alternatives to bone 1. Has superior osteogenic capacity grafts, including a number of implants a. Contributes cells capable ofim used to stabilize the spine, are also sur mediate bone formation veyed. b. Allows for bone induction by i Bone grafts have often played the roles recipient bed where nonosseous '-.-f Dotw Grnfts and JnipfaiUs in Spine Surgery 435 tissue is influenced to change its for example, high speed burring cellular function and become and inadequate irrigation retard osteogenic healing*'"' 2. Lack of histoconipatibility differ 6. Position the canccllous surface ences or ininiunologic problems a. On opposing cancellous surtace 3. Ease of incorporation b. On surrounding soft tissue with 4. No disease transmission ' good blood supply The disadvantages include; c. So that total mass ofgraft is not 1. Additional incision or wider ex too thick to prevent nutrient posure, prolonged operative time, diffusion from recipient bed and increased blood loss 7. Always avoid 2. Increased postoperative morbidity a. Dead space 3. Sacrifice of normal structure and b. Hematoma weakening of donor bone c. Interposition ofnccrotic tissue 4. Risks of significant complications 8. To minimize risk, be aware of 5. Limitations in size, shape, quantity, a. Anatomy and quality b. Potential complications For optimal results harvest autogenous The iliac crest is the most versatile bone canccllous bone in the following manner. graft reserve. It isrelatively subcutaneous 1. In thin strips and easy to harvest in prone, supine, lat a. Not exceeding 5 mm in thick- eral, or other positions. It is expendable, and it has a large reserve of cortical b. To provide maximal exposure and canccllous bone. In addition, it al of superficial cells lows carpentering of different shapes and c. To allow rapid vascularization 2. Graft wrapped in a gauze soaked in patient's blood Anterior Iliac Crest Grafts a. To avoid exposure to high in Anterior iliaccrest bone grafts are used tensity lights for anterior interbody fusion ofthe cervi b. Kept in temperature less than cal, thoracic, or lumbosacral spine. The 42° C^' subcutaneous anterior superior iliac spine c. Not stored in saline or antibiotic and iliac crest and easily palpable. The solution^-'"'' iliac tubercle is the widest portion where d. Without the use of chemical a large quantity ofcorticocancellous bone sterilization'"" is found. (See Fig. 39-8.) 3. Transfer the graft to the recipient A skin incision is made parallel to or in bed as soon as possible to line with the iliac crest. It is advantageous a. Avoid exposure to air for more to center the incision over the iliac tuber than 30 minutes'"'' cle. The incision is carried down to the b. Protect the viability of the sur bone of the crest, and the muscles arc face cells elevated subperiostcally to expose the 4. Place the graft wing of the ilium. a. In wcll-vascularized bone bed The tensor fascia latac, glutens medius, b. In well-decorticated bone sur and glutens minimus originate from the face (cancellous site is superior) lateralaspectof the ilium. They are inner vated by the superior gluteal nerve. The c. With healthy soft tissue cover- { age abdominal muscles are also attached to 5. Minimize surgical trauma because, the iliac crest and arc scgmentally inner- • • • -i.. • .r; • • 1 i:; 436 Spine Surgery: An AnihoIogY vatcd. The incision over the crest is there close to the anterior superior iliac spine, fore "internervous" and safe. fracture may occur. (See Fig. 39-6.) An appropriate osteotome or chisel Avulsion of the anterior superior iliac may be used to outline a cortical window spine may occur by the action of the at in the lateral iliac surface from which to tached muscles, such as the tensor fascia procure the bone graft. Longitudinal lata or sartorius. parallel cuts may be made (Fig. 39-1). Bone may be removed in the form of Strips of cancellous bone may be re block, dowel, strips, and by way ofcorti moved with a curved gauge. Care must cal window or "trap door" (Figs. 39-1 to be taken not to violate the inner table of 39-4). The iliac crest contour can be pre the iliac wing where hernia is a significant served by removing the bone deep to the potential complication. crest, or by temporarily detaching and Bone graft may be obtained from the repositioning it later (Fig. 39-5). The inner table of the iliac wing. However, anterior superior iliac spine should be left there are risks of peritoneal perforation intact to maintain normal appearance. and significant bleeding with formation The region ofthe iliac spine should not be ofhematoma in the retroperitoncal space. weakened by removing bone adjacent to It is important not to carry the incision it. Fracture and displacement of the to or anterior to the anterior superior iliac inguinal ligament may result (Fig. 39-6). spine. Injury to the lateral femoral cuta The wound should be closed properly. neous nerve or the inguinal ligament The muscles and fascia must be sutured to must be avoided. Detachment of the in their original anatomic positions and the guinal ligament may result in inguinal defects closed; an effective drain should hernia. If bicortical bone is taken too be used. / •• ' (/'((//' / \/ / l< Mcu. Fig. 39-1 Corticocanccllous bonegrnftisobtainedfromlateral iliac surface usinglongitudinal parallel cuts with an osteotome or chisel. »•.«) , •> / • 1 ' Bone Grafts and Implants in Spine Surgery 437 Fig. 39-2 Hor.scshoc-sliapcd corticocanccllous bone graft is obtained froin iliac crest using ostco- tontcs positioned parallel to each other. Fig. 39-3 Dowel-cutting instrument is used to obtain iliac graft with two tooled cancellous sur faces and cortical faces on three sides for anterior spinal intcrbody fusion. Fig. 39-4 Cortical "trap door" is used to gain access to iliac cancellous bone. '' 1 I !-•! v'Nr ^ f 438 Spine Surgery: An Anthofogy m Temporary detachment The iliac contour S r of the iliac crest Is preserved intact ^"5 ] i The defect is filled to avoid hernia (Bonecement may be used) Fig. 39-5 Large iliac graft isobtained with preservation of tlie iliac contour. t, Anterior superior iliac spineL \ Inguinal ligament Fig. 39-6 Illustration ofattachment ofinguinal ligament to anterior superior iliac spine. Detachment ofingiiinal ligament may lead to inguinal hernia. Injury to lateral femoral cuta neous nerve should also be avoided. Bofic Crafts aitd Implants in Spine Surgery 439 Posterior Iliac Crest Grafts bone that forms the notch. This can pro The posterior iliac crest provides a duce instability ofthe pelvis. It is impor largequantity of cortical cancelious bone tant to stay cephalad to the sciatic notch graft. The posterior superior iliac crest is and remove bone only from the false pel palpable under the skin dimple in the vis. For a landmark, an imaginary line superior medial aspect of the gluteal re dropped anteriorly from the posterior gion. The iliac crest curves cephalad and superior iliac spine with the patientin the laterally from the posterior superior iliac prone position can be used as the caudal spine. limit of bone removal (see Fig. 39-15, A An oblique, curved or vertical incision and B). Care must be taken not to enter may be made over the posterior iliaccrest the sacroiliacjoint, which may become a or in line with it. The cluneal nerves cross source of persistent pain and instability the iliac crest 7 to 12 cm anterolateral to when injured. the posterior superior iliac spine (see dis A sharp surgical instrument (that is, cussion under Complications) and must an osteotonie or tip of Taylor retractor) be protected (sec Fig. 39-13). may injure the sciatic nerve deep to the A midline spine incision may be ex sciatic notch. Laceration of the superior tended distally and the posterior iliac gluteal vessels is a significant danger in crest approached laterally under the skin this region. The vessels leave the pelvis and subcutaneous fat. This avoids the use via the sciatic notch. A divided vessel can of a second skin incision. easily retract into the pelvis and presentsa The incision is carried down to the very alarming complication (sec discus bone of the crest, and the muscles arc sion under Complications) (sec Fig.
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