Updates in the use of bone grafts in the lumbar spine

There has been a rapid increase in the number of lumbar fusion procedures performed in the last 10 years. Many of these procedures involve the use of bone grafts and specifically bone graft extenders and substitutes. Fusion depends on host and surgical factors including the selection of an appropriate graft. Bone grafts have osteoconductive, osteoinductive, and osteogenic properties. Iliac crest autograft has long been considered the gold standard for bone graft procedures as it inherently imparts all three. However, its use is associated with significant disadvantages including donor site pain, increased operative time, and insufficient availability. Allograft has been used to avoid the complications of donor site morbidity but has increased risks of rejection, disease transmission, and slower incorporation into the host bone. The use of alternative bone grafting options, such as demineralized bone matrix, synthetics (ceramics), bone morphogenetic proteins, collagen-based matrices, autogenous growth factors, and bone marrow aspirate, have become routine in some institutions. This review paper highlights the different bone grafting options currently available, discusses their pros and cons, and briefly reviews the relevant literature.