Comparative Efficacy and Safety of Osteobiologics in Posterior Lumbar Fusion: A Network Meta-Analysis of Randomized...

Study DesignNetwork Meta-Analysis.ObjectiveTo compare the efficacy and safety of osteobiologics used in posterior lumbar spinal fusion (LSF) for degenerative lumbar disorders, setting autologous iliac crest bone graft (AICBG) as the reference standard.MethodsA systematic search of randomized controlled trials (RCTs) evaluating osteobiologics in adult patients undergoing posterior LSF was performed. Primary outcomes were radiologic fusion and osteobiologic-related complications. Secondary outcomes included disability, low back pain, operative time, blood loss, and length of stay (LOS). A frequentist random-effects network meta-analysis (NMA) was performed. Meta-regression was employed to assess the influence of surgical technique on primary outcomes. Risk of bias was evaluated using the Cochrane RoB-2 tool, and certainty of evidence was assessed with the GRADE framework.ResultsThirty-five RCTs including 2298 patients were analyzed. Compared with AICBG, recombinant human bone morphogenetic protein-2 (rhBMP-2) showed significantly higher fusion rates (OR 3.86; 95% CI 2.60-5.74; P < 0.0001) and lower complication risk (OR 0.50; 95% CI 0.34-0.73; P = 0.0004). Disability and pain outcomes were comparable across treatments. rhBMP-2 (MD -21.8 minutes; 95% CI -28.0 to -15.7; P < 0.0001), autologous local bone (MD -12.0 minutes; 95% CI -21.5 to -2.5; P = 0.0133), and ABM/P-15 (MD -17.0 minutes; 95% CI -32.6 to -1.5; P = 0.0322) were associated with shorter operative time. Only rhBMP-2 significantly decreased blood loss (MD -72.6 mL; 95% CI -118.9 to -26.4; P = 0.002), while no treatment reduced LOS.ConclusionsAmong evaluated osteobiologics, rhBMP-2 demonstrated superior efficacy and safety compared to AICBG in posterior LSF. Other agents showed favourable trends without statistical significance, reflecting persistent uncertainty rather than confirmed equivalence.