Charla R. Fischer, Ryan Cassilly, Winifred Cantor, Emmanuel Edusei, Qusai Hammouri, Thomas Errico

June 2013, Volume 22, Issue 6, pp 1423 - 1435 Review Article Read Full Article 10.1007/s00586-013-2718-4

First Online: 26 February 2013


The increased prevalence of spinal fusion surgery has created an industry focus on bone graft alternatives. While autologous bone graft remains the gold standard, the complications and morbidity from harvesting autologous bone drives the search for reliable and safe bone graft substitutes. With the recent information about the adverse events related to bone morhogenetic protein use, it is appropriate to review the literature about the numerous products that are not solely bone morphogenetic protein.


The purpose of this literature review is to determine the recommendations for use of non-bone morphogenetic protein bone graft alternatives in the most common spine procedures based on a quantifiable grading system.

Study design

Systematic literature review.


A literature search of MEDLINE (1946–2012), CINAHL (1937–2012), and the Cochrane Central Register of Controlled Trials (1940–April 2012) was performed, and this was supplemented by a hand search. The studies were then evaluated based on the Guyatt criteria for quality of the research to determine the strength of the recommendation.


In this review, more than one hundred various studies on the ability of bone graft substitutes to create solid fusions and good patient outcomes are detailed.


The recommendations for use of bone graft substitutes and bone graft extenders are based on the strength of the studies and given a grade.

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