Autologous versus allogenic bone grafts in instrumented anterior cervical discectomy and fusion: a prospective study with respect to bone union pattern



The purpose of this prospective semi-randomised comparative study was to compare fusion rates, course of fusion, and occurrence of collapse and subsidence of autologous and allogenic bone grafts in instrumented anterior cervical fusion. The number of fused levels and the smoking status were investigated as potential factors influencing the bone-healing process. No similar prospective study on instrumented anterior cervical discectomy and fusion was found in the literature.


Seventy-nine consecutive patients were operated on using the Smith–Robinson technique with a single instrumentation system at one or two levels. Seventy-six cadaverous fibular bone grafts and 37 autologous iliac-crest bone grafts were inserted. All patients were followed up for at least 2 years.


The radiographs obtained during the follow-up were analysed, and showed no statistical difference in fusion and collapse rate between autografts and allografts. Allografts showed significantly longer time to union. No case of graft migration was observed. No difference was found between fusion and collapse rate with respect to the number of fused levels in general, but greater time to union was seen in two-level fusions. When one- and two-level subgroups were compared, there was no evidence of any significant difference in fusion or collapse rates between autografts and allografts, and the healing process took longer in allogenic grafts. Smoking status did not alter any of the fusion or collapse rates, or the course of bone fusion.


This study demonstrates that allografts are suitable substitutes for autografts in instrumented ACDF. Prolonged time to union observed in allogenic bone grafts does not seem to be an important factor in instrumented procedures. Two-level grafting does not imply a significantly lower fusion rate, but longer time to union can be expected than with single-level instrumented procedures in both allograft and autograft subgroups. Our relatively small number of patients may not have been sufficient to decipher significant differences between smokers and non-smokers in the rate or course of fusion as previously reported.

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  1. 1.

    An HS, Simpson JM, Glover JM, Stephany J (1995) Comparison between allograft plus demineralized bone matrix versus autograft in anterior cervical fusion. A prospective multicenter study. Spine 20:2211–2216

    CAS  PubMed  Google Scholar 

  2. 2.

    Aronson N, Fitzer DL, Bagan M (1968) Anterior cervical fusion by the Smith–Robinson approach. J Neurosurg 29:396–404

    CAS  PubMed  Google Scholar 

  3. 3.

    Bishop RC, Moore KA, Hadley MN (1996) Anterior cervical interbody fusion using autogeneic and allogeneic bone graft substrate: a prospective comparative analysis. J Neurosurg 85:206–210

    CAS  PubMed  Google Scholar 

  4. 4.

    Bohlman HH, Emery SE, Goodfellow DB, Jones PK (1993) Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am 75:1298–1307

    Google Scholar 

  5. 5.

    Brodsky AE, Khalil MA, Sassard WR, Newman BP (1992) Repair of symptomatic pseudoarthrosis of anterior cervical fusion. Posterior versus anterior repair. Spine 17:1137–1143

    CAS  PubMed  Google Scholar 

  6. 6.

    Brown CW, Orme TJ, Richardson HD (1986) The rate of pseudoarthrosis (surgical nonunion) in patients who are smokers and patients who are nonsmokers: a comparison study. Spine 11:942–943

    CAS  PubMed  Google Scholar 

  7. 7.

    Brown MD, Malinin TI, Davis PB (1976) A roentgenographic evaluation of frozen allografts versus autografts in anterior cervical spine fusions. Clin Orthop 119:231–236

    PubMed  Google Scholar 

  8. 8.

    Cloward RB (1958) The anterior approach for removal of ruptured cervical disc. J Neurosurg 15:602–617

    CAS  Google Scholar 

  9. 9.

    Cloward RB (1980) Gas-sterilized cadaver bone grafts for spinal fusion operations. A simplified bone bank. Spine 5:4-10

    CAS  PubMed  Google Scholar 

  10. 10.

    Conolly ES, Seymour R, Adams JE (1965) Clinical evaluation of anterior cervical fusion for degenerative disc disease. J Neurosurg 23:431–437

    PubMed  Google Scholar 

  11. 11.

    Daftari TK, Whitesides TE Jr, Heller JG, Goodrich AC, McCarey BE, Hutton WC (1994) Nicotine on the revascularization of bone graft. An experimental study in rabbits. Spine 19:904–911

    CAS  PubMed  Google Scholar 

  12. 12.

    DePalma AF, Rothman RH, Lewinnek GE, Canale ST (1972) Anterior interbody fusion for severe cervical disc degeneration. Surg Gynecol Obstet 134:755–758

    CAS  PubMed  Google Scholar 

  13. 13.

    Erbe EM, Marx JG, Clineff TD, Bellincampi LD (2001) Potential of an ultraporous beta-tricalcium phosphate synthetic cancellous bone void filler and bone marrow aspirate composite graft. Eur Spine J 10:S141–146

    Article  PubMed  Google Scholar 

  14. 14.

    Farey ID, McAfee PC, Davis RF, Long DM (1990) Pseudoarthrosis of the cervical spine after anterior arthrodesis. Treatment by posterior nerve-root decompression, stabilization and arthrodesis. J Bone Joint Surg Am 72:1171–1177

    CAS  PubMed  Google Scholar 

  15. 15.

    Floyd T, Ohnmeiss D (2000) A meta-analysis of autograft versus allograft in anterior cervical fusion. Eur Spine J 9:398–403

    Article  CAS  PubMed  Google Scholar 

  16. 16.

    Gore DR, Sepic SB (1984) Anterior cervical fusion for degenerated or protruded disc. A review of one hundred forty-six patients. Spine 9:667–671

    CAS  PubMed  Google Scholar 

  17. 17.

    Hanley EN Jr, Levy JA (1989) Surgical treatment of isthmic lumbosacral spondylolisthesis. Analysis of variables influencing results. Spine 14:48–50

    PubMed  Google Scholar 

  18. 18.

    Hilibrand AS, Fye SE, Emery SE, Palumbo MA, Bohlman HH (2001) Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am 83-A:668–673

    Google Scholar 

  19. 19.

    Khan SN, Sama A, Sandhu HS (2001) Bone graft substitutes in spine surgery. Curr Opin Orthop 12:216–222

    Article  Google Scholar 

  20. 20.

    Lind M, Bunger C (2001) Factors stimulating bone formation. Eur Spine J 10:S102–109

    Article  PubMed  Google Scholar 

  21. 21.

    Marchesi DG (2000) Spinal fusion: bone and bone substitutes. Eur Spine J 9:372–378

    Article  CAS  PubMed  Google Scholar 

  22. 22.

    Martin GJ Jr, Haid RW Jr, MacMillan M, Rodts GE Jr, Berkman R (1999) Anterior cervical discectomy with freeze-dried fibula allograft. Overview of 317 cases and literature review. Spine 24:852–858

    Article  PubMed  Google Scholar 

  23. 23.

    Newman M (1993) The outcome of pseudoarthrosis after cervical anterior fusion. Spine 18:2380–2382

    CAS  PubMed  Google Scholar 

  24. 24.

    Nolte PA, van der Krans, Patka P, Janssen IM, Ryaby JP, Albers GH (2001) Low-intensity pulsed ultrasound in the treatment of nonunions. J Trauma 51:693–702

    CAS  PubMed  Google Scholar 

  25. 25.

    Pitzen T, Wilke HJ, Caspar W, Claes L, Steudel WI (1999) Evaluation of a new monocortical screw for anterior cervical fusion and plating by a combined biomechanical and clinical study. Eur Spine J 8:382–387

    CAS  PubMed  Google Scholar 

  26. 26.

    Riley LH Jr, Robinson RA, Johnson KA, Walker AE (1969) The results of anterior interbody fusion of the cervical spine: review of ninety-three consecutive cases. J Neurosurg 30:127–133

    PubMed  Google Scholar 

  27. 27.

    Rish BL, McFadden JT, Penix JO (1976) Anterior cervical fusion using homologous bone grafts: a comparative study. Surg Neurol 5:119–121

    CAS  PubMed  Google Scholar 

  28. 28.

    Robinson RA, Smith GW (1955) Anterolateral cervical disc removal and interbody fusion for cervical disc syndrome. Bull John Hopkins Hospital 96:223–224

    Google Scholar 

  29. 29.

    Robinson RA, Walker AE, Ferlic DC, Wiecking DK (1962) The results of anterior interbody fusion of the cervical spine. J Bone Joint Surg Am 44:1569–1587

    Google Scholar 

  30. 30.

    Shapiro S (1996) Banked fibula and the locking anterior cervical plate in anterior cervical fusions following cervical discectomy. J Neurosurg 84:161–165

    CAS  PubMed  Google Scholar 

  31. 31.

    Silcox DH, Daftari T, Boden SD, Schimandle JH, Hutton WC, Whitesides TE Jr (1995) The effect of nicotine on spinal fusion. Spine 20:1549–1553

    PubMed  Google Scholar 

  32. 32.

    Sonntag VK, Han PP, Vishteh AG (2001) Anterior cervical discectomy. Neurosurgery 49(4):909–912

    CAS  PubMed  Google Scholar 

  33. 33.

    Vernejoul MC de, Bielakoff J, Herve M, Gueris J, Hott M, Modrowski D, Kuntz D, Miravet L, Ryckewaert A (1983) Evidence for defective osteoblastic function. A role for alcohol and tobacco consumption in osteoporosis in middle-aged men. Clin Orthop 179:107–115

    PubMed  Google Scholar 

  34. 34.

    Wang JC, McDonough PW, Endow KK, Delamarter RB (2001) A comparison of fusion rates between single level cervical corpectomy and two level discectomy and fusion. J Spinal Disord 14:222–225

    Article  CAS  PubMed  Google Scholar 

  35. 35.

    Wang JC, McDonough PW, Kanim LE, Endow KK, Delamarter RB (2001) Increased fusion rates with cervical plating for three-level anterior cervical discectomy and fusion. Spine 15; 26(6):643–646

    Google Scholar 

  36. 36.

    White AA, Southwick WO, Deponte RJ, Gainor JW, Hardy R (1973) Relief of pain by anterior cervical spine fusion for spondylosis. A report of sixty-five patients. J Bone Joint Surg Am 55:525–534

    PubMed  Google Scholar 

  37. 37.

    Whitecloud TS, LaRocca SH (1976) Fibular strut graft in reconstructive surgery of the cervical spine. Spine 1:33–43

    Google Scholar 

  38. 38.

    Williams JL, Allen MB Jr, Harkess JW (1968) Late results of cervical discectomy and interbody fusion: some factors influencing the results. J Bone Joint Surg Am 50:277–286

    Google Scholar 

  39. 39.

    Yonenobu K, Fuji T, Ono K, Okada K, Yamomoto T, Harada N (1985) Choice of surgical treatment for multisegmental cervical spondylotic myelopathy. Spine 10:710–716

    CAS  PubMed  Google Scholar 

  40. 40.

    Yoon ST (2001) Cytokines and gene therapy in spine fusion and its potential in cervical fusion. Curr Opin Orthop 12:251–256

    Article  Google Scholar 

  41. 41.

    Zdeblick TA, Ducker TB (1991) The use of freeze-dried allograft bone for anterior cervical fusions. Spine 16:726–727

    CAS  PubMed  Google Scholar 

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The study was supported by the Czech Ministry of Health, grant no. ND/6892-3.

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Correspondence to Petr Suchomel.

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Suchomel, P., Barsa, P., Buchvald, P. et al. Autologous versus allogenic bone grafts in instrumented anterior cervical discectomy and fusion: a prospective study with respect to bone union pattern. Eur Spine J 13, 510–515 (2004).

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  • Anterior cervical spine fusion
  • Internal fixation
  • Autologous bone graft
  • Allogenic bone graft
  • Cigarette smoking