Poster Presentation 51st International Society for the Study of the Lumbar Spine Annual Meeting 2025

Global Practices and Preferences in the Use of Osteobiologics for Anterior Cervical Discectomy and Fusion: An AO Spine Cross-Sectional Study (#107)

Luca Ambrosio 1 , Arun Kumar Viswanadha 2 , Pieter-Paul A. Vergroesen 3 , Zorica Buser 4 , Hans Meisel 5 , Nancy Santesso 6 , Jason PY Cheung 7 , Hai V. Le 8 , Gianluca Vadala' 1 , Amit Jain 9 , Andreas K. Demetriades 10 , Sam K. Cho 11 , Patrick C. Hsieh 12 , Ashish Diwan 13 , Christopher Martin 14 , Sangwook Yoon 15 , Sathish Muthu 16 , AO Spine Knowledge Forum Degenerative 17
  1. Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
  2. Reva Spine Centre, Visakhapatnam, India
  3. Noordwest Hospitals, Alkmaar, The Netherlands
  4. Gerling Institute, Brooklyn, USA
  5. BG Klinikum Bergmannstrost Halle, Halle, Germany
  6. McMaster University, Hamilton, Canada
  7. The University of Hong Kong, Hong Kong SAR, China
  8. University of California, Davis, USA
  9. Johns Hopkins University, Baltimore, USA
  10. Royal Infirmary, Edinburgh, UK
  11. Icahn School of Medicine at Mount Sinai, New York, USA
  12. Keck School of Medicine, University of Southern California, Los Angeles, USA
  13. University of New South Wales, Kogarah, Australia
  14. University of Minnesota, Minneapolis, USA
  15. Emory University, Atlanta, USA
  16. Government Karur Medical College and Hospital, Karur, India
  17. AO Foundation, Davos, Switzerland

Introduction

Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed spine surgeries worldwide and is characterized by a high success rate. Beyond thorough decompression of neural structures, long-term outcomes largely depend on achieving solid bony fusion. This can be attained through various combinations of implants (e.g., cages and plates) and osteobiologics. However, the variability of studies investigating possible alternatives, coupled with differing regulatory aspects across countries, such as reimbursement policies and market availability, has led to a fragmented and inconsistent use of osteobiologics among practitioners. AO Spine recently developed an international guideline, the AO Spine Guideline for the Use of Osteobiologics (AOGO), to summarize the best available evidence. The aim of this study was to evaluate global practices and preferences regarding the use of osteobiologics in ACDF and to identify factors influencing the selection of specific osteobiologics.

 

Methods
A global online survey developed by AO Spine was distributed to spine surgeons. The survey gathered data on demographics, osteobiologic usage, training background, practice patterns, and factors affecting the choice of osteobiologics in ACDF. Descriptive statistics, Chi-square tests, and multiple logistic regression were applied to identify associations between osteobiologic use and variables such as training, cost awareness, and regional practices.

 

Results
A total of 458 surgeons participated, highlighting significant regional differences in osteobiologic preferences. Autologous iliac crest bone graft (AICBG) was the predominant choice in the Asia-Pacific and Middle Eastern regions, while allograft and demineralized bone matrix were more commonly used in North and Latin America (p<0.0001) (Fig. 1). Over half of the respondents reported no formal training in osteobiologics, and 53.1% were unaware of their associated costs. Surgeons in rural settings (OR: 0.10, 95% CI: 0.01–0.52, p=0.014), those in the Asia-Pacific region (OR: 0.38, 95% CI: 0.14–0.97, p=0.045), and those using cages infrequently (OR: 0.11, 95% CI: 0.04–0.26, p<0.0001) were less likely to utilize osteobiologics. Conversely, osteobiologic use was more frequent when costs were not a significant concern (OR: 2.30, 95% CI: 1.42–3.74, p=0.0008).

 

Discussion
Osteobiologic utilization in ACDF varies significantly across global regions and is influenced by surgeon training, cost awareness, and resource availability. Standardized training programs and clearer guidelines are necessary to ensure consistent and effective application of osteobiologics in clinical practice. In this context, the AOGO guideline marks a significant milestone as it is the first to offer extensive evidence-based recommendations for the use of osteobiologics in ACDF.

 

Fig. 1. Regional distribution of the three most common osteobiologics. Abbreviations: AICBG = autologous iliac crest bone graft; DBM = demineralized bone matrix.

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