CHAPTER
100
Structural Grafting for Adult
Spinal Deformity
INTRODUCTION
Biomechanical and clinical research has demonstrated the
advantages of anterior column structural support for the resto-
ration and maintenance of sagittal alignment and for achieving
solid fusion, particularly at the lumbosacral junction. Whether
placed from a dorsal or ventral approach, structural grafts in
line with or ventral to the line of axial load bearing may improve
the segmental sagittal and coronal alignment, effectively resist
physiological axial forces, and help to immobilize the spinal
segment. The result can be optimal spinal alignment and an
increased probability of achieving solid arthrodesis.
In cases of complex spinal deformity, structural grafting may
be a critical part of the correction as well as an essential ele-
ment for the long-term outcome by promoting segmental
arthrodesis. The correction of a severe deformity, whether with
an anterior/posterior procedure, a pedicle subtraction osteot-
omy, or a vertebral column resection, involves significant cor-
rective moments and changes in the position of the axial grav-
ity line. Spinal fixation devices may be used to exert corrective
forces on the spine, but significant long-term cantilever forces
on either anterior or posterior instrumentation without ade-
quate axial structural support are likely to result in implant fail-
ure through fatigue and fracture or pullout. The strategic use
of interbody grafts in spinal deformity surgery may reduce the
corrective forces necessarily applied to fixation points, improve
the correction, and increase the probability of achieving bony
fusion by enhancing segmental rigidity and placing a relatively
large volume of graft material under compression.
The decision-making process regarding structural grafting in
adult patients with spinal deformity can be quite complex.
Among the factors that are often considered are the necessity of
structural grafting and at what levels, whether to use an anterior
or posterior approach, whether to perform a staged or a same-
day procedure, the design and material of the graft, and the type
of nonstructural bone graft or biological material to use with the
structural graft. As with many decisions of this sort in spinal
deformity surgery, no general recommendations can be made
based on unequivocal clinical data. The potential downside of
the complexity introduced by the variety of options available to
the surgeon is offset, however, by the likelihood that a rational
plan can be developed for the safe, effective treatment of each
patient with a high probability of achieving clinical success.
1052
LWBK836_Ch100_p1052-1058.indd 1052
Peter D. Angevine
Keith H. Bridwell
INDICATIONS FOR STRUCTURAL
GRAFTING
The two key indications for structural grafting in adult spinal
deformity surgery are to achieve or maintain correction and
alignment, particularly in the treatment of kyphotic deformi-
ties, and to increase the likelihood of achieving solid arthrod-
esis. These goals are often complementary. The graft may be an
integral element of corrective maneuvers, particularly in the
treatment of an angular kyphosis, or it may be placed to pre-
vent settling and loss of correction or alignment achieved
through other means such as posterior fixation. Likewise, struc-
tural grafting may be performed to be the primary site of arthr-
odesis or planned as an adjunctive procedure to supplement or
foster posterior arthrodesis. In some cases, structural grafting
may not be necessary or desirable; morselized graft material,
typically autologous bone, may be used in these circumstances
(Fig. 100.1).
A common application of structural grafting is interbody
grafting in the distal (caudal to L3) lumbar spine in patients
with degenerative lumbar scoliosis. Patients with degenerative
scoliosis often have decreased bone mineralization and are at
increased risk of implant failure without anterior support.
Proper interbody grafting offloads posterior instrumentation
and decreases the likelihood of implant failure. The lum-
bosacral junction is a region of high probability of pseudarthro-
sis, and interbody grafting reduces the likelihood of nonunion
at that level. In addition, if performed prior to posterior instru-
mentation, the placement of appropriately sized lordotic grafts
can enhance segmental lordosis, correct coronal deformity,
and increase the height of the neural foramina.2 Appropriately
sized grafts are particularly effective, in our experience, in
reducing lateral olisthesis.
In the thoracic spine, grafts may be placed segmentally at
multiple levels as part of an anterior release procedure in a
patient with a relatively inflexible kyphosis or kyphoscoliosis.
Anteriorly placed structural grafts increase the ventral interver-
tebral disc height and produce segmental correction of hyper-
kyphosis. Subsequent posterior instrumentation and segmental
compression, possibly with posterior osteotomies, may then
used to further reduce thoracic kyphosis.
In some cases, the structural graft is essential to achieve a
large correction or to maintain load sharing and to avoid
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Anterior approach?
Yes No
Primary goal
Arthrodesis
Release/
correction
Yes Structural graft
Anterior instrumentation?
No
Morselized graft
Figure 100.1. Decision-making algorithm for structural versus
morselized interbody grafting following thoracic or lumbar discec-
tomy in spinal deformity.
relying solely on posterior instrumentation and fusion. If a sig-
nificant kyphosis remains even after correction of a deformity,
posterior instrumentation and dorsal arthrodesis may not be
sufficient to achieve solid bony fusion. Structural grafting and
anterior arthrodesis reduce the demand on the posterior con-
struct and place the bone graft in compression, thereby improv-
ing the likelihood of achieving a solid fusion.
A single structural graft or multiple segmental grafts placed
at the kyphotic level(s) also maintain the anterior height of the
spine during dorsal compressive correction maneuvers. A ven-
trally placed graft acts as a fulcrum about which the segment
rotates during compression. Achieving correction through
manipulation of the posterior instrumentation requires, of
course, that no rigid anterior instrumentation has been
placed.
Structural grafts increase the likelihood of achieving arthro-
desis by providing structural support and increasing segmental
rigidity. Structural grafts also provide room for nonstructural
bone graft or biologically active material necessary to achieve
solid anterior arthrodesis. Care must be taken, however, to try
to ensure that the nonstructural graft is not entirely shielded
from compressive forces, as that may decrease the likelihood of
achieving fusion.
Particular regions of the spine may have an increased pro-
pensity to nonunion either due to anatomic or due to iatro-
genic factors. The lumbosacral and thoracolumbar junctions,
for example, have been demonstrated to be high-risk areas for
pseudarthrosis in patients with adult spinal deformity.6 Other
potential areas of concern include levels at which wide lamine-
ctomies and facetectomies are performed, reducing the surface
area available for grafting, or areas with significant implant
bulk due to cross-links or rod-to-rod connectors. These may be
some factors considered in determining the need for and loca-
tion of structural interbody grafts.
ANTERIOR VERSUS POSTERIOR
APPROACH
Although structural spinal grafts are, by definition, placed in
the ventral spine, there are several different strategies and tech-
niques for placing the grafts. Some options include a one-stage
all-posterior procedure including transforaminal or posterior
LWBK836_Ch100_p1052-1058.indd 1053
Chapter 100 Structural Grafting for Adult Spinal Deformity 1053
interbody fusion, a 1-day anterior interbody fusion followed by
a posterior procedure, or staged surgery with a posterior proce-
dure followed at some interval (usually 1 to 6 weeks) by an
anterior interbody fusion. The surgeon employs these or other
strategies based on many factors, including the relative advan-
tages and disadvantages of each technique, his or her familiar-
ity with each, patient variables, and the goals of surgery. A brief
summary of these considerations is given here.
Posterior lumbar interbody fusion (PLIF) with structural
grafts has a long established history as an effective method for
placing anterior structural grafts via a posterior approach.3 The
transforaminal lumbar interbody fusion (TLIF) approach may
have benefits over the bilateral PLIF approach by using a more
lateral corridor for access to the disc space and employing a
single graft. Either procedure may be used in many patients as
an alternative method of interbody grafting to a formal ante-
rior approach when the goal is primarily to enhance arthrode-
sis and to achieve a modest amount of segmental lordosis. A
history of extensive abdominal surgery or an unfavorable
patient habitus may make an all-posterior procedure preferable
to a separate anterior procedure. Posterior or transforaminal
interbody grafting may also be the procedure of choice if exten-
sive posterior decompressions or osteotomies are required that
will result in wide posterior access to the intervertebral disc
space.
An anterior approach, on the other hand, may be selected
for the lumbar spine based on several factors. An anterior
approach has the potential benefit of maintaining the posterior
elements for bone grafting surface and avoiding manipulation
of the nerve roots with its attendant risk of postoperative rad-
iculitis. In general, a single, larger-diameter graft can be placed
into the lumbar intervertebral disc space with an anterior
approach compared with a posterior or transforaminal
approach. Significant correction is generally obtained through
the combination of wide discectomies and segmental distrac-
tion with ligamentotaxis. Finally, the addition of multiple poste-
rior or transforaminal interbody grafting procedures to an
extensive posterior operation, such as long instrumentation
with multiple osteotomies, may extend the duration of the sur-
gery unacceptably and a separate anterior surgery may be pref-
erable, often in a separate stage. An anterior-first approach to
structural grafting is avoided, however, if there is severe neural
compression evident on preoperative radiographic studies or a
clinical neurological deficit corresponding to the levels of sur-
gery. In these situations, the posterior procedure, including
neural decompression, is performed prior to correction and
grafting.
Both anterior and posterior approaches for structural graft-
ing are feasible in the thoracic spine, as well. Anterior release
and interbody grafting for large, stiff scoliotic and kyphotic
deformities is an effective technique to achieve maximal cor-
rection. On the other hand, rigid thoracic deformities may be
treated with excellent results with an all-posterior approach for
vertebral column resection, interbody graft placement, and
posterior fixation and arthrodesis.
With the development of improved posterior instrumenta-
tion systems, more extensive deformity correction is possible
through a posterior approach. A posterior-only approach for
complex spinal deformity has obvious benefits over separate
anterior and posterior procedures. The advantages of a single
approach and its attendant potential decrease in morbidity are
not justified, however, if inadequate structural support is
8/26/11 3:02:28 PM
 1054 Section VIII Adult Spinal Deformity

Anterior approach Posterior approach

Thoracic Lumbar Thoracic Lumbar

Osteoporosis No Osteoporosis No Osteoporosis No Osteoporosis No

osteoporosis osteoporosis osteoporosis osteoporosis

Prefer: Prefer: Prefer: Prefer: Prefer: Prefer: Prefer: Prefer:

Allograft Titanium Allograft Allograft Allograft Titanium PEEK Titanium
PEEK PEEK PEEK Titanium PEEK PEEK Allograft Peek
Expandable cage Allograft Expandable cage PEEK Expandable cage Expandable cage Expandable cage

Figure 100.2. Structural graft material/design options for thoracic and lumbar vertebral resection
(corpectomy) for spinal deformity. Titanium, vertical titanium cage; PEEK, polyetheretherketone. Expandable
cage may be PEEK or titanium.

obtained through a posteriorly placed graft. Further study is
necessary to determine the relative clinical and radiographic
outcomes with the various approaches.
STRUCTURAL GRAFTING
MATERIALS AND DESIGN
After determining the need for structural grafting and decid-
ing on an approach and an overall surgical strategy, the sur-
geon must select the type of graft to use. There is a wide variety
of graft materials and designs available, and the selection is
increasing. The surgeon should be familiar with the potential
advantages and disadvantages of the different materials and
designs to make an informed decision for each patient.
Although there are no ironclad rules regarding graft material
or design selection, some grafts are better suited than others to
use in particular circumstances (Fig. 100.2, Table 100.1).
AUTOGRAFT
Although autologous bone has a long history of use in the spine
and an ideal theoretical risk/benefit profile as a graft material,
it is of limited use as a structural graft material in adult spinal
deformity patients. Structural autograft, which is essentially bi-
and tricortical iliac crest, is limited in quantity and size. In addi-
tion, the strength of the graft in resisting axial loading depends
upon the mineral density of the bone, which can be low in the
adult deformity patient population. Finally, autograft harvest-
ing is associated with significant potential morbidity including
graft site complications and chronic pain.
Specialized autologous grafts do, however, have a role in
severe kyphotic deformities. In the case of a very stiff kyphosis
in which a significant residual local deformity is expected, a
bowstring graft may be used to offload the posterior instru-
mentation. In these cases, a vascularized structural rib or fibu-
lar autograft may be used to span multiple segments to main-
tain alignment and increase the likelihood of an anterior
arthrodesis.
Other than this uncommon scenario, the use of autologous
bone as structural graft in adult spinal deformity is limited. It
remains, however, the gold standard material for morselized,
nonstructural bone grafting. Autograft bone is packed within
and around the structural graft to provide the substrate for the
ultimate arthrodesis.

TABLE 100.1 Indications for use of Graft Materials

Indication

Intervertebral Anterior Thoracic or

Fusion Thoracic VCR Lumbar VCR Lumbar Corpectomy Osteoporosis
Graft material/ Vertical Ti cage
design PEEK
Structural allograft
Expandable cage
(PEEK or Ti)

PEEK, polyetheretherketone; VCR, vertebral column resection.

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ALLOGRAFT
A wide variety of allogeneic structural grafts are available that
do not have many of the manifest limitations of autologous
grafts. A small study that compared radiographic and clinical
outcomes of patients who underwent revision surgery for pseu-
darthrosis or lumbar flatback using autogenous tricortical iliac
crest or femoral ring allograft (FRA) found that, despite a
higher pseudarthrosis rate, the cohort of patients that received
the FRA had a higher proportion of patients that achieved an
overall successful outcome. The cohort of allograft patients was
older and had a higher proportion of patients with flatback
compared with the autograft group.1
Allogeneic bone must be processed to remove proteins that
might cause an immune response. Options for allogeneic bone
include fresh frozen, freeze dried, and irradiated. All processing
methods affect the osteogenic potential of the graft and may also
alter the structural characteristics of the graft. None, however,
completely eliminates the risk of disease transmission.
Machined structural allografts are available that minimize
the variation in quality between grafts. These are typically har-
vested from regions of dense cancellous bone such as the prox-
imal femur or calcaneus and oriented such that, when placed
in the spine, the axial forces are aligned in the direction of
loading of the bone in its original site.
Long-term (at least 5-year) follow-up of patients with sagittal
plane deformity who underwent posterior segmental spinal
instrumentation, posterolateral arthrodesis with autogenous
bone, and anterior structural grafting with fresh-frozen allograft
(tricortical iliac crest or tibial or femoral ring) demonstrated a
98.5% arthrodesis rate (based on plain radiographs) and no
significant collapse with loss of correction.7 Although the use of
recombinant human bone morphogenetic protein-2 (rhBMP-2)
with stand-alone FRA has been associated with a high propor-
tion of pseudarthroses, the use of FRA with rhBMP-2 and poste-
rior pedicle screw fixation has been shown to result in a high
likelihood of fusion in short-segment lumbar constructs.8,10 The
applicability of these results to the adult spinal deformity popu-
lation is not certain.
TITANIUM
Vertical titanium cages (distinct from threaded titanium cages)
are versatile, widely available structural grafting devices. Com-
pared with allograft, polyetheretherketone (PEEK), and carbon
fiber grafts there is a large internal volume for a given overall
graft diameter available for the placement of graft material.
The cages come in many diameters, cross-sectional and longi-
tudinal shapes, and precut lengths. They may be customized in
the operating room to fit most defects.
The thin profile of the graft interface with the vertebral
body and the high modulus of elasticity may increase the likeli-
hood of graft subsidence. To minimize this possibility, the end
plates should be meticulously prepared and the subchondral
boney end plate preserved and the devices should engage the
peripheral aspect of the end plate where the bone is densest. In
a series of 50 patients with a variety of diagnoses, the mean loss
of correction from immediately after surgery until final follow-up
(2 or more years) was 2 and less than 1 in the sagittal and coro-
nal planes, respectively. There was also a high degree of agree-
ment among multiple assessors regarding the interpretability of
LWBK836_Ch100_p1052-1058.indd 1055
Chapter 100 Structural Grafting for Adult Spinal Deformity 1055
radiographs for determining fusion status in the presence of
titanium cages.4 Our experience has not demonstrated a high
degree of subsidence of titanium vertical cages or loss of lum-
bar lordosis when used in the distal lumbar spine in adult spinal
deformity patients. Larger-diameter titanium cages and the use of
an internal end ring have been shown to increase the strength of
the implant--vertebra interface.5
PEEK/CARBON FIBER
Synthetic grafts in a variety of materials are now available. Two
of the most commonly used materials are PEEK and carbon
fiber; both have the advantage of being configurable to a wide
variety of shapes. Wider contact areas and moduli of elasticity
close to that of bone may reduce the likelihood of subsidence
and graft settling. This comes, however, at a cost of smaller
internal diameters and lower volumes available for the place-
ment of bone graft. Because PEEK and carbon fiber are both
radiolucent, grafts typically include radio-opaque markers to
allow evaluation of intraoperative fluoroscopy and postopera-
tive radiographs.
A study of the biomechanics of graft design and end plate
preparation found that, in vitro, the most important factors
associated with decreased resistance to axial force were
increased age, decreased bone mineral density, and decreased
end plate coverage by the graft. With peripheral engagement
of the end plate by the graft removal of the central bony end
plate did not significantly reduce the strength of the vertebra in
resisting an axial load applied to the graft.11
EXPANDABLE DEVICES
A recent development in spinal devices is the expandable cage.
Made of titanium or PEEK, these devices are placed into a
defect in the anterior spine, typically after a corpectomy, and
mechanically expanded to engage the end plates proximally
and distally. Several studies have been published that support
the use of these devices in patients with tumors. One significant
advantage is that they eliminate the need to precisely measure
the defect and select or cut the graft to fit tightly. Their expand-
ability can also facilitate the placement of an anterior graft
from a posterior approach.9,12 Their use in adult deformity
remains to be investigated and reported.
COMPLICATIONS
In addition to the potential complications attendant to the
overall surgical procedure, there are specific complications
that may be encountered with the use of structural grafts. Struc-
tural grafts may dislodge from their initial position. In some
cases, only a small migration may occur that is of no clinical
significance. On the other hand, the graft may completely dis-
lodge, no longer provide structural support, and put adjoining
visceral or vascular structures at risk. Revision surgery, often
with replacement of the graft, is indicated in most cases.
It may be expected that, with the application of axial load-
ing to the structural graft, some degree of subsidence of the
graft relative to the adjacent vertebral bodies will occur. This
may be minimized with the placement of instrumentation,
either anterior or posterior, that shields the graft from the full
8/26/11 3:02:28 PM
 1056 Section VIII Adult Spinal Deformity
axial load. A small amount of subsidence is not likely to lead to
a suboptimal radiographic or clinical outcome. Significant sub-
sidence can, however, result in loss of correction, pseudarthro-
sis, instrumentation failure, or a combination of these. End
plate preparation, graft selection, and graft placement should
all be performed to minimize the likelihood of significant sub-
sidence. Care must be taken to preserve the boney end plates,
and grafts should be sized and placed to engage the denser
bone at the periphery of the end plate rather than the central
cancellous bone.
Nonunion may also occur in the setting of structural graft-
ing. It is possible, however, to have an asymptomatic nonunion
at the site of the structural graft if a solid posterior arthrodesis
has been achieved. The assessment of the state of an anterior
fusion with a structural graft may be complicated by artifact.
Flexion and extension radiographs and high-resolution
computed tomography (CT) scans with multiplanar reconstruc-
tions are used to assess the status of the arthrodesis. Operative
CASE 100.1 Degenerative scoliosis. Anterior lumbar interbody fusion
A 70-year-old woman presented with severe, progressive
back and leg pain despite maximal medical management.
Anteroposterior (AP) and lateral radiographs show a degen-
erative lumbar scoliosis (Figs. 100.3A and B). She under-
went a two-stage procedure consisting of a posterior
A B
Figure 100.3. (A and B) Preoperative anteroposterior (AP) and lateral radiographs. (C and D) Postopera-
tive AP and lateral radiographs.
LWBK836_Ch100_p1052-1058.indd 1056
exploration and revision may be indicated in the presence of
symptoms consistent with a pseudarthrosis.
CONCLUSION
Structural grafting is an essential component of the surgical treat-
ment of many patients with adult spinal deformity. In degenera-
tive lumbar scoliosis, lumbar and lumbosacral interbody grafting,
through either an anterior or a posterior approach, is performed
as an adjunctive procedure to the posterior instrumentation and
arthrodesis to improve the correction and to increase the likeli-
hood of achieving a solid fusion. In more complex deformity sur-
gery, particularly kyphosis corrections, structural grafting is often
integral to achieving and maintaining correction. Careful preop-
erative planning and selection and placement of appropriate
structural grafts are essential to achieving clinical success in the
surgical treatment of adult spinal deformity.
lumbar decompression and instrumented fusion and,
1 week later, a paramedian retroperitoneal approach to
L2-S1 for anterior structural grafting with vertical titanium
cages and rhBMP-2. Six-month postoperative radiographs
are shown in Figures 100.3C and D.
C D
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 Chapter 100 Structural Grafting for Adult Spinal Deformity 1057

CASE 100.2 Postlaminectomy kyphosis. Transforaminal lumbar interbody fusion, staged transpsoas
interbody fusion

A 41-year-old man presented 5 years after a multilevel lum-
bar laminectomy for lumbar stenosis with complaints of an
inability to stand erect and severe back pain (Figs. 100.4A
and B). He underwent an L2 pedicle subtraction osteotomy
and posterior instrumented fusion with TLIF
at L1-2 and L5-S1. Six weeks later a minimally invasive
transpsoas approach was used to perform an L2-3 interbody
fusion. All grafts were PEEK. One-year postoperative radio-
graphs are shown in Figures 100.4C and D.

A B C D

Figure 100.4. (A and B) Preoperative anteroposterior (AP) and lateral radiographs. (C and D) Postopera-
tive AP and lateral radiographs.

7. Molinari RW, Bridwell KH, Klepps SJ, Baldus C. Minimum 5-year follow-up of anterior
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