Postoperative pain following posterior iliac crest bone graft harvesting in spine surgery: a prospective, randomized trial

Publication date: Available online 14 November 2017
Source:The Spine Journal
Author(s): Evan D. Sheha, Dennis S. Meredith, Grant D. Shifflett, Benjamin T. Bjerke, Sravisht Iyer, Jennifer Shue, Joseph Nguyen, Russel C. Huang
Background ContextPost-operative pain at the site of bone graft harvest for posterior spine fusion is reported to occur in 6% to 39% of cases. However, the area around the posterior, superior iliac spine is a frequent site of referred pain for many structures. Therefore, many postoperative spine patients may have pain in the vicinity of the posterior iliac crest that may not in fact be caused by bone graft harvesting. The literature may then overestimate the true incidence of postoperative iliac crest pain.PurposeWe performed a prospective study testing the hypothesis that patients will not report significantly higher visual analog scores over the graft harvest site when compared to the contralateral, non-harvested side.Study design/SettingProspective, randomized cohort studyPatient SamplePatients aged 18-75 years undergoing elective spinal fusion of 1-2 levels between L4 and S1 for spinal stenosis and spondylolisthesis were randomized to left-sided or right-sided iliac crest bone graft (ICBG) donor sites and blinded to the side of harvest.Outcome MeasuresPrimary outcome was a 10-point Visual Analog Scale (VAS) for pain over the left and right posterior superior iliac spine.MethodsBone graft was harvested via spinal access incisions without making a separate skin incision over the crest. Each patient's non-harvested side served as an internal control. Data points were recorded by patients on their study visit sheets pre-operatively and at 6 weeks, 3 months, 6 months and 1 year post-operatively.ResultsForty patients were enrolled in the study (23 females) with an average follow-up of 8.1 months (1.5 – 12 months). Mean age was 51.7 years (23-77 years). Left and right side ICBG harvesting was performed equally between the 40 patients. The average volume of graft harvested from the left was 35.3 mL (15-70 mL) and 36.1 mL (15-60 mL) from the right. There was no statistical difference between pre-operative VAS score on the harvested side compared to the non-harvested side (p=0.415). Post-operatively, there were consistently higher VAS scores on the operative side; however, these differences were not statistically significant at 6 weeks (p=0.111), 3 months (p=0.440), 6 months (p=0.887), or 12 months (p=0.240). Both groups did, however, show statistically significant improvements in VAS scores over time within the operative and non-operative sides (p<0.05). Graft volume had no effect on the VAS scores (p=0.382).ConclusionsThe current literature does not adequately illuminate the incidence of post-operative pain at the site of harvest and the relative magnitude of this pain in comparison to the patient's residual low back pain. This is the first study to blind the patient to the laterality of bone graft harvesting. Our randomized investigation showed that while pain on the surgical side was slightly higher, it was neither clinically or statistically different from the non-surgical side. Our conclusion supports surgeons' use of autologous bone graft, which offers a cost-effective, efficacious spinal fusion supplement.



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