Comparing efficacy, utility, and cost challenges of osteobiological agents.
| Agent | Properties | Efficacy | Costs | Challenges | Opportunities |
| Bone morphogenetic proteins | Proteins involved in the differentiation of osteoblasts and chondroblasts | Comparable and high | High | Variable fusion rates across different procedures, associated with serious complications | New delivery methods to reduce dose-limiting effects; advantages outweigh risks in vulnerable population |
| Platelet-rich plasma | Contains growth factors | Promising | Unavailable | Lack of standardization in research protocols | High fusion rates |
| Autologous conditioned serum | Growth factors extracted from the patient’s serum | Inconclusive | Unavailable | No evidence regarding improving fusion rates | Cost-effective |
| Demineralized bone matrix | Graft extender containing growth factors | Effective, but as an adjunct | Lower than nonautologous graft materials but still relatively high | Extreme variability in the number and types of products available for an accurate comparison, limited data for use in anterior spinal fusions | Improved clinical outcomes, lower intraoperative blood loss, and improved physical function. |
| Biomaterial scaffolds (ceramics and polypeptide-based compounds) | Synthetic grafts made of osteoconductive materials | Variable | High | Limited use in the anterior spine, increased resorption rates, brittle and weak in tension-based posterior spinal fusions | High efficacy in spinal fusion, synthetic, biodegradable, nontoxic, and noninflammatory. |
| Stem cells (mesenchymal and adipose-derived) | Possessing autocrine and paracrine properties, effective for lineage progression and differentiation | Limited studies in humans | High | Low yield of mesenchymal stem cells from bone marrow, difficulty in increasing their concentration in implanted grafts, potential risks associated with systemic viral or bacterial toxicity, immunity to certain viral strains, and ethical concerns surrounding genetic engineering and cell therapy. | Improved postsurgery outcomes, comparable uptake, reduced healing time, comorbidities and systemic factors do not affect their outcomes adversely. |
| Cellular bone matrices | Osteoconductive grafts made by combining allogeneic bone with allogeneic stem cells | Promising | High | Lack of FDA requirement for preclinical or clinical data before commercial usage, effective concentration threshold rates still unknown. | High fusion rates |
Abbreviation: FDA, US Food and Drug Adminstration.