Although autologous bone graft from the iliac crest is the gold standard for most spinal fusion applications, it is known to cause significant graft-site morbidity. Unlike the traditional corticocancellous allograft, the intracortical method leaves the iliac crest in continuity and decreases the surgical incision and overall area of dissection. We hypothesized this modified technique would decrease pain and complication rate. We first performed an extensive literature review to ascertain which questions, variables, and results were found to be statistically significant regarding the postoperative course and complication rates in patients who underwent iliac crest bone grafting. We then created an Iliac Crest Bone Graft survey that was mailed to 293 patients who had undergone intracortical iliac crest bone graft at our institution to assess postoperative pain and complications.
One hundred one (34.5%) surveys were returned. Differences in chronic pain between the surgical types (cervical, lumbosacral, traumatic, and scoliosis) using the intracortical technique showed a trend toward statistical significance (F=2.42, P<.071); this trend was mostly due to no chronic pain reported in the cervical and traumatic groups. Patients experiencing chronic pain at their graft site using the intracortical technique had a statistically significant difference in pain between the same incision versus a separate incision (F=5.05, P<.027), with a separate incision having lower reported pain. After meta-analyses were performed with articles obtained in the literature search using the traditional corticocancellous technique and compared to our results, the only variable that obtained statistical significance was decreased chronic pain at 2 years with the intracortical method in our study (P<.001).
Autologous iliac crest bone graft is used as an adjunct treatment for fractures, in the treatment of nonunions, as a packing of osseous lesions, and as an aid in obtaining arthrodesis. In fact, arthrodesis of the spine has become the most common reason for autologous bone graft harvest.1 Approximately 200,000 autologous bone grafts are harvested annually in the United States, most commonly from the posterior iliac crest.2
The iliac crest is the most common donor site because of easy access and procurement.3 Iliac crest bone grafts contain osteogenic properties (determined and inducible osteogenic precursor cells), osteoinductive properties (noncollagenous bone matrix proteins, including growth factors), and osteoconductive properties (bone mineral and collagen).1 The cancellous component of autograft contains greater osteogenic potential because of the large number of surviving cells in the marrow, a trabecular environment favoring vascular ingrowth, and the accessibility of osteoinductive proteins.1 Cortical bone has less osteogenic potential, however, and because it is compact bone, it is resistant to vascular ingrowth and remodeling.1 Autografts that are used in nonloaded or tension environments, such as the posterior or posterolateral spine, do not require cortical integrity.1 In addition, autografts are also nonimmunogenic and decrease the risk of disease transmission compared to allografts and other synthetic substitutes.3 Because of these properties, autologous bone grafting has become the most commonly used source of graft and is the gold standard for most spinal fusion applications.
The major drawback to the use of autologous iliac crest bone graft is graft-site morbidity. Major complications of iliac crest bone grafting include deep infection, iliac fracture, chronic pain, arterial injury, arteriovenous fistula formation, abdominal organ herniation, pelvic instability, ureteral injury, major hematoma formation requiring operative irrigation, and nerve injury.1-19 Minor complications of iliac crest bone grafting include temporary pain, transient gait disturbances, superficial hematomas, superficial seromas, scar dysesthesia, local numbness and tenderness, hypertrophic scars, stitch abscesses, and prolonged drainage.1-19
The most common symptoms attributable to the donor site are pain and sensory disturbances.3 Previous studies have indicated that although major complications are rare, minor complications are common, with rates ranging from 10% to 39%.4,,5 During the immediate postoperative period, patients may experience more pain from the donor site than from the primary spinal operation.6 In addition, the cause of long-lasting and sometimes permanent pain at the donor site is unknown.7 Other disadvantages of autologous bone graft include limited volume of cancellous bone, increased operative time, increased blood loss, and temporary disruption of the normal donor-site bone structure.8
The traditional method of obtaining the iliac crest bone graft is to make an incision over the iliac crest, detach the origin of the gluteus maximus, and remove strips of corticocancellous bone using osteotomes. Although this provides the surgeon with a large amount of bone graft, it also involves a substantial surgical dissection.9 The proximity of the bone graft site to vascular and neurological structures accounts for many of the most serious complications in bone graft surgery.2 In addition, interference with the insertion of the gluteus muscles causes an inherent risk of gait disturbances.10
Mirovsky and Neuwirth7 described a modified technique that involves making a window in the cortical bone of the iliac crest and then using gouges to extract the cancellous bone through the defect. This procedure, called intracortical, leaves the iliac crest in continuity and decreases the surgical incision as well as the area of dissection.7 Based on an extensive literature review, only one study comparing the results of corticocancellous versus intracortical methods of iliac crest bone grafting has been published previously.7 The results of this study did not show any statistically significant differences in regard to pain or postoperative bleeding.7 However, the study was determined to be underpowered based on a subsequent review.11 We hypothesized that the modified technique for iliac crest bone grafting decreases pain and complication rates compared to the traditional technique.
Materials and Methods
One of the authors (R.F.T.) has been using the intracortical method to obtain iliac crest cancellous autograft for the past decade. Instead of removing the outer cortex of the ilium with the underlying cancellous bone using osteotomes, a small window in the iliac crest cortex (trap door) is made and curettes are used to harvest the cancellous bone from between the cortices. After the bone has been harvested, the cortical window is replaced into its osteotomy site in the iliac crest.
To examine our hypothesis, patients who had undergone the intracortical method of iliac crest bone grafting for spinal surgery at our institution were identified using an electronic database. Institutional review board approval was obtained for research involving humans, and the Iliac Crest Bone Graft Survey, along with a description of the research and consent forms, was mailed to 293 patients who had undergone the intracortical method of iliac crest bone grafting.
The Iliac Crest Bone Graft Survey was constructed by first performing an extensive literature review to ascertain which questions, variables, and results were found to be statistically significant in previous studies regarding the postoperative course and complication rates in patients who had iliac crest bone grafting. Eighteen published articles, which included primary studies, literature reviews, and case reports were selected and analyzed. Based on these analyses, we constructed the Iliac Crest Bone Graft Survey. The first part of the survey collected demographic data including sex, age, date of surgery, type of spinal surgery (cervical, thoracic, lumbar, post-traumatic, or scoliosis), the area of bone grafting (anterior or posterior), the presence of a separate incision, and the present or past use of tobacco.
The next part of the survey ascertained the level of pain experienced by patients. Pain was subdivided into acute and chronic (>6 months).3-4,8 Each section contained questions regarding peak intensity, use of analgesic medications, problems with daily activities due to pain, timing of the pain resolution, and a visual analogscale (VAS).3-4,8 The VAS is a validated instrument of subjective pain based on a scale of 1 (minimal pain) to 10 (worst pain ever experienced).3-4,8 Questions regarding permanent disabilities were included in the chronic pain section. Questions regarding skin irritability; cosmetic appearance; numbness; presence of postoperative hematomas, seromas, and infections; and the occurrence of arterial and neural injuries at the donor site also were asked.3-4,8 Finally, patients were asked to rate their overall satisfaction with the iliac crest bone grafting procedure (Table 1).
After a collection period of 6 months, 101 (34.5%) surveys were returned. Unfortunately, not all 101 surveys had every question completed, as omitted and partially completed answers occurred frequently (Table 1). Thus, there are different numbers of respondents for certain questions. A power analysis determined 38 patients were needed to achieve a 95% chance of detecting a 10% difference between groups.
Thirty-one men and 71 women returned the survey. Patient ages ranged from 13 to 77 years; mean age was 50.6 years, and the mode was 56 years (6 patients). The surgical dates ranged from February 2000 to March 2005, with the majority of respondents having undergone surgery between 2002 and 2004. The majority of patients had bone graft taken for lumbosacral spinal surgery requiring fusion (61.7%), followed by surgery to correct scoliosis (18.1%), cervical surgery (17%), and post-traumatic surgery (3.2%). Seven patients (6.9%) were current smokers, and 38 patients (37.6%) quit smoking perioperatively. Iliac crest bone graft was taken through the same incision in 65 patients, through a separate incision in 29 patients; 7 patients replied they were unsure (Table 2).
The 101 surveys were analyzed, and the results were dummy-coded into a spreadsheet using Statistical Package for Social Sciences (SPSS Inc, Chicago, Illinois) software for Windows. The software subsequently was used to tabulate the results for all of the responses.
Acute Pain and Complications
The first broad category was pain and complications within the first 6 months postoperatively (acute). Pain at the donor site in the first 6 months was present in 47 patients (46.5%), with a mean VAS score of 5.16 (1=no pain and 10=worst pain ever experienced) (Table 3). The peak intensity of pain (42 responses) occurred at 1 week for 17 patients (40.5%), 1 month for 14 patients (33.3%), 3 months for 9 patients (21.4%), and 6 months for 2 patients (4.8%).
Of the 43 responses to the question on whether pain medication was used, 13 patients (30.2%) reported using no medication and 30 patients (69.8%) reported using some type of pain medication. Of the 30 patients who used pain medication, 9 (20.9%) used nonsteroidal anti-inflammatory medications (NSAIDs), 11 (25.6%) used narcotics occasionally, and 10 (23.3%) used narcotics daily. Of 59 respondents, 28 (47.5%) reported problems with activities of daily living (ADL), with problems occurring equally during walking, bending over, stair climbing, and sleeping. For patients who experienced acute pain, 43 (91.7%) reported pain was present in the direct area of the iliac crest bone graft. The disappearance of pain in the direct area (43 responses) occurred at 1 month for 13 patients (30.2%), 3 months for 9 patients (20.9%), 6 months for 8 patients (18.6%), and never for 13 patients (30.2%).
Chronic Pain and Complications
The second broad category included pain and complications at the graft site that persisted >6 months after the iliac crest bone grafting procedure (chronic). Chronic pain was present in 20 patients (20.2%), with a mean VAS of 5.72 (Table 3). The peak intensity of the residual pain (17 responses) occurred at 6 months for 9 patients (52.9%), 12 months for 4 patients (23.5%), 18 months for 2 patients (11.8%), and 24 months for 2 patients (11.8%).
Of the 19 responses to the question on whether pain medication was used chronically, 3 patients (15.8%) reported using no medication and 16 patients (84.2%) reported using some type of pain medication. Of the 16 patients who used pain medication, 8 (57.9%) used NSAIDs, 6 (31.6%) used narcotics occasionally, and 2 (10.5%) used narcotics daily. For patients who experienced chronic pain (18 responses), 100% reported pain was present in the direct donor site area of the iliac crest bone grafting. At >6 months postoperatively, 16 of 56 respondents (28.6%) reported problems with ADL, with problems occurring equally during walking, bending over, stair climbing, and sleeping. However, only 8 of 87 respondents (9.2%) viewed themselves as having permanent disabilities.
Scar Problems, Postoperative Complications, and Overall Satisfaction
The third broad category dealt with scar problems, postoperative complications, and overall satisfaction. Persistent skin irritability at the incision site was present in 3 of 70 respondents (4.3%) (Table 3).
Of the 58 responses to the question regarding the cosmetic appearance of the scar, 40 patients (69%) were very satisfied, 11 patients (19%) were satisfied, 6 patients (10.3%) were somewhat satisfied, and 1 patient (1.7%) was somewhat dissatisfied. None of the respondents reported being dissatisfied or very dissatisfied (Table 4).
Numbness at the scar site within the first 6 months was present in 23 of 91 respondents (25.3%). Seventeen of 21 respondents (81%) stated the numbness was directly over the iliac crest bone donor graft site. Numbness that persisted >6 months was present in 11 of 81 respondents (13.6%) (Table 3). Other symptoms at the scar site were present in 22 respondents (21%), with burning and tingling being cited in the majority of responses (22.7% for both symptoms).
Postoperative hematoma occurred in only 2 of 96 respondents (2.1%), and both cases were treated by observation only. Postoperative infection occurred in only 1 of 95 respondents (1.1%) and was treated with antibiotics and observation. Postoperative seroma occurred in 4 of 94 respondents (4.3%), with 3 of the 4 occurring in the first week. Two of the seromas were treated with aspiration, and 2 were treated with observation (Table 5). None of the 101 respondents reported any arterial injuries, neural injuries (meralgia paresthetica), or postoperative iliac crest fractures.
Of the 96 patients who responded to the question on overall satisfaction, 76 (79.2%) were very satisfied, 16 (16.7%) were satisfied, 2 (2.1%) were somewhat satisfied, and 2 (2.1%) were somewhat dissatisfied. None of the patients who responded reported being dissatisfied or very dissatisfied (Table 4).
Analysis of variance (ANOVA) was performed using SPSS to determine whether there were any statistically significant differences among participants in this study. Differences in pain by sex for acute pain (F=1.09, P<.299) and chronic pain (F=0.87, P<.353) were not statistically significant. Differences in acute pain by surgical types (cervical, lumbosacral, traumatic, and scoliosis) were not statistically significant (F=1.03, P<.384). However, differences in chronic pain between the surgical types showed a statistical trend toward significance (F=2.42, P<.071); this statistical trend was attributed to chronic pain being reported in the cervical and traumatic groups.
Patient ages were broken down into the following groups: 13 to 39 years, 40 to 59 years, and >60 years. There were no statistically significant differences due to age in either acute pain (F=0.24, P<.788) or chronic pain (F=0.23, P<.794). Differences in pain among active smokers versus nonsmokers were not statistically significant for either acute pain (F=0.40, P<.842) or chronic pain (F=0.32, P<.572). Differences in pain for patients having their graft obtained from the same incision versus a separate incision were not statistically significant for acute pain (F=0.11, P<.745). However, for patients with chronic pain, there was a statistically significant difference in pain between those with the same incision versus a separate incision (F=5.05, P<.027); those patients who had a separate incision reported less pain (Table 6).
Mann-Whitney tests were performed to compare the results from the previous studies found in the literature search with the results from this survey; Fisher exact tests could not be performed, as the subject numbers were too large. Significant differences were found with the study by Goulet et al2 when looking at complications within the traditional method. The intracortical method had significantly lower levels of residual pain (P<<.01), lower levels of pain at 2 years (P<.001), and decreased chronic use of prescription analgesics (P<.001) compared to the traditional method.
Statistically significant decreased amounts of altered sensation (P<<.05) and improved amounts of satisfaction with the scar (P<.001) were found between our intracortical method and the traditional method reported in the study by Joshi and Kostakis.12 Chronic pain using the intracortical method was decreased compared with the study by Heary et al6 using the traditional method (P<.025), and pain at 2 years was decreased compared to the study by Cricchio and Lundgren10 using the traditional method (P<.025). Ambulation difficulty at 3 months was decreased using the intracortical method compared to the study by Silber et al13 using the traditional method (P<.001), and chronic donor-site sensory changes were decreased compared to the study by Banwart et al4 using the traditional method (P<.01).
For the study by Mirovsky and Neuwirth7 involving both the corticocancellous and the intracortical methods of iliac crest bone graft procurement, pain at 24 months was statistically decreased in our study compared to their corticocancellous method (P<<.001) and their intracortical method (P<.01). When meta-analyses were performed with the articles obtained in the literature search and compared to our results, the only variable that obtained statistical significance was decreased chronic pain at 2 years2,7,10 with the intracortical method in our study (P<.001) (Table 7).
A breakdown of the respondents in this study who had iliac crest bone graft taken via the intracortical approach showed 46.5% had acute donor-site pain and 20.2% had chronic donor-site pain at 6 months, but only 2.1% reported pain at 2 years. When the patient population was examined more closely, 61.7% of our patients had bone graft taken for lumbosacral degenerative spinal surgery requiring fusion, a subset of patients that has been shown to have the worst results in donor-site pain.5,14,15 In addition, at least 63.4% of our patients had the iliac crest graft taken from the same incision (6.9% of respondents were not sure), another subset reported to have poorer results in donor-site pain.14,16 Despite the fact that approximately two-thirds of our patients in each category were the most difficult patients in regard to pain, our results regarding pain were similar to other studies using the traditional technique of obtaining iliac crest autografts in the acute and chronic stages. These similar results are compared to studies that involved a percentage of the bone grafts for nonspinal applications,2,8,10,12 bone grafts in children only,17 and bone grafts for cervical fusions only.13 By 2 years, our reported pain incidence was statistically lower than the studies using the traditional technique that reported a 2-year score.2,7,10
Of the patients in this study, 47.5% had acute problems with ADL, 28.6% had chronic problems with ADL, 4.3% had persistent skin irritability, 25.3% had acute donor-site numbness, and 13.6% had chronic donor-site numbness. However, complications included only 2 hematomas, 1 superficial infection, and 4 seromas, none of which resulted in a return to the operating room. Unlike reports using the traditional technique, no arterial injuries, meralgia paresthetica, hernias, or postoperative iliac crest fractures occurred in our study population.8,18,19
Analysis of variance was performed to determine whether any statistically significant differences occurred in our patient population using the intracortical method of iliac crest bone procurement. The results were consistent with several stated concepts in the literature. There was no statistically significant difference in pain by sex.6,12 The statistical trend toward significance (F<=2.42, P<.071) in chronic pain based on surgical type was due to the absence of chronic pain in the cervical and traumatic groups as opposed to the lumbosacral degenerative group within our study.5,14,15 Differences in chronic pain for having a same incision versus a separate incision also was statistically significant in our study.14,16 Finally, although we did not go through each patients chart to review postoperative pain and numbness as reported by the surgeon, we did not expect such a high positive pain and donor-site numbness response rate based on the returned self-reported surveys, a fact that has been well-documented in multiple studies.2,4,6,14,15,20
This retrospective study surveyed patients, and therefore, asking about pain may have encouraged overreporting by power of suggestion and a memory bias concerning when the pain ended and where it really occurred. The presence, duration, or characterization of pain or numbness from around the eventual graft site was not graded by patients preoperatively. In the study Mirovsky and Neuwirth,7 even when the bone graft was harvested on the contralateral side from the patients sciatica, 56% reported severe pain at the donor and recipient site, a suggestion that donor-site pain is part of a general pain syndrome with high association between back, leg, and donor-site pain. The resultant rates of spinal fusion and graft site healing were not obtained. However, one study compared iliac crest donor sites in 23 patients who had a donor-site reconstruction versus 23 patients who did not have a reconstruction.21 Despite computed tomography scans at 6 months showing 100% donor-site fusion in the reconstructed group, a Short Form 36 Health Survey evaluation at 12 months postoperatively demonstrated no differences in pain relief.
Although a meta-analysis was performed, a standard population was impossible to obtain from previous studies due to varying patient populations, sites of iliac crest bone graft procurement, underlying pathology, and procedures for which the bone graft was obtained. Finally, the response rate to our study was 34.5%, with the overwhelming majority of the surveys being only partially complete. This may contribute toward a bias of overreporting of pain, since a response rate <50% has an increasing likelihood that a response bias is present.22 Even if pain was overreported by our patients, the resultant pain associated with the intracortical technique was statistically less in the long run than in equivalent studies using the traditional technique. Overreporting of pain would have eliminated such a difference, not created it. We also would note that 95.9% of our respondents reported being satisfied or very satisfied. In fact, several surveys were returned with impromptu messages by the patients stating the surgery had changed their lives and they were grateful, despite the pain from the iliac crest graft site.
Despite the relatively recent advent of multiple bone graft substitutes, autologous iliac crest bone grafting is still considered the gold standard due to its osteoinductive and osteoconductive properties. However, iliac crest bone grafting has been associated with multiple complications and comorbidities. The intracortical method of iliac crest bone grafting leaves the iliac crest in continuity and decreases the surgical incision and area of dissection. In this study, despite having a patient population that has been shown to fare the worst with postoperative graft site pain (the majority having the graft taken for lumbosacral fusion through the same incision), our results with regard to pain were equivalent to studies using the traditional technique and actually improved at the 2-year mark.
Due to the current health care cost crisis and the overwhelming cost of some of the bone graft substitutes, a multicenter, 2-armed prospective study using the traditional and the intracortical iliac crest bone grafting technique on patients who require lumbar or lumbosacral spinal fusion surgery would further illuminate whether there is indeed a difference in the postoperative comorbidities between these 2 procedures. It is possible, as several authors have eluded to, that patients who undergo spine surgery for degenerative conditions represent a subset of the population with a generalized pain syndrome and a greater risk for development of postoperative pain.2,6,7 Despite any future results, patients should be advised preoperatively that there is a risk of donor-site pain and comorbidities, and that symptoms improve significantly by 6 to 12 months based on a statistical review of the literature.
- Sandhu HS, Grewal HS, Parvataneni H. Bone grafting for spinal fusion. Orthop Clin North Am. 1999; 30(4):685-698.
- Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone graft: complications and functional assessment. Clin Orthop Relat Res. 1997; 339:76-81.
- Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of anterior and posterior iliac crest bone graft in terms of harvest-site morbidity and functional outcomes. J Bone Joint Surg Am. 2002; 84(5):716-720.
- Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity: a statistical evaluation. Spine (Phila Pa 1976). 1995; 20(9):1055-1060.
- Robertson PA, Wray AC. Natural history of posterior iliac crest bone graft donation for spinal surgery: a prospective analysis of morbidity. Spine (Phila Pa 1976). 2001; 26(13):1473-1476.
- Heary RF, Schlenk RP, Sacchieri TA, Barone D, Brotea C. Persistent iliac crest donor site pain: independent outcome assessment. Neurosurgery. 2002; 50(3):510-517.
- Mirovsky Y, Neuwirth MG. Comparison between the outer table and intracortical methods of obtaining autogenous bone graft from the iliac crest. Spine (Phila Pa 1976). 2000; 25(13):1722-1725.
- Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA. Complications of iliac crest bone graft harvesting. Clin Orthop Relat Res. 1996; 329:300-309.
- Behairy YM, Al-Sebai W. A modified technique for harvesting full-thickness iliac crest bone graft. Spine (Phila Pa 1976). 2001; 26(6):695-697.
- Cricchio G, Lundgren S. Donor site morbidity in two different approaches to anterior iliac crest bone harvesting. Clin Implant Dent Relat Res. 2003; 5(3):161-169.
- Weinstein JN. The intracortical method of bone harvesting from the iliac crest did not reduce pain or bleeding at the donor site. J Bone Joint Surg Am. 2000; 82(12):1809.
- Joshi A, Kostakis GC. An investigation of post-operative morbidity following iliac crest graft harvesting. Br Dent J. 2004; 196(3):167-171.
- Silber JS, Anderson DG, Daffner SD, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2003; 28(2):134-139.
- Fernyhough JC, Schimandle JJ, Weigel MC, Edwards CC, Levine AM. Chronic donor site pain complicating bone graft harvesting from the posterior iliac crest for spinal fusion. Spine (Phila Pa 1976). 1992; 17(12):1474-1480.
- Summers BN, Eisenstein SM. Donor site pain from the ilium: a complication of lumbar spine fusion. J Bone Joint Surg Br. 1989; 71(4):677-680.
- Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma. 1989; 3(3):192-195.
- Skaggs DL, Samuelson MA, Hale JM, Kay RM, Tolo VT. Complications of posterior iliac crest bone grafting in spine surgery in children. Spine (Phila Pa 1976). 2000; 25(18):2400-2402.
- Porchet F, Jaques B. Unusual complications at iliac crest bone graft donor site: experience with two cases. Neurosurgery. 1996; 39(4):856-859.
- Fernando TL, Kim SS, Mohler DG. Complete pelvic ring failure after posterior iliac bone graft harvesting. Spine (Phila Pa 1976). 1999; 24(20):2101-2104.
- Colterjohn NR, Bednar DA. Procurement of bone graft from the iliac crest: an operative approach with decreased morbidity. J Bone Joint Surg Am. 1997; 79(5):756-759.
- Epstein NE, Hollingsworth R. Does donor site reconstruction following anterior cervical surgery diminish postoperative pain? J Spinal Disord Tech. 2003; 16(1):20-26.
- Singleton R, Straits BC, Straits MM, McAllister RJ. Approaches to Social Research. New York, NY: Oxford University Press; 1988.
Dr Lementowski is from the Long Island Jewish Department of Orthopedics, Great Neck, Dr Lucas is from the Department of Orthopedics, New York Medical College, Valhalla, and Dr Taddonio is from the Sections of Scoliosis Surgery and Spinal Surgery, New York Medical College, Valhalla, and the Department of Orthopedic Surgery, Columbia University College of Physicians and Surgeons, White Plains, New York.
Dr Taddonio is a paid consultant for Depuy Spine and was a paid consultant for Globus Spine in 2008. Drs Lementowski and Lucas have no relevant financial relationships to disclose.
Correspondence should be addressed to: Peter W. Lementowski, MD, Long Island Jewish Department of Orthopedics, 825 Northern Blvd, Ste 302, Great Neck, NY 11021 (email@example.com).