What Graft Should Be Used in Pediatric Posterior Spinal Fusion? Current Trends and Perspective Among Experts

Background: Bone graft use for pediatric posterior spinal fusion (PSF) is highly variable and can lead to additional cost and risk. Biological failures of fusion are rare in children, suggesting that higher-risk grafts used for their perceived efficacy in adults may be unnecessary. This study aims to assess current expert perspectives on graft choice for pediatric PSF to provide guidance in this unique population, thus aiding risk and cost minimization. Methods: We conducted an institutional review board–approved Research Electronic Data Capture (REDCap) survey of surgeon members from an international spine deformity study group. Participants were asked about their graft choices for a routine adolescent idiopathic scoliosis case. Results: Of the 49 invited surgeons, 35 (71%) completed the survey. Most respondents (57%) had over 20 years of experience and performed more than 75 pediatric spine deformity surgeries annually (63%). The majority (83%) used local autograft and cancellous allograft, with 51% using this combination without additional graft products. Surgeons cited side-effect profile, clinical evidence, cost, and training as primary factors influencing graft choice. Notably, 42% of participants acknowledged that iliac crest bone graft (ICBG) and bone morphogenic protein (BMP)-2 may promote better bone formation but were not routinely used due to costs and potential side effects. Conclusions: This expert survey suggests that local autograft combined with allograft represents the prevailing graft strategy among experienced surgeons. However, there is considerable variability in the adjunct use of other graft types/additives indicating a need for further research to establish the value of these adjuncts in pediatric PSF relative to risks and costs. Key Concepts: (1) Bone graft choices vary widely among pediatric spine surgeons, with some using higher-risk grafts that lack evidence in children, even though fusion success rates are similar regardless of graft type. (2) An international survey of experienced pediatric spine deformity surgeons identified local autograft combined with cancellous allograft as the prevailing baseline strategy, with most surgeons avoiding additional graft products. (3) This choice is primarily influenced by side-effect profile, available clinical evidence, cost considerations, and training. (4) Among surgeons who do use adjunct grafts, the specific products selected vary considerably, reflecting heterogeneous practice patterns. (5) Given the low rate of biologic fusion failure in children, further research is needed to clarify when additional graft products provide value beyond the baseline strategy.