Electrical stimulation therapies for spinal fusions: current concepts

Electrical stimulation therapies have been used for more than 30 years to enhance spinal fusions. Although their positive effects on spinal fusions have been widely reported, the mechanisms of action of the technologies were only recently identified. Three types of technologies are available clinically: direct current, capacitive coupling, and inductive coupling. The latter is the basis of pulsed electromagnetic fields and combined magnetic fields. This review summarizes the current concepts on the mechanisms of action, animal and clinical studies, and cost justification for the use of electrical stimulation for spinal fusions. Scientific studies support the validity of electrical stimulation treatments. The mechanisms of action of each of the three electrical stimulation therapies are different. New data demonstrates that the upregulation of several growth factors may be responsible for the clinical success seen with the use of such technologies.

[1]  J. Simmons.  Treatment of failed posterior lumbar interbody fusion (PLIF) of the spine with pulsing electromagnetic fields. , 1985, Clinical orthopaedics and related research.

[2]  E. Karplus,et al.  Bicarbonate dependence of ion current in damaged bone , 1996, Calcified Tissue International.

[3]  B. Bose.  Outcomes after posterolateral lumbar fusion with instrumentation in patients treated with adjunctive pulsed electromagnetic field stimulation , 2001, Advances in therapy.

[4]  D. Bushinsky,et al.  Effects of osteoclastic resorption on bone surface ion composition. , 1996, The American journal of physiology.

[5]  J. Gan,et al.  DIRECT CURRENT AND CAPACITIVE COUPLING ELECTRICAL STIMULATION UPREGULATES OSTEOPROMOTIVE FACTORS FOR SPINAL FUSIONS , 2004 .

[6]  D. Kucharzyk.  A controlled prospective outcome study of implantable electrical stimulation with spinal instrumentation in a high-risk spinal fusion population. , 1999, Spine.

[7]  J. Heckman,et al.  Pulsed Electromagnetic Fields Increase Growth Factor Release by Nonunion Cells , 2001, Clinical orthopaedics and related research.

[8]  A. Rogozinski,et al.  Efficacy of Implanted Bone Growth Stimulation in Instrumented Lumbosacral Spinal Fusion , 1996, Spine.

[9]  B. Boyan,et al.  Pulsed electromagnetic field stimulation of MG63 osteoblast‐like cells affects differentiation and local factor production , 2000, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[10]  R. Nasca.  Point Of View: Complications in the Adult Spinal Deformity Patient Having Combined Surgery: Does Revision Increase the Risk? , 1999 .

[11]  M. Heilmann,et al.  Use of Electromagnetic Fields in a Spinal Fusion: A Rabbit Model , 1997, Spine.

[12]  T. Kawase,et al.  Effects of prostaglandin E2 and F2α on cytoplasmic pH in a clonal osteoblast‐like cell line, MOB 3–4 , 1991, Journal of cellular physiology.

[13]  C. Brighton,et al.  Electrical stimulation induces the level of TGF-beta1 mRNA in osteoblastic cells by a mechanism involving calcium/calmodulin pathway. , 1997, Biochemical and biophysical research communications.

[14]  J. Lane.  BMPs: why are they not in everyday use? , 2001, The Journal of bone and joint surgery. American volume.

[15]  I. Reid,et al.  Parathyroid hormone depresses cytosolic pH and DNA synthesis in osteoblast-like cells. , 1988, The American journal of physiology.

[16]  M. Laursen,et al.  Recombinant bone morphogenetic protein-7 as an intracorporal bone growth stimulator in unstable thoracolumbar burst fractures in humans: preliminary results , 1999, European Spine Journal.

[17]  R. Savini,et al.  Pulsing electromagnetic fields (PEMFs) in spinal fusion: preliminary clinical results. , 1992, La Chirurgia degli organi di movimento.

[18]  J. Kanczler,et al.  Pulsed electromagnetic fields simultaneously induce osteogenesis and upregulate transcription of bone morphogenetic proteins 2 and 4 in rat osteoblasts in vitro. , 1998, Biochemical and biophysical research communications.

[19]  W C Hutton,et al.  An Experimental Lumbar Intertransverse Process Spinal Fusion Model: Radiographic, Histologic, and Biomechanical Healing Characteristics , 1995, Spine.

[20]  P. Govoni,et al.  Pulsed electromagnetic field stimulation on posterior spinal fusions: a histological study in rats. , 1994, Journal of spinal disorders.

[21]  Allen J. Meril.  Direct Current Stimulation of Allograft in Anterior and Posterior Lumbar Interbody Fusions , 1994, Spine.

[22]  H. Sandhu,et al.  Use of Recombinant Human Bone Morphogenetic Protein-2 in Spinal Fusion Applications , 2002, Spine.

[23]  W. Kane,et al.  Direct Current Electrical Bone Growth Stimulation for Spinal Fusion , 1988, Spine.

[24]  T. K. Hunt,et al.  Hydrogen peroxide stimulates macrophage vascular endothelial growth factor release. , 2001, American journal of physiology. Heart and circulatory physiology.

[25]  J. Lane,et al.  Safety Profile for the Clinical Use of Bone Morphogenetic Proteins in the Spine , 2002, Spine.

[26]  N. Kahanovitz,et al.  The effect of electromagnetic pulsing on posterior lumbar spinal fusions in dogs. , 1994, Spine.

[27]  C T Brighton,et al.  Field distributions in vertebral bodies of the rat during electrical stimulation: a parametric study. , 1989, IEEE transactions on bio-medical engineering.

[28]  S. Pollack,et al.  Signal Transduction in Electrically Stimulated Bone Cells , 2001, The Journal of bone and joint surgery. American volume.

[29]  M. Fukase,et al.  Second messenger signaling in the regulation of cytosolic pH and DNA synthesis by parathyroid hormone (PTH) and PTH‐related peptide in osteoblastic osteosarcoma cells: Role of Na+/H+ exchange , 1992, Journal of cellular physiology.

[30]  S. Pollack,et al.  Theoretical determination of the current density distributions in human vertebral bodies during electrical stimulation , 1990, IEEE Transactions on Biomedical Engineering.

[31]  M. Nagai,et al.  Pulsating Electromagnetic Field Stimulates mRNA Expression of Bone Morphogenetic Protein-2 and -4 , 1994, Journal of dental research.

[32]  L. Bonewald,et al.  Pulsed electromagnetic fields affect phenotype and connexin 43 protein expression in MLO‐Y4 osteocyte‐like cells and ROS 17/2.8 osteoblast‐like cells , 2003, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[33]  Joseph D. Smucker,et al.  Effects of Direct Current Electrical Stimulation on Gene Expression of Osteopromotive Factors in a Posterolateral Spinal Fusion Model , 2007, Spine.

[34]  S. Pollack,et al.  Field distribution in vertebral bodies of the rat during electrical stimulation: a parameter study , 1989, IEEE Transactions on Biomedical Engineering.

[35]  J. Wozney,et al.  Characterization of rhBMP-2 pharmacokinetics implanted with biomaterial carriers in the rat ectopic model. , 1999, Journal of biomedical materials research.

[36]  D. Lorich,et al.  Biochemical Pathway Mediating the Response of Bone Cells to Capacitive Coupling , 1998, Clinical orthopaedics and related research.

[37]  J. Kanczler,et al.  Pulsed Electromagnetic Fields Simultaneously Induce Osteogenesis and Upregulate Transcription of Bone Morphogenetic Proteins 2 and 4 in Rat Osteoblastsin Vitro , 1998 .

[38]  Thomas L. Smith,et al.  Microcirculatory effects of pulsed electromagnetic fields , 2004, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[39]  J. France,et al.  The Efficacy of Direct Current Stimulation for Lumbar Intertransverse Process Fusions in an Animal Model , 2001, Spine.

[40]  Bruce Simon,et al.  Electromagnetic fields increase in vitro and in vivo angiogenesis through endothelial release of FGF‐2 , 2004, FASEB journal : official publication of the Federation of American Societies for Experimental Biology.

[41]  Roy K. Aaron,et al.  Upregulation of basal TGFβ1 levels by EMF coincident with chondrogenesis – implications for skeletal repair and tissue engineering , 2002 .

[42]  L. Titus,et al.  Gene expression during autograft lumbar spine fusion and the effect of bone morphogenetic protein 2 , 1998 .

[43]  C. Andrew L. Bassett,et al.  Generation of Electric Potentials by Bone in Response to Mechanical Stress , 1962, Science.

[44]  W. Hayes,et al.  In vivo evaluation of coralline hydroxyapatite and direct current electrical stimulation in lumbar spinal fusion. , 1999, Spine.

[45]  D. Bushinsky.  Metabolic alkalosis decreases bone calcium efflux by suppressing osteoclasts and stimulating osteoblasts. , 1996, The American journal of physiology.

[46]  R. Marks,et al.  Spine fusion for discogenic low back pain: Outcomes in patients treated with or without pulsed electromagnetic field stimulation , 2000, Advances in therapy.

[47]  S. Arnoczky,et al.  The Efficacy of Direct Current Electrical Stimulation to Enhance Canine Spinal Fusions , 1990, Clinical orthopaedics and related research.

[48]  F. P. Magee,et al.  Combined magnetic fields increase insulin-like growth factor-II in TE-85 human osteosarcoma bone cell cultures. , 1995, Endocrinology.

[49]  J. Kanczler,et al.  Effect of faradic products on direct current-stimulated calvarial organ culture calcium levels. , 1999, Biochemical and biophysical research communications.

[50]  B. Simon,et al.  P53. Effects of capacitive coupling electrical stimulation on expression of growth factors in a rabbit posterolateral spine fusion model , 2004 .

[51]  V. Mooney,et al.  A Randomized Double-Blind Prospective Study of the Efficacy of Pulsed Electromagnetic Fields for Interbody Lumbar Fusions , 1990, Spine.

[52]  N. Kahanovitz,et al.  The Effect of Postoperative Electromagnetic Pulsing on Canine Posterior Spinal Fusions , 1984, Spine.

[53]  W. Hutton,et al.  The Marshall R. Urist Young Investigator Award. Gene expression during autograft lumbar spine fusion and the effect of bone morphogenetic protein 2. , 1998, Clinical orthopaedics and related research.

[54]  R. J. Pawluk,et al.  Effects of Electric Currents on Bone In Vivo , 1964, Nature.

[55]  Di Chen,et al.  Bone Morphogenetic Proteins , 2004, Growth factors.

[56]  R. Puno,et al.  The Use of Implantable Direct Current Stimulation in Multilevel Spinal Fusion Without Instrumentation: A Prospective Clinical and Radiographic Evaluation With Long‐Term Follow‐Up , 1996, Spine.

[57]  E. Dawson.  Bone morphogenetic proteins BMPs. Letter. , 2003, The spine journal : official journal of the North American Spine Society.

[58]  F. P. Magee,et al.  IGF‐II receptor number is increased in TE‐85 osteosarcoma cells by combined magnetic fields , 1995, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research.

[59]  J. Bubis,et al.  Stimulation of Bone Formation by Electrical Current on Spinal Fusion , 1986, Spine.

[60]  J M Toth,et al.  Direct Current Electrical Stimulation Increases the Fusion Rate of Spinal Fusion Cages , 2000, Spine.

[61]  S. Bulstra,et al.  Osteogenic activity of OP-1 bone morphogenetic protein (BMP-7) in a human fibular defect , 1999 .

[62]  F. P. Magee,et al.  Combined magnetic fields accelerate and increase spine fusion: a double-blind, randomized, placebo controlled study. , 2002, Spine.

[63]  F. P. Magee,et al.  The role of insulin-like growth factor II in magnetic field regulation of bone formation , 1994 .

[64]  F. Kaplan,et al.  Treatment of castration-induced osteoporosis by a capacitively coupled electrical signal in rat vertebrae. , 1989, The Journal of bone and joint surgery. American volume.

[65]  L. Fay,et al.  The Effect of Pulsed Electromagnetic Fields on Instrumented Posterolateral Spinal Fusion and Device‐Related Stress Shielding , 1997, Spine.

[66]  John R. Johnson,et al.  A double-blind study of capacitively coupled electrical stimulation as an adjunct to lumbar spinal fusions. , 1999, Spine.

[67]  N. Kahanovitz,et al.  The effect of varied electrical current densities on lumbar spinal fusions in dogs. , 2001, The spine journal : official journal of the North American Spine Society.