Bone Morphogenic Protein Is a Viable Adjunct for Fusion in Minimally Invasive Transforaminal Lumbar Interbody Fusion

Abstract

Study DesignComparison of prospectively collected data of patients undergoing minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) with and without recombinant human bone morphogenic protein 2 (BMP).PurposeTo compare the clinical, radiological outcome and complications of patients undergoing MIS-TLIF with and without BMP.Overview of LiteratureBMP is an effective fusion enhancer with potential complications. Direct comparison of MIS-TLIF with and without BMP is limited to retrospective studies with short follow-up.MethodsFrom June 2005 to February 2011, consecutive cases of MIS-TLIF performed by a single surgeon were included. North American Spine Society (NASS) score, Oswestry disability index (ODI), Short Form-36 (SF-36), and visual analogue score (VAS) were assessed preoperatively and at 6 and 24 months postoperatively. Fusion rates and complications were noted.ResultsThe 252 cases comprised 104 non-BMP and 148 BMP cases. The BMP group was significantly older (mean age, 60.2 vs. 53.9; p<0.01). Preoperative scores were similar. Immediate postoperative morphine usage was significantly lower in the BMP group (12.4 mg vs. 20.1 mg, p<0.01). At 6 months, the BMP group had lower VAS back and leg pain scores (p<0.01). At 2 years, the BMP group had better leg pain scores (p<0.01), ODI (15.4 vs. 20.3, p=0.04) and NASS scores (8.8 vs. 15.8, p<0.01). Both groups showed significant clinical improvement compared to their preoperative levels. The BMP group attained a significantly higher rate of fusion at 6 months follow-up (88.4% vs. 76.8%, p=0.016) with no difference at 2 years. The non-BMP and BMP group had 12 (11.5%) and 9 (6.1%) complications and 5 (4.8%) and 2 (1.4%) reoperations, respectively.ConclusionsThe use of BMP to augment fusion in MIS-TLIF is an acceptable alternative that has potential benefits of less pain in early and intermediate postoperative follow-up.

Orthobiologics in minimally invasive lumbar fusion

“…In a prospective study of 252 patients, Siddiqui et al obtained fusion rates of 88.4% and 98.5% at six-month and two-year follow up, respectively. Compared to patients treated with other materials (autograft and/or DBM), the rhBMP-2 group achieved a significantly greater rate of fusion at the six-month interval (88.4% vs. 76.8%, P=0.016), though there was no difference between groups two years (41). In this study, patients underwent fusion with an interbody cage packed with autograft and rhBMP-2, and the remaining disk space was filled with autograft alone (41).…”

Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies

“…As a result, BMPs seem to acquire osteoinductive characteristics, and therefore, they have been studied for their bone healing and growth potential [ 32 ]. To circumvent post-operative morbidity and complications after harvesting ICBG, the recombinant human BMP-2 (rhBMP-2) is employed as a potent bone graft enhancer [ 165 ]. Clinically, rhBMP-2 has been proven not only to improve bone fusion but also improve recovery in back pain [ 166 ].…”

Spinal Biologics in Minimally Invasive Lumbar Surgery

“…However, two large-scale retrospective studies with a combined cohort of over 600,000 patients concluded that there is no evidence of increased malignancy with the use of rhBMP-2 [ 110 , 111 ]. From the 8 studies that met our inclusion criteria utilizing rhBMP-2 in MIS-TLIF, Nandyala et al documented a case of rhBMP-2 related neuroforaminal bone growth and cage migration/osteolysis and Siddiqui et al reported two cases of bone overgrowth with radiculopathy, a case of osteolysis, and two cases of radiculitis [ 49 , 70 ].…”

“…While the site of rhBMP-2 insertion can vary based on surgeon preference and the pathologies, the relative dose of rhBMP-2 also differed. Of all the MIS-TLIF studies we included, Tsahtsarlis and Wood, Siddiqui et al, and Nandyala et al reported using 1.4 mg, 4.2 mg, and either 4.2 mg or 12 mg, respectively [ 49 , 70 , 71 ]. Notably, the majority of these studies used CT scans as the method of evaluation for fusion during their postoperative follow-ups ( Table 3 ).…”