RhBMP-2 use in lumbar fusion surgery is associated with transient immediate post-operative leg pain
ABSTRACT Supra-physiological rhBMP loads during spinal fusion may trigger local inflammation and post-operative radiculitis. MRI is an effective tool to detect nerve root compression in severe post-operative leg pain. The aim of this study was to determine if recombinant bone morphogenic protein 2 (rhBMP-2) is associated with immediate post-operative leg pain without evidence of root compression using MRI.
All patients undergoing posterolateral and posterior interbody lumbar spinal fusions with rhBMP-2 between July 2007 and January 2009 at a single surgeon practice were retrospectively reviewed for incidence of severe immediate post-operative leg pain. Patients that presented with immediate post-operative leg pain were interviewed and Oswestry Disability Indices calculated.
Sixty-four rhBMP-2 treated patients and 40 controls were included. Pre-operative demographics and diagnoses were similar and inter-body cages were used equally. Immediate post-operative leg pain incidence was 25 and 12.5% in the rhBMP-2 and non-rhBMP-2 groups, respectively. 17.2% of the patients treated with rhBMP-2 had immediate post-operative leg pain without evidence of nerve root compression on MRI versus 7.5% of the patients treated without rhBMP-2. At follow-up, leg pain incidence was 11.6 and 7.6% in rhBMP-2 and non-rhBMP-2 groups, respectively. There was no difference in Oswestry Disability Indices between groups (36.5 ± 31.2 vs. 23.0 ± 25.5).
RhBMP-2 associated radiculitis presenting as immediate post-operative leg pain without MRI evidence of neuronal compression occurs in 17% of the patients with rhBMP-2 assisted fusion. Patients should be pre-operatively counselled regarding immediate post-operative leg pain with rhBMP-2.
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ABSTRACT: Spine fusion is considered to be the gold standard for the treatment of most degenerative and traumatic spinal conditions. Bone graft is still the best choice to achieve fusion and currently autologous and allograft bone are the main sources for bone grafting procedures. Autologous bone has by far the most osteogenic potential, but it is limited and it can lead to a donor site pain condition. Allograft bone is an important source when structural or large volumes of grafts are required. Concerns related to the use of both autografts and allografts has led to the search for alternatives, but synthetic bone graft substitutes as yet offer only a partial solution to the management of localized bone loss. They possess some of the desired mechanical qualities of bone as well as osteointegrative/conductive properties, but are largely reliant on viable periosteum/bone for their success. The advent of composite synthetic bone graft substitutes and biologically active factors is moving closer to the goal of obtaining a synthetic bone graft substitute that mimics the native bone in both mechanical and osteogenic properties.Archivio di Ortopedia e Reumatologia 12/2012; 123(3). DOI:10.1007/s10261-012-0030-1
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ABSTRACT: Anterior lumbar interbody fusion (ALIF) is an established treatment for structural instability associated with symptomatic disk degeneration (SDD). Stand-alone ALIF offers many advantages, however, it may increase the risk of non-union. Recombinant human bone morphogenetic protein-2 (BMP-2) may enhance fusion rate but is associated with postoperative complication. The optimal dose of BMP-2 remains unclear. This study assessed the fusion and subsidence rates of stand-alone ALIF using the SynFix-LR interbody cage with 6 ml/level of BMP-2. Thirty-two ALIF procedures were performed by a single surgeon in 25 patients. Twenty-five procedures were performed for SDD without spondylolisthesis (SDD group) and seven procedures were performed for SDD with grade-I olisthesis (SDD-olisthesis group). Patients were followed-up for a mean of 17 ± 6 months. Solid fusion was achieved in 29 cases (90.6 %) within 6 months postoperatively. Five cases of implant subsidence were observed (16 %). Four of these occurred in the SDD-olisthesis group and one occurred in the SDD group (57 % vs. 4 % respectively; p = 0.004). Three cases of subsidence failed to fuse and required revision. The body mass index of patients with olisthesis who developed subsidence was higher than those who did not develop subsidence (29 ± 2.6 vs. 22 ± 6.5 respectively; p = 0.04). No BMP-2 related complications occurred. The overall fusion rate of stand-alone ALIF using the SynFix-LR system with BMP-2 was 90.6 %, comparable with other published series. No BMP-2 related complication occurred at a dose of 6 mg/level. Degenerative spondylolisthesis and obesity seemed to increase the rate of implant subsidence, and thus we believe that adding posterior fusion for these cases should be considered.European Spine Journal 08/2013; 22(12). DOI:10.1007/s00586-013-2948-5 · 2.47 Impact Factor
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ABSTRACT: BACKGROUND CONTEXT: Bone morphogenetic protein-2 (BMP-2) has been used to successfully promote spine fusion, but side-effects including nerve inflammation have been observed. PURPOSE: To investigate the direct neurotoxic effects of BMP-2 and test the hypotheses that the use of BMP binding proteins, such as secreted phosphoprotein 24 kD (Spp24), can reduce or eliminate these effects. STUDY DESIGN: In vitro experiments and in vivo analysis in a rodent model. METHODS: In vitro, dorsal root ganglion cells were cultured in the presence of BMP-2 with and without Spp24 and calcitonin gene-related peptide and Substance P, markers of neuroinflammation, were measured by immunohistochemistry. In vivo, rats underwent a left-sided laminotomy at L5 to expose the S1 nerve root and were randomized into four different groups according to the intervention at the laminotomy site: collagen sponge only (no BMP-2 or Spp24), BMP-2 in a collagen sponge only, BMP-2 in a collagen sponge+an empty collagen sponge to act as a barrier, and BMP-2 in a collagen sponge+Spp24 in a collagen sponge to act as a barrier. Functional evaluation was done using the Basso, Beattie, and Bresnahan scale and immunohistochemical analyses were performed using calcitonin gene-related peptide and Substance P staining. RESULTS: The neuroinflammatory effects of BMP-2 in vitro were ameliorated by the addition of Spp24. Similarly, in vivo, Spp24 reduced the expression of markers on neuroinflammation in animals treated with BMP-2 and also improved the function after BMP-2 administration. CONCLUSIONS: These results confirm that BMP binding proteins have great potential as adjuvant therapies to limit BMP-2 related side-effects in spine surgery.The spine journal: official journal of the North American Spine Society 09/2014; 15(2). DOI:10.1016/j.spinee.2014.09.021 · 2.80 Impact Factor