TLIF with rhBMP-2 yields modest complication rate

Owens K. Eur Spine J. doi: 10.1007/s00586-010-1494-7.

Kentucky researchers have described the perioperative complications and complication rates of transforaminal lumbar interbody spine fusion procedures with recombinant human bone morphogenetic protein-2.

Surgeons often use bone morphogenetic protein (BMP) as an iliac crest bone graft substitute for transforaminal lumbar interbody spine fusion (TLIF). To date, information on TLIF-related complications with rhBMP-2 have come from small series or isolated cases, so actual complication rates are largely unknown, according to Kirk Owens, MD, and colleagues, University of Louisville School of Medicine.

In this large, consecutive series, the researchers reviewed the inpatient and outpatient records of 204 patients who underwent TLIF with rhBMP-2 between 2003 and 2007. There were 113 women and 81 men; mean age was 49.3 years.

The researchers classified complications they observed within a 3-month perioperative period according to etiology and severity. There were three groups of wound problems: wound infection, hematoma/seroma or persistent drainage/superficial dehiscence. Owens and colleagues evaluated neurologic deficits and radiculopathies to identify a clear etiology, such as a misplaced screw, and any potential relationship to BMP-2 usage.

Overall, 47 of 204 patients (21.6%) had complications. Thirteen patients (6.4%) had major complications, and 34 patients (16.7%) had minor complications. The researchers found that 13 patients (6.4%) had new or more severe postoperative neurologic complaints; 6 required additional surgery. There was one malpositioned pedicle screw and one epidural hematoma. Four patients (2%) had a localized seroma/hematoma in the foraminal area that caused neural compression; all needed revision surgery. Another patient developed vertebral osteolysis that caused foraminal narrowing and radiculopathy; however, this resolved without additional surgery. Six patients had persistent radiculopathy without a clear cause on imaging studies. Six patients developed wound-related problems; there were three wound infections, one hematoma/seroma and two cases of persistent drainage/dehiscence.

This is an important study in terms of establishing the incidence of complications with BMP. The final point in the abstract is key. Clinicians need to balance the complication rate vs. the benefit of solid fusion. Cost effectiveness is an additional issue. Consider also that we cannot lose sight of the relatively benign nature of chronic problems from iliac crest graft harvest vs. sometimes debilitating long-term radiculitis.

– David A. Wong, MD, MSc, FRCS(C)
Past President North American Spine Society
Past Chairman AAOS Patient Safety Committee
Co-Chairman NASS Patient Safety Task Force
Co-Chairman NASS Performance Measures Advisory Committee
Co-Chairman NASS Value Task Force
Director Advanced Center for Spinal Microsurgery Presbyterian St. Luke's Medical Center
Denver