Revision surgery after interbody fusion with rhBMP-2: A cautionary tale for spine surgeons

Shaun D. Rodgers, Bryan Marascalchi, Bartosz T. Grobelny, Michael L. Smith, Uzma Samadani

Research output: Contribution to journalArticle

Abstract

Recombinant human bone morphogenetic protein-2 (rhBMP-2) promotes the induction of bone growth and is widely used in spine surgery to enhance arthrodesis. Recombinant human BMP-2 has been associated with a variety of complications including ectopic bone formation, adjacent-level fusion, local bone resorption, osteolysis, and radiculitis. Some of the complications associated with rhBMP-2 may be the result of rhBMP-2 induction of the inflammatory host response. In this paper the authors report on a patient with prior transforaminal lumbar interbody fusion (TLIF) using an interbody cage packed with rhBMP-2, in which rhBMP-2 possibly contributed to vascular injury during an attempted anterior lumbar interbody fusion. This 63-year-old man presented with a 1-year history of worsening refractory low-back pain and radiculopathy caused by a Grade 1 spondylolisthesis at L4-5. He underwent an uncomplicated L4-5 TLIF using an rhBMP-2-packed interbody cage. Postoperatively, he experienced marginal improvement of his symptoms. Within the next year and a half the patient returned with unremitting low-back pain and neurogenic claudication that failed to respond to conservative measures. Radiological imaging of the patient revealed screw loosening and pseudarthrosis. He underwent an anterior retroperitoneal approach with a plan for removal of the previous cage, complete discectomy, and placement of a femoral ring. During the retroperitoneal approach the iliac vein was adhered with scarring and fibrosis to the underlying previously operated L4-5 interbody space. During mobilization the left iliac vein was torn, resulting in significant blood loss and cardiac arrest requiring chest compression, defibrillator shocks, and blood transfusion. The patient was stabilized, the operation was terminated, and he was transferred to the intensive care unit. He recovered over the next several days and was discharged at his neurological baseline. The authors propose that the rhBMP-2-induced host inflammatory response partially contributed to vessel fibrosis and scarring, resulting in the life-threatening vascular injury during the reoperation. Spine surgeons should be aware of this potential inflammatory fibrosis in addition to other reported complications related to rhBMP-2.

Original languageEnglish (US)
Pages (from-to)582-587
Number of pages6
JournalJournal of Neurosurgery: Spine
Volume18
Issue number6
DOIs
StatePublished - Jun 1 2013
Externally publishedYes

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Reoperation
Spine
Iliac Vein
Radiculopathy
Fibrosis
Vascular System Injuries
Low Back Pain
Cicatrix
Spondylolisthesis
Diskectomy
Pseudarthrosis
Osteolysis
Defibrillators
recombinant human bone morphogenetic protein-2
Surgeons
Arthrodesis
Bone Development
Bone Resorption
Thigh
Heart Arrest

Keywords

  • Anterior lumbar interbody fusion
  • Complications
  • Lumbar spine
  • Recombinant human bone morphogenetic protein
  • Retroperitoneal approach
  • Vascular injury

ASJC Scopus subject areas

  • Surgery
  • Neurology
  • Clinical Neurology

Cite this

Revision surgery after interbody fusion with rhBMP-2 : A cautionary tale for spine surgeons. / Rodgers, Shaun D.; Marascalchi, Bryan; Grobelny, Bartosz T.; Smith, Michael L.; Samadani, Uzma.

In: Journal of Neurosurgery: Spine, Vol. 18, No. 6, 01.06.2013, p. 582-587.

Research output: Contribution to journalArticle

Rodgers, Shaun D. ; Marascalchi, Bryan ; Grobelny, Bartosz T. ; Smith, Michael L. ; Samadani, Uzma. / Revision surgery after interbody fusion with rhBMP-2 : A cautionary tale for spine surgeons. In: Journal of Neurosurgery: Spine. 2013 ; Vol. 18, No. 6. pp. 582-587.
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