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Son JI, Lee YS, Ko MJ, Wui SH, Park SW. Effect of Mixture of Recombinant Human Bone Morphogenic Protein-2 and Demineralized Bone Matrix in Lateral Lumbar Interbody Fusion. J Korean Neurosurg Soc 2024; 67:354-363. [PMID: 37850225 PMCID: PMC11079555 DOI: 10.3340/jkns.2023.0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/21/2023] [Accepted: 10/11/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE This study aims to determine the optimal dose of recombinant-human bone morphogenic protein-2 (rhBMP-2) for successful bone fusion in minimally invasive lateral lumbar interbody fusion (MIS LLIF). Previous studies show that rhBMP is an effective alternative to autologous iliac crest bone graft, but the optimal dose remains uncertain. The study analyzes the fusion rates associated with different rhBMP doses to provide a recommendation for the optimal dose in MIS LLIF. METHODS Ninety-three patients underwent MIS LLIF using demineralized bone matrix (DBM) or a mixture of rhBMP-2 and DBM as fusion material. The group was divided into the following three groups according to the rhBMP-2 usage : group A, only DBM was used (n=27); group B, 1 mg of rhBMP-2 per 5 mL of DBM paste (n=41); and group C, 2 mg of rhBMP-2 per 5 mL of DBM paste (n=25). Demographic data, clinical outcomes, postoperative complication and fusion were assessed. RESULTS At 12 months post-surgery, the overall fusion rate was 92.3% according to Bridwell fusion grading system. Groups B and C, who received rhBMP-2, had significantly higher fusion rates than group A, who received only DBM. However, there was no significant increase in fusion rate when the rhBMP-2 dosage was increased from group B to group C. The groups B and C showed significant improvement in back pain and Oswestry disability index compared to the group A. The incidence of screw loosening was decreased in groups B and C, but there was no significant difference in the occurrence of other complications. CONCLUSION Usage of rhBMP-2 in LLIF surgery leads to early and increased final fusion rates, which can result in faster pain relief and return to daily activities for patients. The benefits of using rhBMP-2 were not significantly different between the groups that received 1 mg/5 mL and 2 mg/5 mL of rhBMP-2. Therefore, it is recommended to use 1 mg of rhBMP-2 with 5 mL of DBM, taking both economic and clinical aspects into consideration.
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Affiliation(s)
- Jun Ik Son
- Department of Neurosurgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Young-seok Lee
- Department of Neurosurgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Myeong Jin Ko
- Department of Neurosurgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Seong-Hyun Wui
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Seung Won Park
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
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Gao S, Chen B, Zhu Z, Du C, Zou J, Yang Y, Huang W, Liao J. PI3K-Akt signaling regulates BMP2-induced osteogenic differentiation of mesenchymal stem cells (MSCs): A transcriptomic landscape analysis. Stem Cell Res 2023; 66:103010. [PMID: 36580886 DOI: 10.1016/j.scr.2022.103010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/30/2022] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
Bone morphogenetic protein 2 (BMP2) effectively induced mesenchymal stem cells (MSCs) osteogenic differentiation hold great potential for bone tissue engineering. However, a global mechanistic view of BMP2-induced osteogenic differentiation of MSCs remains to be fully elucidated. Here, human umbilical cord-derived MSCs (UC-MSCs) were induced with BMP2, three days and five days later, total RNA were extracted and subjected to RNA-sequencing (RNA-Seq) followed with bioinformatic analysis. Osteogenic differentiation abilities were evaluated with Alkaline phosphatase (ALP) staining and osteogenic differentiation marker expression at both mRNA and protein levels. We identified that adenoviral vectors effectively transduced in UC-MSCs and expressed BMP2 in high efficiency. Both on day 3 and day 5, differentially expressed genes (DEGs) were highly enriched in PI3K-Akt signaling pathway. As for the common DEGs among total BMP2 group vs control group, BMP2 (day 3) versus control (day 3) and BMP2 (day 5) versus control (day 5), there were 105 DGEs and highly enriched in PI3K-Akt signaling pathway. Finally, we found that PI3K-Akt signaling inhibitor dramatically inhibited BMP2-iduced osteogenic differentiation of UC-MSCs. We firstly identified that PI3K-Akt signaling pathway plays a pivotal role in BMP2-induced osteogenic differentiation of MSCs, which may apply a new perspective for BMP2 based bone tissue engineering.
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Affiliation(s)
- Shengqiang Gao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Bowen Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Zhenglin Zhu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Chengcheng Du
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Jing Zou
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Yaji Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China
| | - Wei Huang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China.
| | - Junyi Liao
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Orthopedic Research Laboratory, Chongqing Medical University, Chongqing 400016, China.
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Palackdkharry CS, Wottrich S, Dienes E, Bydon M, Steinmetz MP, Traynelis VC. The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis). PLoS One 2022; 17:e0274634. [PMID: 36178925 PMCID: PMC9524710 DOI: 10.1371/journal.pone.0274634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND & IMPORTANCE This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward. METHODS The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions. RESULTS Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic. DISCUSSION & CONCLUSION DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.
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Affiliation(s)
| | - Stephanie Wottrich
- Case Western Reserve School of Medicine, Cleveland, Ohio, United States of America
| | - Erin Dienes
- Arcsology®, Mead, Colorado, United States of America
| | - Mohamad Bydon
- Department of Neurologic Surgery, Orthopedic Surgery, and Health Services Research, Mayo Clinic School of Medicine, Rochester, Minnesota, United States of America
| | - Michael P. Steinmetz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine Neurologic Institute, Cleveland, Ohio, United States of America
| | - Vincent C. Traynelis
- Department of Neurosurgery, Rush University School of Medicine, Chicago, Illinois, United States of America
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Granel H, Bossard C, Collignon AM, Wauquier F, Lesieur J, Rochefort GY, Jallot E, Lao J, Wittrant Y. Osteogenic Effect of Fisetin Doping in Bioactive Glass/Poly(caprolactone) Hybrid Scaffolds. ACS OMEGA 2022; 7:22279-22290. [PMID: 35811886 PMCID: PMC9260777 DOI: 10.1021/acsomega.2c01109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/07/2022] [Indexed: 06/15/2023]
Abstract
Treating large bone defects or fragile patients may require enhancing the bone regeneration rate to overcome a weak contribution from the body. This work investigates the osteogenic potential of nutrient fisetin, a flavonoid found in fruits and vegetables, as a doping agent inside the structure of a SiO2-CaO bioactive glass-poly(caprolactone) (BG-PCL) hybrid scaffold. Embedded in the full mass of the BG-PCL hybrid during one-pot synthesis, we demonstrate fisetin to be delivered sustainably; the release follows a first-order kinetics with active fisetin concentration being delivered for more than 1 month (36 days). The biological effect of BG-PCL-fisetin-doped scaffolds (BG-PCL-Fis) has been highlighted by in vitro and in vivo studies. A positive impact is demonstrated on the adhesion and the differentiation of rat primary osteoblasts, without an adverse cytotoxic effect. Implantation in critical-size mouse calvaria defects shows bone remodeling characteristics and remarkable enhancement of bone regeneration for fisetin-doped scaffolds, with the regenerated bone volume being twofold that of nondoped scaffolds and fourfold that of a commercial trabecular bovine bone substitute. Such highly bioactive materials could stand as competitive alternative strategies involving biomaterials loaded with growth factors, the use of the latter being the subject of growing concerns.
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Affiliation(s)
- Henri Granel
- INRAE,
Human Nutrition Unit (UNH), ECREIN Team, TSA 50400, 28 Place Henri Dunant, Clermont-Ferrand, Auvergne-Rhone-Alpes 63001, France
| | - Cédric Bossard
- Université
Clermont Auvergne, Laboratoire De Physique De Clermont Ferrand, 4 Avenue Blaise Pascal, Clermont-Ferrand, Auvergne-Rhône-Alpes 63001, France
| | - Anne-Margaux Collignon
- Descartes
University of Paris Faculty of Dental Surgery, Laboratoires Pathologies,
Imagerie et Biothérapies Orofaciales,1 Rue Maurice Arnoux, Montrouge, Île-De-France 92120, France
| | - Fabien Wauquier
- INRAE,
Human Nutrition Unit (UNH), ECREIN Team, TSA 50400, 28 Place Henri Dunant, Clermont-Ferrand, Auvergne-Rhone-Alpes 63001, France
| | - Julie Lesieur
- Descartes
University of Paris Faculty of Dental Surgery, Laboratoires Pathologies,
Imagerie et Biothérapies Orofaciales,1 Rue Maurice Arnoux, Montrouge, Île-De-France 92120, France
| | - Gael Y. Rochefort
- Descartes
University of Paris Faculty of Dental Surgery, Laboratoires Pathologies,
Imagerie et Biothérapies Orofaciales,1 Rue Maurice Arnoux, Montrouge, Île-De-France 92120, France
| | - Edouard Jallot
- Université
Clermont Auvergne, Laboratoire De Physique De Clermont Ferrand, 4 Avenue Blaise Pascal, Clermont-Ferrand, Auvergne-Rhône-Alpes 63001, France
| | - Jonathan Lao
- Université
Clermont Auvergne, Laboratoire De Physique De Clermont Ferrand, 4 Avenue Blaise Pascal, Clermont-Ferrand, Auvergne-Rhône-Alpes 63001, France
| | - Yohann Wittrant
- INRAE,
Human Nutrition Unit (UNH), ECREIN Team, TSA 50400, 28 Place Henri Dunant, Clermont-Ferrand, Auvergne-Rhone-Alpes 63001, France
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Zhu L, Liu Y, Wang A, Zhu Z, Li Y, Zhu C, Che Z, Liu T, Liu H, Huang L. Application of BMP in Bone Tissue Engineering. Front Bioeng Biotechnol 2022; 10:810880. [PMID: 35433652 PMCID: PMC9008764 DOI: 10.3389/fbioe.2022.810880] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/01/2022] [Indexed: 01/15/2023] Open
Abstract
At present, bone nonunion and delayed union are still difficult problems in orthopaedics. Since the discovery of bone morphogenetic protein (BMP), it has been widely used in various studies due to its powerful role in promoting osteogenesis and chondrogenesis. Current results show that BMPs can promote healing of bone defects and reduce the occurrence of complications. However, the mechanism of BMP in vivo still needs to be explored, and application of BMP alone to a bone defect site cannot achieve good therapeutic effects. It is particularly important to modify implants to carry BMP to achieve slow and sustained release effects by taking advantage of the nature of the implant. This review aims to explain the mechanism of BMP action in vivo, its biological function, and how BMP can be applied to orthopaedic implants to effectively stimulate bone healing in the long term. Notably, implantation of a system that allows sustained release of BMP can provide an effective method to treat bone nonunion and delayed bone healing in the clinic.
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Affiliation(s)
- Liwei Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
| | - Yuzhe Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Ao Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhengqing Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Youbin Li
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Chenyi Zhu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhenjia Che
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Tengyue Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - He Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
- *Correspondence: He Liu, ; Lanfeng Huang,
| | - Lanfeng Huang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- *Correspondence: He Liu, ; Lanfeng Huang,
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Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE The aim of this study was to evaluate the prevalence of pseudarthrosis following antepsoas (ATP) lumbar and lumbosacral fusions. SUMMARY OF BACKGROUND DATA Pseudarthrosis is a feared complication following spinal fusions and may affect their clinical outcomes. To date there are no sufficient data on the fusion rate following ATP lumbar and lumbosacral arthrodesis. METHODS This is a retrospective review of 220 patients who underwent lumbar minimally invasive antepsoas (MIS-ATP) fusions between January 2008 and February 2019 who have at least 1-year postoperative computed tomography (CT) follow-up scans. Fusion was graded using CT scans imaging and adopting a 1-4 grading scale (1, definitely fused; 2, likely fused; 3, likely not fused; 4, definitely not fused/nonunion). Grades 3 or 4 indicate pseudarthrosis. RESULTS A total of 220 patients (average age: 66 years, 82 males (37.2%), and 127 (57.7%) smokers) were included. Eight patients (3.6%) developed pseudarthrosis. A total of 693 discs were addressed using the ATP approach. Of those, 681 (98.3%) were considered fused (641 levels [92.5%] were "definitely fused" and 40 levels [5.8%] were "Likely fused") and 12 discs (1.7%) developed pseudarthrosis (seven levels [1.0%] were "likely not fused" and five levels (0.7%) were "definitely not fused"). The highest rate of pseudarthrosis was found at L5-S1 (4.8%) compared to the L1-L5 discs (0-2%). Of 127 smokers, six developed pseudarthrosis (odds ratio = 2.3, P = 0.3). The fusion rates were 95.3% and 97.8% for smokers and nonsmokers, respectively. Of the eight patients who developed pseudarthrosis, only four (50%) were symptomatic, of whom two (25%) required revision surgery. Both of these patients were smokers. The overall revision rate due to pseudarthrosis was 0.9% (two of 220 patients). CONCLUSION The MIS-ATP technique results in a high fusion rate (96.4% of patients; 98.3% of levels). Pseudarthrosis was noted mostly at the L5-S1 discs and in smokers.Level of Evidence: 4.
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Wu H, Yin G, Pu X, Wang J, Liao X, Huang Z. Inhibitory Effects of Combined Bone Morphogenetic Protein 2, Vascular Endothelial Growth Factor, and Basic Fibroblast Growth Factor on Osteoclast Differentiation and Activity. Tissue Eng Part A 2021; 27:1387-1398. [PMID: 33632010 DOI: 10.1089/ten.tea.2020.0325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Bone morphogenetic protein 2 (BMP-2), vascular endothelial growth factor (VEGF), and basic fibroblast growth factors (bFGF) are important regulators of bone development and bone remodeling involving the coordination of osteoblast-mediated bone formation and osteoclast-mediated bone resorption. The synergistic promotions of these growth factors on osteogenesis in the appropriate combination have been confirmed by a lot of studies, but the effect of this combined application on osteoclastogenesis still remains ambiguous. On the basis of comparing the osteoclastic potentials under stimulation of BMP-2, VEGF, or bFGF alone, this study focused on their combined effects on the differentiation and activity of osteoclasts. Our results showed that osteoclastogenesis was enhanced to some extent under the stimulation of BMP-2, VEGF, or bFGF alone, and the potential of these three growth factors to stimulate osteoclastogenesis was VEGF > BMP-2 > bFGF. However, the treatment with the combination of BMP-2 (50 ng/mL), VEGF (1 ng/mL), and bFGF (10 ng/mL), the most suitable dose combination for osteogenesis optimized in our previous study, weakened osteoclast differentiation confirmed by smaller tartrate-resistant acid phosphatase (TRAP)-positive multinucleated cells, lower TRAP activity, and lower expression of dendritic cell-specific transmembrane protein, an important molecule regulating osteoclast fusion. Moreover, BMP-2, VEGF, and bFGF in combination also moderately inhibited the bone-resorbing activity of mature osteoclasts by suppressing the expression of osteoclast-specific genes cathepsin K, and matrix metalloproteinase-9. The underlying molecular mechanisms involved the suppression of the receptor activator of nuclear factor-κB ligand-induced c-Fos levels and the activation of nuclear factor of activated T cells c1, two major transcription factors in osteoclast differentiation. Taken together, our study showed that the combination of BMP-2 (50 ng/mL), VEGF (1 ng/mL), and bFGF (10 ng/mL) promoted osteoblastogenesis but inhibited osteoclastogenesis. Thus, the simultaneous use of BMP-2 (50 ng/mL), VEGF (1 ng/mL), and bFGF (10 ng/mL) in an appropriate combination might improve efficacious bone regeneration in a clinical setting. Impact statement Few studies have addressed the combined effects of multiple growth factors on osteoclasts. This study demonstrated that the simultaneous use of bone morphogenetic protein 2 (BMP-2; 50 ng/mL), vascular endothelial growth factor (VEGF; 1 ng/mL), and basic fibroblast growth factors (bFGF; 10 ng/mL), the most suitable dose combination for osteogenesis optimized in our previous study, showed inhibitory effects on the differentiation and activity of osteoclasts. Our results suggest that the growth factor signaling pathways in osteoclasts may interact with each other. Furthermore, this study could provide new insights into the optimal application of BMP-2, VEGF, and bFGF for bone repair and regeneration.
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Affiliation(s)
- Huan Wu
- College of Biomedical Engineering, Sichuan University, Chengdu, P.R. China
| | - Guangfu Yin
- College of Biomedical Engineering, Sichuan University, Chengdu, P.R. China
| | - Ximing Pu
- College of Biomedical Engineering, Sichuan University, Chengdu, P.R. China
| | - Juan Wang
- College of Biomedical Engineering, Sichuan University, Chengdu, P.R. China
| | - Xiaoming Liao
- College of Biomedical Engineering, Sichuan University, Chengdu, P.R. China
| | - Zhongbing Huang
- College of Biomedical Engineering, Sichuan University, Chengdu, P.R. China
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Phani Kiran S, Sudhir G. Minimally invasive transforaminal lumbar interbody fusion - A narrative review on the present status. J Clin Orthop Trauma 2021; 22:101592. [PMID: 34603954 PMCID: PMC8463772 DOI: 10.1016/j.jcot.2021.101592] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/12/2021] [Accepted: 09/06/2021] [Indexed: 01/01/2023] Open
Abstract
Minimally invasive lumbar transforaminal interbody fusion (MIS TLIF) has become the most commonly performed lumbar fusion procedure. There are multiple variables such as bone graft properties, use of rhBMP (recombinant human bone morphogenic protein), interbody cage properties, image guidance techniques, etc., that may impact the outcomes and fusion rates. Radiation exposure to the patient as well as to the operating team is an important concern. The minimally invasive anterior approaches for lumbar fusion with ability to insert larger cages and achieve better sagittal correction have added another option in management of lumbar degenerative deformities. A literature review of recent studies and systematic reviews on different aspects impacting the outcomes of MIS TLIF has been done to define the present status of the procedure in this narrative review. Iliac crest bone graft can help achieve very good fusion rate without significantly increasing the morbidity. RhBMP is most potent enhancer of fusion and the adverse effects can be avoided by surgical technique and using lower dose. The use of navigation techniques has reduced the radiation exposure to patient and the surgeons but the benefit seems to be significant only in long segment fusions.
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Key Words
- ALIF, Anterior lumbar interbody fusion
- Bone graft substitutes
- DBM, Demineralised Bone Matrix
- JOABPEQ, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire
- LLIF, Lateral lumbar interbody fusion
- MIISA, Minimally Invasive Interbody Selection Algorithm
- MIS TLIF
- MIS TLIF, Minimally invasive transforaminal interbody fusion
- Minimally invasive lumbar interbody fusion
- Navigation assisted lumbar fusion
- OLIF, Oblique lumbar interbody fusion
- SiCaP, Silicate-substituted Calcium Phosphate
- Transforaminal interbody fusion
- XLIF, Extreme lateral lumbar interbody fusion
- rhBMP, recombinant human bone morphogenic protein
- β-TCP, β-Tricalcium Phosphate
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Affiliation(s)
- S. Phani Kiran
- Gleneagles Global Health City, Chennai, India,Corresponding author. Gleneagles Global Health City, 439 Cheran Nagar, Perumbakkam, Chennai, 600100, Tamilnadu, India.
| | - G. Sudhir
- Department of Spine Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Seeherman HJ, Wilson CG, Vanderploeg EJ, Brown CT, Morales PR, Fredricks DC, Wozney JM. A BMP/Activin A Chimera Induces Posterolateral Spine Fusion in Nonhuman Primates at Lower Concentrations Than BMP-2. J Bone Joint Surg Am 2021; 103:e64. [PMID: 33950879 DOI: 10.2106/jbjs.20.02036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Supraphysiologic bone morphogenetic protein (BMP)-2 concentrations are required to induce spinal fusion. In this study, a BMP-2/BMP-6/activin A chimera (BV-265), optimized for BMP receptor binding, delivered in a recombinant human collagen:CDHA [calcium-deficient hydroxyapatite] porous composite matrix (CM) or bovine collagen:CDHA granule porous composite matrix (PCM), engineered for optimal BV-265 retention and guided tissue repair, was compared with BMP-2 delivered in a bovine absorbable collagen sponge (ACS) wrapped around a MASTERGRAFT Matrix (MM) ceramic-collagen rod (ACS:MM) in a nonhuman primate noninstrumented posterolateral fusion (PLF) model. METHODS In vivo retention of 125I-labeled-BV-265/CM or PCM was compared with 125I-labeled-BMP-2/ACS or BMP-2/buffer in a rat muscle pouch model using scintigraphy. Noninstrumented PLF was performed by implanting CM, BV-265/CM, BV-265/PCM, or BMP-2/ACS:MM across L3-L4 and L5-L6 or L3-L4-L5 decorticated transverse processes in 26 monkeys. Computed tomography (CT) images were acquired at 0, 4, 8, 12, and 24 weeks after surgery, where applicable. Manual palpation, μCT (microcomputed tomography) or nCT (nanocomputed tomography), and histological analysis were performed following euthanasia. RESULTS Retention of 125I-labeled-BV-265/CM was greater than BV-265/PCM, followed by BMP-2/ACS and BMP-2/buffer. The CM, 0.43 mg/cm3 BMP-2/ACS:MM, and 0.05 mg/cm3 BV-265/CM failed to generate PLFs. The 0.15-mg/cm3 BV-265/CM or 0.075-mg/cm3 BV-265/PCM combinations were partially effective. The 0.25-mg/cm3 BV-265/CM and 0.15 and 0.3-mg/cm3 BV-265/PCM combinations generated successful 2-level PLFs at 12 and 24 weeks. CONCLUSIONS BV-265/CM or PCM can induce fusion in a challenging nonhuman primate noninstrumented PLF model at substantially lower concentrations than BMP-2/ACS:MM. CLINICAL RELEVANCE BV-265/CM and PCM represent potential alternatives to induce PLF in humans at substantially lower concentrations than BMP-2/ACS:MM.
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Affiliation(s)
- Howard J Seeherman
- Orthopedic Research and Pharmaceutical Development Consultant, Cambridge, Massachusetts
| | | | | | | | | | - Douglas C Fredricks
- Bone Healing Research Lab and Iowa Spine Research Lab Orthopedic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - John M Wozney
- Orthopedic Research and Pharmaceutical Development Consultant, Hudson, Massachusetts
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10
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Reece EM, O'Neill RC, Davis MJ, Abu-Ghname A, Ropper AE, Bohl M, Xu DS, Winocour SJ. Vascularized Scapular Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives. Semin Plast Surg 2021; 35:25-30. [PMID: 33994875 DOI: 10.1055/s-0041-1723833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Spinal fusion can be challenging to obtain in patients with complex spinal pathology. Medial scapular vascularized bone grafts (S-VBGs) are a novel approach to supplement cervicothoracic arthrodesis in patients at high risk of failed spinal fusion. In this article, we discuss the benefits of using VBGs compared with both nonvascularized bone grafts and free vascularized bone flaps and the surgical technique, feasibility, and limitations specific to the S-VBG.
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Affiliation(s)
- Edward M Reece
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Rebecca C O'Neill
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | | | - Michael Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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11
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Wang E, Stickley C, Manning J, Varlotta CG, Woo D, Ayres E, Abotsi E, Vasquez-Montes D, Fischer CR, Stieber J, Quirno M, Protopsaltis TS, Passias PG, Buckland AJ. Biologics and Minimally Invasive Approach to TLIFs: What Is the Risk of Radiculitis? Int J Spine Surg 2020; 14:804-810. [PMID: 33046541 DOI: 10.14444/7114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Bone morphogenetic protein (BMP) and allograft containing mesenchymal stem cells (live cell) are popular biologic substitutes for iliac crest autograft used in transforaminal lumbar interbody fusion (TLIF). Use of these agents in the pathogenesis of postoperative radiculitis remains controversial. Recent studies have independently linked minimally invasive (MIS) TLIF with increased radiculitis risk compared to open TLIF. The purpose of this study was to assess the rate of postoperative radiculitis in open and MIS TLIF patients along with its relationship to concurrent biologic adjuvant use. METHODS Patients ≥18 years undergoing single-level TLIF from June 2012 to December 2018 with minimum 1-year follow-up were included. Outcome measures were rate of radiculitis, intra- and postoperative complications, revision surgery; length of stay (LOS), and estimated blood loss (EBL). RESULTS There were 397 patients: 223 with open TLIFs, 174 with MIS TLIFs. One hundred and fifty-nine surgeries used bone morphogenetic protein (BMP), 26 live cell, 212 neither. Open TLIF: higher mean EBL, LOS, and Charlson Comorbidity Index (CCI) than MIS. Postoperative radiculitis in 37 patients (9.32% overall): 16 cases MIS BMP (15.69% of their cohort), 6 MIS without BMP (8.33%), 5 open BMP (8.77%), 10 open without BMP (6.02%). MIS TLIF versus open TLIF: no differences in 1-year reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. BMP versus non-BMP: no differences in reoperation rates, infection/wound complication, pseudarthrosis, or postoperative complication rate. Multivariate logistic regression found that neither BMP (P = .109) nor MIS (P = .314) was an independent predictor for postoperative radiculitis when controlled for age, gender, body mass index, and CCI. Using paired open and MIS groups (N = 168 each) with propensity score matching, these variables were still not independently associated with radiculitis (P = .174 BMP, P = .398 MIS). However, the combination of MIS with BMP was associated with increased radiculitis risk in both the entire patient cohort (odds ratio [OR]: 2.259 [1.117-4.569], P = .023, N = 397) and PSM cohorts (OR: 2.196 [1.045-4.616], P = .038, N = 336) compared to other combinations of surgical approach and biologic use. CONCLUSION Neither the MIS approach nor BMP use is an independent risk factor for post-TLIF radiculitis. However, risk of radiculitis significantly increases when they are used in tandem. This should be considered when selecting biological adjuvants for MIS TLIF. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Erik Wang
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Carolyn Stickley
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Jordan Manning
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | | | - Dainn Woo
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Ethan Ayres
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Edem Abotsi
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | | | - Charla R Fischer
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Jonathan Stieber
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Martin Quirno
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | | | - Peter G Passias
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Aaron J Buckland
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, New York.,Melbourne Orthopaedic Group, Melbourne, Australia
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12
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Habib M, Horne DA, Hussein K, Coughlin D, Waldorff EI, Zhang N, Ryaby JT, Lotz JC. Magnetic Nanoparticles Synergize with Pulsed Magnetic Fields to Stimulate Osteogenesis In Vitro. Tissue Eng Part A 2020; 27:402-412. [PMID: 32746770 DOI: 10.1089/ten.tea.2020.0102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Delayed bone healing is a major challenge in orthopedic clinical practice, highlighting a need for technologies to overcome ineffective cell growth and osteogenic differentiation. The objective of this study was to investigate the synergistic effects of the PhysioStim (PEMF) signal with iron-ion doped tri-calcium phosphate bone substitute on human mesenchymal stem cell (hMSC) osteogenesis in vitro. Intrinsically magnetic nano-bone substitutes (MNBS) were developed with single particles on the order of 100 nm, saturation magnetization of 0.425 emu/g, and remanent magnetization of 0.013 emu/g. MNBS were added to hMSC culture and cell viability, alkaline phosphatase (ALP) activity, mineralization, and osteogenic gene expression in the presence and absence of PEMF were quantified for up to 10 days. MNBS attached to the surface of and were internalized by hMSCs when cultured together for 4 days and had no impact on cell viability with PEMF exposure for up to 7 days. Although total ALP activity was significantly increased with PEMF treatment alone, with a peak at day 5, PEMF combined with MNBS significantly increased ALP activity, with a peak at day 3, compared with all other groups (p < 0.01). The shift can be explained by significantly increased extracellular ALP activity beginning at day 2 (p < 0.01). PEMF combined with MNBS demonstrated continuously increasing mineralization overtime, with significantly greater Alizarin Red S concentration compared with all other groups at day 7 (p < 0.01). Increases in ALP activity and mineral content were in agreement with osteogenic gene expression that demonstrated peak ALP gene expression at day 1, and upregulated BMP-2, BGLAP, and SPP1 gene expression at day 7 (p < 0.05). The results of this study demonstrate the synergistic effects of PEMF and MNBS on osteogenesis and suggest that PEMF and MNBS may provide a method for accelerated bone healing.
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Affiliation(s)
- Mohamed Habib
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA.,Mechanical Engineering Department, Al Azhar University, Cairo, Egypt
| | - Devante A Horne
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA.,The UC Berkeley-UCSF Graduate Program in Bioengineering, University of California, Berkeley, and University of California, San Francisco, San Francisco, USA
| | - Khaled Hussein
- Mechanical Engineering Department, Al Azhar University, Cairo, Egypt
| | - Dezba Coughlin
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | | | | | | | - Jeffrey C Lotz
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA.,The UC Berkeley-UCSF Graduate Program in Bioengineering, University of California, Berkeley, and University of California, San Francisco, San Francisco, USA
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13
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Roberti F, Arsenault K. Minimally Invasive Lumbar Decompression and Removal of Symptomatic Heterotopic Bone Formation After Spinal Fusion with Recombinant Human Bone Morphogenetic Protein-2. World Neurosurg 2020; 141:430-436. [PMID: 32387785 PMCID: PMC7202823 DOI: 10.1016/j.wneu.2020.04.235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 11/15/2022]
Abstract
We present a case of symptomatic heterotopic bone formation following revision of posterolateral lumbar fusion/instrumentation and "off-label" use of recombinant human bone morphogenetic protein-2, treated successfully with the use of a minimally invasive tubular approach.
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Affiliation(s)
- Fabio Roberti
- Section of Neurosurgery, Cleveland Clinic Indian River Hospital, Vero Beach, Florida, USA; Department of Neurosurgery, The George Washington University, Washington, DC, USA.
| | - Katie Arsenault
- Section of Neurosurgery, Cleveland Clinic Indian River Hospital, Vero Beach, Florida, USA
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14
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The minimally effective dose of bone morphogenetic protein in posterior lumbar interbody fusion: a systematic review and meta-analysis. Spine J 2020; 20:1286-1304. [PMID: 32339767 DOI: 10.1016/j.spinee.2020.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTENT The risks and benefits of recombinant human bone morphogenetic protein-2 (BMP) in posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) have been widely reported. However, the BMP dose associated with such reports varied widely. Additionally, data on the location of BMP placement on complications and fusion are lacking. PURPOSE To determine the minimally effective dose (MED) of BMP which results in optimal fusion rates while minimizing complications; to determine the effects of the location of BMP placement has on fusion rates and complications. STUDY DESIGN Systematic review and meta-analysis. STUDY SAMPLE Adult patients undergoing PLIF/TLIF for degenerative indications. OUTCOME MEASURES Rates of radiculitis, fusion, osteolysis, heterotopic bone formation, and new cancer diagnosis. METHODS PubMed, Embase, and Cochrane Database were used to identify studies published between January 1, 2011 and April 30, 2019 reporting BMP usage in adult patients who underwent PLIF/TLIF degenerative indications. A qualitative and quantitative synthesis was performed to evaluate the MED of BMP and the effect of location of BMP placement on fusion and complications. Complications were defined as osteolysis, heterotopic bone growth, radiculitis, and rate of new cancer diagnosis. Complications and fusion outcomes were each pooled according to commercially available BMP doses. Additionally, complications and fusion outcomes were pooled according to 4 location groups (interbody cage only, interbody cage + posterolateral gutter [PLG], cage + interspace, and interspace + PLG). Heterogeneity was assessed with Q and I2 statistics. RESULTS Twenty-two articles, totaling 2,729 patients were included. Sixteen studies reported fusion and 15 reported complications. Among fusion studies, the mean BMP/level ranged from 1.28 to 12 mg/level. Among complication studies, the mean BMP/level ranged from 6.7 to 23.6 mg/level. The pooled overall fusion rate was 94.0% (91.4-95.8 confidence intervals). There was no significant difference in fusion and complication rates between different BMP doses. Thirteen studies included data on the location of BMP placement with 1,823 patients. At each BMP location, the fusion rate was not significantly different across the dose ranges (1.28-12 mg/level). We found the fusion rate to be marginally higher in the interspace + PLG group compared to the other groups. When BMP was placed in the interbody cage there was a mild increase in the rate of osteolysis compared to other placement locations. CONCLUSIONS Fusion and complication rates did not differ significantly between different doses of BMP with the lowest MED for fusion as low as 1.28 mg/level. The location of BMP placement does not significantly affect fusion or complication rates.
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15
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Vascularized Iliac Bone Graft for Complex Closure During Spinal Deformity Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2345. [PMID: 31942366 PMCID: PMC6952161 DOI: 10.1097/gox.0000000000002345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/15/2019] [Indexed: 02/07/2023]
Abstract
Spinal pseudarthrosis is failure of bony union across a segment where arthrodesis has been attempted. A variety of treatment approaches have been proposed to promote bony union, including use of vascularized bone graft. We report a successful application of vascularized pedicled iliac crest bone graft (ICBG) to treat recurrent lumbar and sacral pseudarthrosis. The vascularized ICBG offers the advantages of biocompatibility, mechanical stability, and minimal antigenicity. Vascularized bone transfers to the spine undergo fusion without resorption, even in the presence of compressive and rotatory forces. With its ease of access within the operative field and limited donor site morbidity, vascularized ICBG is an ideal orthobiologic that expedites time to bony union.
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16
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Minimally Effective Dose of Bone Morphogenetic Protein in Minimally Invasive Lumbar Interbody Fusions: Six Hundred Ninety Patients in a Dose-Finding Longitudinal Cohort Study. Spine (Phila Pa 1976) 2019; 44:989-995. [PMID: 30817730 DOI: 10.1097/brs.0000000000002993] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective longitudinal cohort. OBJECTIVE We sought to demonstrate the minimally effective bone morphogenetic protein (BMP) dose to achieve fusion in minimally invasive transforaminal lumbar interbody fusions. SUMMARY OF BACKGROUND DATA Multiple studies have been conducted, which used a wide range of BMP doses for lumbar fusions highlighting associated risks and benefits. There is, however, a paucity in the literature in determining the minimally effective dose. METHODS Consecutive patients who underwent transforaminal lumbar interbody fusion from 2009 to 2014 were reviewed. Fusion was determined by a combination of computed tomography and dynamic x-ray by independent radiologists. We used backward stepwise multiple logistic regression with fusion as the dependent variable to determine whether BMP dose/level was a significant predictor for fusion. To determine the minimally effective dose of BMP/level, separate logistic regressions for different BMP dose ranges and sensitivity analyses were used. A P value ≤0.025 was considered significant. RESULTS There were 1102 interspaces among 690 patients. Average BMP dose was 1.28 mg/level. Overall fusion was 95.2% with a mean follow-up of 19 months. BMP dose/level was a significant predictor for fusion. Odds of fusion increased by 2.02 when BMP dose range was increased from (0.16-1 mg/level) to (1.0-2 mg/level), but fusion odds did not increase when BMP dose increased to more than 2 mg/level. CONCLUSION BMP dose/level was a significant predictor for fusion. There was a significant increase in odds of fusion when BMP dose increased from 0.16 to 1 mg/level to 1.0 to 2 mg/level. No benefit from increasing the dose more than 2 mg/level was found, suggesting 1.0 mg/level to be the minimally effective BMP dose. LEVEL OF EVIDENCE 3.
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17
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Weiss H, Garcia RM, Hopkins B, Shlobin N, Dahdaleh NS. A Systematic Review of Complications Following Minimally Invasive Spine Surgery Including Transforaminal Lumbar Interbody Fusion. Curr Rev Musculoskelet Med 2019; 12:328-339. [PMID: 31302861 PMCID: PMC6684700 DOI: 10.1007/s12178-019-09574-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To assess complications after minimally invasive spinal surgeries including transforaminal lumbar interbody fusion (MI-TLIF) by reviewing the most recent literature. RECENT FINDINGS Current literature demonstrates that minimally invasive surgery (MIS) in spine has improved clinical outcomes and reduced complications when compared with open spinal procedures. Recent studies describing MI-TLIF primarily for degenerative disk disease, spondylolisthesis, and vertebral canal stenosis cite over 89 discrete complications, with the most common being radiculitis (ranging from 2.8 to 57.1%), screw malposition (0.3-12.7%), and incidental durotomy (0.3-8.6%). Minimally invasive spine surgery has a distinct set of complications in comparison with other spinal procedures. These complications vary based on the exact MIS procedure and indication. The most frequently documented MI-TLIF complications in current published literature were radiculitis, screw malposition, and incidental durotomy.
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Affiliation(s)
- Hannah Weiss
- Department of Neurosurgery, Northwestern University, 676 N Saint Clair, NMH/Arkes Family Pavilion Suite 2210, Chicago, IL, 60611, USA
| | - Roxanna M Garcia
- Department of Neurosurgery, Northwestern University, 676 N Saint Clair, NMH/Arkes Family Pavilion Suite 2210, Chicago, IL, 60611, USA
- Institute for Public Health and Medicine (IPHAM), Center for Healthcare Studies, Northwestern University, Chicago, IL, USA
| | - Ben Hopkins
- Department of Neurosurgery, Northwestern University, 676 N Saint Clair, NMH/Arkes Family Pavilion Suite 2210, Chicago, IL, 60611, USA
| | | | - Nader S Dahdaleh
- Department of Neurosurgery, Northwestern University, 676 N Saint Clair, NMH/Arkes Family Pavilion Suite 2210, Chicago, IL, 60611, USA.
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18
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The Use of Bone Morphogenetic Protein in the Intervertebral Disk Space in Minimally Invasive Transforaminal Lumbar Interbody Fusion: 10-year Experience in 688 Patients. Clin Spine Surg 2019; 32:E272-E276. [PMID: 30839419 DOI: 10.1097/bsd.0000000000000800] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
STUDY DESIGN Retrospective Cohort. OBJECTIVE The objective of this study was to characterize one surgeon's experience over a 10-year period using rhBMP-2 in the disk space for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA MIS TLIF has been utilized as a technique for decreasing patients' immediate postoperative pain, decreasing blood loss, and shortened hospital stays. Effectiveness and complications of rhBMP-2's use in the disk space is limited because of its off-label status. METHODS Retrospective analysis of consecutive MIS TLIFs performed by senior author between 2004 and 2014. rhBMP-2 was used in the disk space in all cases. Patients were stratified based on the dose of rhBMP-2 utilized. Patients had 9 to 12 month computerized tomography scan to evaluate for bony fusion and continued follow-up for 18 months. RESULTS A total of 688 patients underwent a MIS TLIF. A medium kit of rhBMP-2 was utilized in 97 patients, and small kit was used in 591 patients. Fusion rate was 97.9% and this was not different between the 2 groups with 96/97 patients fusing in the medium kit group and 577/591 patients fusing in the small kit group. Five patients taken back to the operating room for symptomatic pseudoarthrosis, 4 reoperated for bony hyperostosis, and 10 radiographic pseudoarthroses that did not require reoperation. A statistically significant difference in the rate of foraminal hyperostosis was found when using a medium sized kit of rhBMP-2 was 4.12% (4/97 patients), compared with a small kit (0/591 patients, P=0.0004). CONCLUSIONS Utilization of rhBMP-2 in an MIS TLIF leads to high fusion rate (97.9%), with an acceptable complication profile. The development of foraminal hyperostosis is a rare complication that only affected 0.6% of patients, and seems to be a dose related complication, as this complication was eliminated when a lower dose of rhBMP-2 was utilized. LEVEL OF EVIDENCE Level IV.
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19
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Bindal S, Bindal SK, Bindal M, Bindal AK. Noninstrumented Lumbar Fusion with Bone Morphogenetic Proteins for Spinal Stenosis with Spondylolisthesis in the Elderly. World Neurosurg 2019; 126:e1427-e1435. [PMID: 30904805 DOI: 10.1016/j.wneu.2019.02.251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study examined the use of noninstrumented posterolateral lumbar fusion with bone morphogenetic protein (BMP) and compared its effectiveness with that of instrumented fusion for the treatment of lumbar spinal stenosis (LSS) with spondylolisthesis in elderly patients. METHODS This study was a retrospective review of 93 patients treated in a single-surgeon neurosurgical private practice over a 15-year period. Fifty-nine patients over the age of 65 who underwent noninstrumented posterolateral fusion with rhBMP-2 (Infuse) for LSS with spondylolisthesis were compared with 34 patients who underwent instrumented fusion without rhBMP-2. Outcomes in terms of reoperation rate, pain improvement, Oswestry Disability Index (ODI) score, and number of extra follow-up visits due to persistent problems were characterized by the use of t tests and χ2 tests. RESULTS The reoperation rate in the noninstrumented rhBMP-2 fusion group was significantly lower than in the instrumented fusion group (17.6% vs. 3.4%, P = 0.048). The mean pain improvement was significantly higher in the noninstrumented rhBMP-2 group at 3 months (8.1 vs. 6.0, P < 0.001, 95% confidence interval [CI] 1.2 to 3.0) and at 1 year (7.25 vs. 5.6, P = 0.030, 95% CI 0.3 to 3.1). The ODI score improvement was significantly higher in the noninstrumented rhBMP-2 group (51 vs. 42.8, P < 0.001, 95% CI 4.7 to 11.6). The mean number of additional follow-up visits per patient was significantly lower in the noninstrumented rhBMP-2 group (0.068 vs. 1.23, P < 0.001, 95% CI 0.59 to 1.75). CONCLUSION Noninstrumented posterolateral lumbar fusion with rhBMP-2 in elderly patients with LSS and spondylolisthesis is a viable alternative to instrumented fusion based on clinical outcomes measured in this study.
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20
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Sebastian AS, Wanderman NR, Currier BL, Pichelmann MA, Treder VM, Fogelson JL, Clarke MJ, Nassr AN. Prospective Evaluation of Radiculitis following Bone Morphogenetic Protein-2 Use for Transforaminal Interbody Arthrodesis in Spine Surgery. Asian Spine J 2019; 13:544-555. [PMID: 30866616 PMCID: PMC6680045 DOI: 10.31616/asj.2018.0277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/13/2018] [Indexed: 11/30/2022] Open
Abstract
Study Design Prospective observational cohort study. Purpose This study aims to evaluate the safety and efficacy of bone morphogenetic protein-2 (BMP-2) in transforaminal lumbar interbody fusion (TLIF) with regard to postoperative radiculitis. Overview of Literature Bone morphogenetic protein (BMP) is being used increasingly as an alternative to iliac crest autograft in spinal arthrodesis. Recently, the use of BMP in TLIF has been examined, but concerns exist that the placement of BMP close to the nerve roots may cause postoperative radiculitis. Furthermore, prospective studies regarding the use of BMP in TLIF are lacking. Methods This prospective study included 77 patients. The use of BMP-2 was determined individually, and demographic and operative characteristics were recorded. Leg pain was assessed using the Visual Analog Scale (VAS) for pain and the Sciatica Bothersome Index (SBI) with several secondary outcome measures. The outcome data were collected at each follow-up visit. Results Among the 77 patients, 29 were administered with BMP. Postoperative leg pain significantly improved according to VAS leg and SBI scores for the entire cohort, and no clinically significant differences were observed between the BMP and control groups. The VAS back, Oswestry Disability Index, and Short-Form 36 scores also significantly improved. A significantly increased 6-month fusion rate was noted in the BMP group (82.8% vs. 55.3%), but no significant differences in fusion rate were observed at the 12- and 24-month follow-up. Heterotopic ossification was observed in seven patients: six patients and one patient in the BMP and control groups, respectively (20.7% vs. 2.1%). However, no clinical effect was observed. Conclusions In this prospective observational trial, the use of BMP in TLIF did not lead to significant postoperative radiculitis, as measured by VAS leg and SBI scores. Back pain and other functional outcome scores also improved, and no differences existed between the BMP and control groups. The careful use of BMP in TLIF appears to be both safe and effective.
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Affiliation(s)
| | | | | | | | - Vickie M Treder
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ahmad N Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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21
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Overley SC, McAnany SJ, Anwar MA, Merrill RK, Lovy A, Guzman JZ, Zhadanov S, Doshi A, Rothenberg E, Vaishnav A, Gang C, Qureshi SA. Predictive Factors and Rates of Fusion in Minimally Invasive Transforaminal Lumbar Interbody Fusion Utilizing rhBMP-2 or Mesenchymal Stem Cells. Int J Spine Surg 2019; 13:46-52. [PMID: 30805286 DOI: 10.14444/6007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Several fusion adjuncts exist to enhance fusion rates during minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The objective of this study was to compare fusion rates in patients undergoing MI-TLIF with either rhBMP-2 or cellularized bone matrix (CBM). Methods We conducted a single surgeon retrospective cohort study of patients who underwent MI-TLIF with either rhBMP-2 or CBM placed in an interbody cage. Single and multilevel procedures were included. Fusion was assessed on computed tomography scans at 12-month follow-up by an independent, blinded, board-certified neuroradiologist. Fusion rates and rate of revision surgery were compared with a Fisher exact test between the 2 groups. A multivariate regression analysis was performed to identify patient factors that were predictive of radiographic nonunion after MI-TLIF. Results A total of 93 fusion levels in 78 patients were reviewed. Thirty-nine patients received CBM, and 39 patients received rhBMP-2. The patients receiving rhBMP-2 were older on average (61.4 vs 55.6, P = .03). The overall fusion rate was 68% in the CBM group (32/47 levels) and 78% in the rhBMP-2 group (36/46) (P = .35). Only preoperative hypertension was predictive of radiographic nonunion (odds ratio = 3.5, P = .05). There were 3 smokers in the CBM group and 4 smokers in the BMP group, and 1 in each group experienced radiographic pseudarthrosis. A total of 4 patients, 3 in the CBM group and 1 in the BMP group (P = .61), required revision for symptomatic pseudarthrosis. All of these patients had a single-level index procedure. Conclusions There were no differences in radiographic fusion and rate of revision surgery in patients who underwent MI-TLIF with either rhBMP-2 or CBM as fusion adjuncts. Level of Evidence 3. Clinical Relevance Both rhBMP-2 and CBMs can be used as effective fusion adjuncts without any clear advantage of one over the other.
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Affiliation(s)
- Samuel C Overley
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Steven J McAnany
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Muhammad A Anwar
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert K Merrill
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew Lovy
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Javier Z Guzman
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sergey Zhadanov
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amish Doshi
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Edward Rothenberg
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Avani Vaishnav
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Catherine Gang
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sheeraz A Qureshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Ishida W, Ramhmdani S, Xia Y, Kosztowski TA, Xu R, Choi J, De la Garza Ramos R, Elder BD, Theodore N, Gokaslan ZL, Sciubba DM, Witham TF, Bydon A, Wolinsky JP, Lo SFL. Use of Recombinant Human Bone Morphogenetic Protein-2 at the C1-C2 Lateral Articulation without Posterior Structural Bone Graft in Posterior Atlantoaxial Fusion in Adult Patients. World Neurosurg 2018; 123:e69-e76. [PMID: 30448576 DOI: 10.1016/j.wneu.2018.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/07/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Posterior atlantoaxial fusion is an important armamentarium for neurosurgeons to treat several pathologies involving the craniovertebral junction. Although the potential advantages of recombinant human bone morphogenetic protein-2 (rhBMP-2) are well documented in the lumbar spine, its indication for C1-C2 fusion has not been well characterized. In our institution, we apply rhBMP-2 to the C1-C2 joint either alone or with hydroxyapatite, locally harvested autograft chips, and/or morselized allogenic bone graft for selected cases-without conventional posterior structural bone graft. We report the clinical outcomes of the surgical technique to elucidate its feasibility. METHODS We performed a single-center, retrospective review of data from 2008 to 2016 and identified 69 patients who had undergone posterior atlantoaxial fusion with rhBMP-2. The clinical records of these patients were reviewed, and the baseline characteristics, operative data, and postoperative complications were collected and statistically analyzed. RESULTS The average age of the 69 patients was 60.8 ± 4.5 years, and 55.1% were women. With an average follow-up period of 21.1 ± 4.2 months, the C1-C2 fusion rate was 94.3% (65 of 69), and the average time to fusion was 11.4 ± 2.6 months (range, 5-23). The overall reoperation rate was 10.1% (7 of 69), with instrumentation failure in 7 patients (10.1%), adjacent segment disease in 2 (2.9%), and postoperative dysphagia and dyspnea in 2 patients (2.9%). No ectopic bone formation or soft tissue edema developed. CONCLUSIONS Although retrospective and from a single center, our study has shown that rhBMP-2 usage at the C1-C2 joint without posterior structural bone grafting is a safe and reasonable surgical option.
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Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Seba Ramhmdani
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Yuanxuan Xia
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Thomas A Kosztowski
- Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Risheng Xu
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - John Choi
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Rafael De la Garza Ramos
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Benjamin D Elder
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Jean-Paul Wolinsky
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Sheng-Fu L Lo
- Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.
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23
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Emami A, Faloon M, Sahai N, Dunn CJ, Issa K, Thibaudeau D, Sinha K, Hwang KS. Risk Factors for Pseudarthrosis in Minimally-Invasive Transforaminal Lumbar Interbody Fusion. Asian Spine J 2018; 12:830-838. [PMID: 30213165 PMCID: PMC6147882 DOI: 10.31616/asj.2018.12.5.830] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 01/31/2018] [Indexed: 01/01/2023] Open
Abstract
Study Design Retrospective cohort study (level of evidence: 4). Purpose To describe the potential comorbid, operative, and radiographic risk factors for the development of clinically-relevant pseudarthrosis following minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF). Overview of Literature MIS-TLIF has shown long-term clinical outcomes with decreased perioperative morbidity and earlier return to work, similar to those of open TLIF. However, unsuccessful fusion still remains a concern. The impacts of various patient, operative, and radiographic risk factors have not been evaluated for their potential association with pseudarthrosis related to MIS-TLIF. Methods Between 2012 and 2015, 204 consecutive patients underwent one or two-level MIS-TLIF at St. Joseph's University Medical Center, Paterson, NJ, USA; they had a minimum of 1 year of follow-up. The patients were divided into two cohorts: those who developed clinically-relevant pseudarthrosis and those who did not. Clinically-relevant pseudarthrosis was determined by both evidence on computed tomography and presence of continued clinical symptoms at 1-year follow-up. Results Revision surgery was the only identified non-radiographic factor associated with pseudarthrosis. Disc angle had the highest (R2=0.8), followed by anterior disc height (R2=0.79). Although posterior disc height and the ratio of anterior to posterior disc height showed a marked relationship with the outcome, the R2-values were <0.3, thus indicating a less-strong correlation. The overall pseudarthrosis rate was 8%. No statistically significant differences were identified between the two cohorts with respect to mean age, sex, medical comorbidities, smoking status, or number of levels fused. Conclusions Clinically-relevant pseudarthrosis is not uncommon following MIS-TLIF. In the current study, undergoing revision surgery, disc angle, and anterior disc height were observed to be associated with clinically-relevant pseudarthrosis. This study demonstrated that the patient population may benefit from an alternate approach.
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Affiliation(s)
- Arash Emami
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
| | - Michael Faloon
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
| | - Nikhil Sahai
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
| | - Conor J Dunn
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
| | - Kimona Issa
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
| | - Daniel Thibaudeau
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
| | - Kumar Sinha
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
| | - Ki Soo Hwang
- Department of Orthopaedic Surgery, Seton Hall University School of Health and Medical Sciences, South Orange, NJ, USA
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Spinal Biologics in Minimally Invasive Lumbar Surgery. Minim Invasive Surg 2018; 2018:5230350. [PMID: 29850240 PMCID: PMC5907390 DOI: 10.1155/2018/5230350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 02/25/2018] [Indexed: 12/28/2022] Open
Abstract
As the use of minimally invasive spine (MIS) fusion approaches continues to grow, increased scrutiny is being placed on its outcomes and efficacies against traditional open fusion surgeries. While there are many factors that contribute to the success of achieving spinal arthrodesis, selecting the optimal fusion biologic remains a top priority. With an ever-expanding market of bone graft substitutes, it is important to evaluate each of their use as it pertains to MIS techniques. This review will summarize the important characteristics and properties of various spinal biologics used in minimally invasive lumbar surgeries and compare their fusion rates via a systematic review of published literature.
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25
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Esmail N, Buser Z, Cohen JR, Brodke DS, Meisel HJ, Park JB, Youssef JA, Wang JC, Yoon ST. Postoperative Complications Associated With rhBMP2 Use in Posterior/Posterolateral Lumbar Fusion. Global Spine J 2018; 8:142-148. [PMID: 29662744 PMCID: PMC5898669 DOI: 10.1177/2192568217698141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective database review. OBJECTIVE Posterior/posterolateral lumbar fusion (PLF) is an effective treatment for a variety of spinal disorders; however, variations in surgical technique have different complication profiles. The aim of our study was to quantify the frequency of various complications in patients undergoing PLF with and without human recombinant bone morphogenetic protein 2 (rhBMP2). METHODS We queried the orthopedic subset of the Medicare database (PearlDiver) between 2005 and 2011 for patients undergoing PLF procedures with and without rhBMP2. Complication and reoperation rates were analyzed within 1 year of the index procedure. Complications assessed include: acute renal failure, deep vein thrombosis, dural tear, hematoma, heterotopic ossification, incision and drainage, cardiac complications, nervous system complications, osteolysis, pneumonia, pseudarthrosis, pulmonary embolism, radiculopathy, respiratory complications, sepsis, urinary retention, urinary tract infection, mechanical, and wound complications. Chi-square analysis was used to calculate the complication differences between the groups. RESULTS Our data revealed higher overall complication rates in patients undergoing PLF with rhBMP2 versus no_rhBMP2 (76.9% vs 68.8%, P < .05). Stratified by gender, rhBMP2 males had higher rates of mechanical complications, pseudarthrosis, and reoperations compared with no_rhBMP2 males (P < .05), whereas rhBMP2 females had higher rates of pseudarthrosis, urinary tract infection, and urinary retention compared with no_rhBMP2 females (P < .05). CONCLUSION Our data revealed higher overall complication rates in PLF patients given rhBMP2 compared with no_rhBMP2. Furthermore, our data suggests that rhBMP2-associated complications may be gender specific.
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Affiliation(s)
- Nabil Esmail
- University of Southern California, Los Angeles, CA, USA
| | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Jong-Beom Park
- Uijongbu St. Mary’s Hospital, The Catholic University of Korea School of Medicine, Uijongbu, Korea
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26
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Hoppe S, Albers CE, Elfiky T, Deml MC, Milavec H, Bigdon SF, Benneker LM. First Results of a New Vacuum Plasma Sprayed (VPS) Titanium-Coated Carbon/PEEK Composite Cage for Lumbar Interbody Fusion. J Funct Biomater 2018. [PMID: 29538285 PMCID: PMC5872109 DOI: 10.3390/jfb9010023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to assess the performance of a new vacuum plasma sprayed (VPS) titanium-coated carbon/polyetheretherketone (PEEK) cage under first use clinical conditions. Forty-two patients who underwent a one or two segment transforaminal lumbar interbody fusion (TLIF) procedure with a new Ca/PEEK composite cage between 2012 and 2016 were retrospectively identified by an electronic patient chart review. Fusion rates (using X-ray), patient’s satisfaction, and complications were followed up for two years. A total of 90.4% of the patients were pain-free and satisfied after a follow up (FU) period of 29.1 ± 9 (range 24–39) months. A mean increase of 3° in segmental lordosis in the early period (p = 0.002) returned to preoperative levels at final follow-ups. According to the Bridwell classification, the mean 24-month G1 fusion rate was calculated as 93.6% and the G2 as 6.4%. No radiolucency around the cage (G3) or clear pseudarthrosis could be seen (G4). In conclusion, biological properties of the inert, hydrophobic surface, which is the main disadvantage of PEEK, can be improved with VPS titanium coating, so that the carbon/PEEK composite cage, which has great advantages in respect of biomechanical properties, can be used safely in TLIF surgery. High fusion rates, good clinical outcome, and low implant-related complication rates without the need to use rhBMP or additional iliac bone graft can be achieved.
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Affiliation(s)
- Sven Hoppe
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Christoph E Albers
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Tarek Elfiky
- Spine Surgery Unit, El-Hadra University Hospital, Alexandria University, Alexandria 21561, Egypt.
| | - Moritz C Deml
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Helena Milavec
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Sebastian F Bigdon
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
| | - Lorin M Benneker
- Department of Orthopedic Surgery and Traumatology, Spine Unit, Inselspital, Bern University Hospital, Bern 3010, Switzerland.
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27
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Khan TR, Pearce KR, McAnany SJ, Peters CM, Gupta MC, Zebala LP. Comparison of transforaminal lumbar interbody fusion outcomes in patients receiving rhBMP-2 versus autograft. Spine J 2018; 18:439-446. [PMID: 28822825 DOI: 10.1016/j.spinee.2017.08.230] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/20/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Recombinant human bone morphogenetic protein 2 (rhBMP-2) plays a pivotal role in complex spine surgery. Despite its limited approval, the off-label use of rhBMP-2 is prevalent, particularly in transforaminal lumbar interbody fusions (TLIFs). PURPOSE To determine the effectiveness and safety of rhBMP-2 use in TLIF procedures versus autograft. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Patients older than 18 years undergoing spine surgery for lumbar degenerative spine disease at a single academic institution. OUTCOME MEASURES Clinical outcome was determined according to patient records. Radiographic outcome was determined according to plain X-rays and computed tomography (CT). METHODS A retrospective study from 1997 to 2014 was conducted on 191 adults undergoing anterior-posterior instrumented spinal fusion with TLIF at a single academic institution. Patient data were gathered from operative notes, follow-up clinic notes, and imaging studies to determine complications and fusion rates. One hundred eighty-seven patients fit the criteria, which included patients with a minimum of one TLIF, and had a minimum 2-year radiographic and clinical follow-up. Patients were further classified into a BMP group (n=83) or non-BMP group (n=104). Three logistic regression models were run using rhBMP-2 exposure as the independent variable. The respective outcome variables were TLIF-related complications (radiculitis, seroma, osteolysis, and ectopic bone), surgical complications, and all complications. RESULTS Bone morphogenetic protein (n=83) and non-BMP (n=104) groups had similar baseline demographics (sex, diabetes, pre-existing cancer). On average, the BMP and non-BMP groups were similarly aged (51.9 vs. 47.9 years, p>.05), but the BMP group had a shorter follow-up time (3.03 vs. 4.06 years; p<.001) and fewer smokers (8 vs. 21 patients; p<.048). The fusion rate for the BMP and non-BMP groups was 92.7% and 92.3%, respectively. The pseudoarthrosis rate was 7.5% (14 of 187 patients). Radiculitis was observed in seven patients in the BMP group (8.4%) and two patients in the non-BMP group (1.9%). Seroma was observed in two patients in the BMP group (2.4%) and none in the non-BMP group. No deep infections were observed in the BMP group, and in one patient in the non-BMP group (0.96%). Although patients exposed to BMP were at a significantlygreater risk of developing radiculitis and seroma (odds ratio [OR]=4.53, confidence interval [CI]=1.42-14.5), BMP exposure was not a significant predictor of surgical complications (OR=0.32, CI=0.10-1.00) or overall complications (OR=1.11, CI=0.53-2.34). The outcome of TLIF-related complications was too rare and the confidence interval too wide for practical significance of the first model. CONCLUSION Evidence supports the hypothesis that off-label use of rhBMP-2 in TLIF procedures is relatively effective for achieving bone fusion at rates similar to patients receiving autograft. Patients exhibited similar complication rates between the two groups, with the BMP group exhibiting slightly higher rates of radiculitis and seroma.
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Affiliation(s)
- Taleef R Khan
- Department of Orthopedics-Spine Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Kalin R Pearce
- BJC Institute of Health, Washington University's Brown School of Social Work, 425 S. Euclid Ave, Suite 5505, St. Louis, MO 63110, USA
| | - Steven J McAnany
- Department of Orthopedics-Spine Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Colleen M Peters
- Department of Orthopedics-Spine Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Munish C Gupta
- Department of Orthopedics-Spine Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Lukas P Zebala
- Department of Orthopedics-Spine Surgery, Washington University in Saint Louis, Saint Louis, MO, USA.
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28
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Transforaminal Lumbar Interbody Fusion: Traditional Open Versus Minimally Invasive Techniques. J Am Acad Orthop Surg 2018; 26:124-131. [PMID: 29337717 DOI: 10.5435/jaaos-d-15-00756] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Recently, minimally invasive spine arthrodesis has gained popularity among spine surgeons. Minimally invasive techniques have advantages and disadvantages compared with traditional open techniques. Comparisons between short-term outcomes of minimally invasive transforaminal interbody fusion and open transforaminal interbody fusion in terms of estimated blood loss, postoperative pain, and hospital length of stay have been well documented and generally favor the minimally invasive technique. However, the advantages of minimally invasive transforaminal interbody fusion must be evaluated in the context of long-term results, such as patient-reported outcomes and the success of arthrodesis. Because the literature is equivocal in identifying the superior technique for successful long-term outcomes, more study is needed. Patient safety, the risk of complications, and the cost of these techniques also must be considered.
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29
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Cho JH, Lee JH, Yeom JS, Chang BS, Yang JJ, Koo KH, Hwang CJ, Lee KB, Kim HJ, Lee CK, Kim H, Suk KS, Nam WD, Han J. Efficacy of Escherichia coli-derived recombinant human bone morphogenetic protein-2 in posterolateral lumbar fusion: an open, active-controlled, randomized, multicenter trial. Spine J 2017; 17:1866-1874. [PMID: 28652196 DOI: 10.1016/j.spinee.2017.06.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/01/2017] [Accepted: 06/20/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The efficacy and safety of recombinant human bone morphogenetic protein-2 (rhBMP-2) as a bone graft substitute in spinal fusion has been widely researched. However, no study of the efficacy and safety of Escherichia coli-derived rhBMP-2 (E.BMP-2) with a hydroxyapatite (HA) carrier has been proposed. PURPOSE This study aimed to compare the efficacy and safety of fusion materials between E.BMP-2 and autogenous iliac bone graft in posterolateral fusion (PLF). STUDY DESIGN/SETTING An open, active-controlled, randomized, multicenter trial was carried out. PATIENT SAMPLE This study included 93 patients who underwent single-level lumbar or lumbosacral PLF. OUTCOME MEASURES The primary outcome measure was computed tomography (CT)-based fusion rate at 12 and 24 weeks. Secondary outcome measures were fusion grade by radiographs and CT at 12 and 24 weeks and changes in Oswestry Disability Index (ODI), Short Form-36 (SF-36) Health Survey, and visual analogue scale (VAS). METHODS Patients who underwent 1-level PLF (between L1 and S1) for severe spinal stenosis or grade 1 spondylolisthesis were randomized to receive E.BMP-2 with an HA carrier (E.BMP-2 group) or autogenous iliac bone graft (AIBG group). Thin-section CT (<2 mm), VAS, ODI, and SF-36 were obtained pre- and postoperatively at 12 and 24 weeks. Outcome measures were compared between the groups. RESULTS A total of 100 patients were enrolled in this trial. Among them, 93 patients underwent planned surgery. Preoperative demographic and clinical data showed no difference between groups. CT-based fusion rates were 100.0% (41/41) for the E.BMP-2 group and 90.2% (46/51) for the AIBG group (p=.062) at 12 weeks and 100.0% (41/41) and 94.1% (48/51) (p=.251) at 24 weeks, respectively. Fusion grade based on radiographs and CT showed non-inferiority of the E.BMP-2 group compared with the AIBG group. All clinical parameters improved postoperatively. However, there was no difference in changes in VAS, ODI, or SF-36 between the groups. No serious adverse event related to E.BMP-2 was found. CONCLUSIONS The fusion rate of E.BMP-2 was comparable with that of AIBG following PLF. Good clinical efficacy and safety of E.BMP-2 in spinal fusion were also revealed. It was also suggested that HA shows suitability as a carrier for E.BMP-2. Thus, E.BMP-2 with an HA carrier can be an alternative bone graft material in spinal fusion.
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Affiliation(s)
- Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Hyup Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, South Korea.
| | - Jin Sup Yeom
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Sungnam, South Korea
| | - Bong-Soon Chang
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jae Jun Yang
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, South Korea
| | - Ki Hyoung Koo
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, South Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kwang Bok Lee
- Department of Orthopaedic Surgery, School of Medicine, Research Institute of Clinical Medicine of Chonbuk National University Hospital-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea
| | - Ho-Joong Kim
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Sungnam, South Korea
| | - Choon-Ki Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hyoungmin Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Soo Suk
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Woo Dong Nam
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Jumi Han
- Clinical Development Center, Daewoong Pharmaceutical Co., Ltd., Seoul, South Korea
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30
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Kim BJ, Arai Y, Park EM, Park S, Bello A, Han IB, Lee SH. Osteogenic Potential of Tauroursodeoxycholic Acid as an Alternative to rhBMP-2 in a Mouse Spinal Fusion Model. Tissue Eng Part A 2017; 24:407-417. [PMID: 28826347 DOI: 10.1089/ten.tea.2016.0349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The non-union rate after lumbar spinal fusion is potentially as high as 48%. To support efficient bone regeneration, recombinant human bone morphogenetic protein-2 (rhBMP-2) is commonly used as it is regarded as the most potent bone-inducing molecule. However, recently, there have been increasing concerns on the use of rhBMP-2 such as serious complications, including seroma and heterotopic ossification, and the low quality of bone at the center of fusion mass. Thus, many studies were conducted to find and to develop a potential alternative to rhBMP-2. In this study, we investigated the osteogenic potential of tauroursodeoxycholic acid (TUDCA) in the mouse fusion model and compared its effects with rhBMP-2. Twenty-four mice underwent bilateral posterolateral lumbar spinal fusion bone formation at L4-L5. Collagen sponge infused with saline, TUDCA, or rhBMP-2 was implanted at the fusion area. Two and 4 weeks postimplantation, bone formation and tissue regeneration were evaluated via micro-computed tomography and histological analysis. Compared with the TUDCA-treated group, the rhBMP-2 treatment produced a higher amount of bone fusion formation after 2 weeks but also showed higher resorption of the centralized bone after 4 weeks. Interestingly, the TUDCA-treated group developed higher trabecular thickness compared with rhBMP-2 after 4 weeks. Moreover, TUDCA treatment showed distinct angiogenic activity in human umbilical vein endothelial cells as confirmed by an in vitro tube formation assay. Our findings suggest that TUDCA is comparable to rhBMP-2 in supporting bone regeneration and spinal bone formation fusion by increasing trabecular thickness and promoting angiogenesis. Finally, our results indicate that TUDCA can be utilized as a potential alternative to rhBMP-2.
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Affiliation(s)
- Byoung Ju Kim
- 1 Department of Biomedical Science, College of Life Science, CHA University , Seongnam-si, Korea
| | - Yoshie Arai
- 1 Department of Biomedical Science, College of Life Science, CHA University , Seongnam-si, Korea
| | - Eun-Mi Park
- 1 Department of Biomedical Science, College of Life Science, CHA University , Seongnam-si, Korea
| | - Sunghyun Park
- 1 Department of Biomedical Science, College of Life Science, CHA University , Seongnam-si, Korea
| | - Alvin Bello
- 1 Department of Biomedical Science, College of Life Science, CHA University , Seongnam-si, Korea
| | - In-Bo Han
- 1 Department of Biomedical Science, College of Life Science, CHA University , Seongnam-si, Korea.,2 Department of Neurosurgery, CHA Bundang Medical Center, CHA University , Seongnam-si, Korea
| | - Soo-Hong Lee
- 1 Department of Biomedical Science, College of Life Science, CHA University , Seongnam-si, Korea
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31
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Neuroforaminal Bone Growth Following Minimally Invasive Transforaminal Lumbar Interbody Fusion With BMP: A Computed Tomographic Analysis. Clin Spine Surg 2017. [PMID: 28632565 DOI: 10.1097/bsd.0000000000000347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Computed tomographic analysis. OBJECTIVE To identify radiographic patterns of symptomatic neuroforaminal bone growth (NFB) in patients who have undergone a single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) augmented with bone morphogenetic proteins (BMP) utilizing computed tomography (CT). SUMMARY OF BACKGROUND DATA BMP induces osteoblast differentiation leading to new bone formation. The association of BMP utilization and heterotopic bone formation after an MIS-TLIF has been described. However, studies have been limited in their patient population and details regarding diagnosis and treatment of NFB. MATERIALS AND METHODS Postoperative CT scans of the symptomatic and asymptomatic patients were analyzed to identify patterns of heterotopic bone growth on axial and sagittal views. The area of bone growth at the disk level, lateral recess, adjacent foramen, and retrovertebral area were measured. Mann-Whitney U test was used to compare the areas of bone growth between cohorts. RESULTS Postoperative CT images between 18 symptomatic and 13 asymptomatic patients were compared. On axial views, the symptomatic patients demonstrated greater areas of bone growth at the disk level (164.0±92.4 vs. 77.0±104.9 mm), and lateral recess (69.6±70.5 and 5.9±12.5 mm) as well as in the total cross-sectional area (290.3±162.1 vs. 119.4±115.6 mm). On sagittal imaging, the mean bone growth at the subarticular level (148.7±185.1 vs. 35.8±37.4 mm) and the total cross-sectional area (298.4±324.4 vs. 85.8±76.3 mm) were greater in symptomatic patients (P<0.01). Amount of BMP utilized and operative levels were no different between cohorts. CONCLUSIONS The findings of the present study suggest that an anatomic association exists between recalcitrant postoperative radiculopathy and NFB following an MIS-TLIF with BMP. Increased total bone growth as measured on serial axial and sagittal sections was associated with postoperative radiculopathy. The association between radiculopathy and the extension of BMP-induced bone growth toward the traversing nerve root appeared the most significant.
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Cyst-Like Osteolytic Formations in Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) Augmented Sheep Spinal Fusion. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 187:1485-1495. [PMID: 28502475 DOI: 10.1016/j.ajpath.2017.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 03/27/2017] [Accepted: 03/30/2017] [Indexed: 11/20/2022]
Abstract
Multiple case reports using recombinant human bone morphogenetic protein-2 (rhBMP-2) have reported complications. However, the local adverse effects of rhBMP-2 application are not well documented. In this report we show that, in addition to promoting lumbar spinal fusion through potent osteogenic effects, rhBMP-2 augmentation promotes local cyst-like osteolytic formations in sheep trabecular bones that have undergone anterior lumbar interbody fusion. Three months after operation, conventional computed tomography showed that the trabecular bones of the rhBMP-2 application groups could fuse, whereas no fusion was observed in the control group. Micro-computed tomography analysis revealed that the core implant area's bone volume fraction and bone mineral density increased proportionately with rhBMP-2 dose. Multiple cyst-like bone voids were observed in peri-implant areas when using rhBMP-2 applications, and these sites showed significant bone mineral density decreases in relation to the unaffected regions. Biomechanically, these areas decreased in strength by 32% in comparison with noncystic areas. Histologically, rhBMP-2-affected void sites had an increased amount of fatty marrow, thinner trabecular bones, and significantly more adiponectin- and cathepsin K-positive cells. Despite promoting successful fusion, rhBMP-2 use in clinical applications may result in local adverse structural alterations and compromised biomechanical changes to the bone.
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Litrico S, Langlais T, Pennes F, Gennari A, Paquis P. Lumbar interbody fusion with utilization of recombinant human bone morphogenetic protein: a retrospective real-life study about 277 patients. Neurosurg Rev 2017; 41:189-196. [DOI: 10.1007/s10143-017-0834-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/29/2017] [Accepted: 02/20/2017] [Indexed: 11/28/2022]
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Oliveira ORGD, Martins SPR, Lima WGD, Gomes MM. O uso de proteínas morfogenéticas ósseas (BMP) e pseudoartroses, uma revisão de literatura. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Bone Morphogenic Protein Is a Viable Adjunct for Fusion in Minimally Invasive Transforaminal Lumbar Interbody Fusion. Asian Spine J 2016; 10:1091-1099. [PMID: 27994786 PMCID: PMC5165000 DOI: 10.4184/asj.2016.10.6.1091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/20/2016] [Accepted: 05/07/2016] [Indexed: 11/21/2022] Open
Abstract
Study Design Comparison 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). Purpose To compare the clinical, radiological outcome and complications of patients undergoing MIS-TLIF with and without BMP. Overview of Literature BMP 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. Methods From 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. Results The 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. Conclusions The 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.
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Hershman S, Jenis LG. BMP 2 usage in posterior lumbar fusion in degenerative conditions. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.semss.2016.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Vavken J. Bio-augmented spinal fusion-the best is yet to come. JOURNAL OF SPINE SURGERY (HONG KONG) 2016; 2:345-347. [PMID: 28097255 PMCID: PMC5233856 DOI: 10.21037/jss.2016.12.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 10/12/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Julia Vavken
- University Hospital of Basel, University of Basel, Basel, Switzerland
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Joseph JR, Smith BW, La Marca F, Park P. Comparison of complication rates of minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion: a systematic review of the literature. Neurosurg Focus 2016; 39:E4. [PMID: 26424344 DOI: 10.3171/2015.7.focus15278] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECT Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and lateral lumbar interbody fusion (LLIF) are 2 currently popular techniques for lumbar arthrodesis. The authors compare the total risk of each procedure, along with other important complication outcomes. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies (up to May 2015) that reported complications of either MI-TLIF or LLIF were identified from a search in the PubMed database. The primary outcome was overall risk of complication per patient. Secondary outcomes included risks of sensory deficits, temporary neurological deficit, permanent neurological deficit, intraoperative complications, medical complications, wound complications, hardware failure, subsidence, and reoperation. RESULTS Fifty-four studies were included for analysis of MI-TLIF, and 42 studies were included for analysis of LLIF. Overall, there were 9714 patients (5454 in the MI-TLIF group and 4260 in the LLIF group) with 13,230 levels fused (6040 in the MI-TLIF group and 7190 in the LLIF group). A total of 1045 complications in the MI-TLIF group and 1339 complications in the LLIF group were reported. The total complication rate per patient was 19.2% in the MI-TLIF group and 31.4% in the LLIF group (p < 0.0001). The rate of sensory deficits and temporary neurological deficits, and permanent neurological deficits was 20.16%, 2.22%, and 1.01% for MI-TLIF versus 27.08%, 9.40%, and 2.46% for LLIF, respectively (p < 0.0001, p < 0.0001, p = 0.002, respectively). Rates of intraoperative and wound complications were 3.57% and 1.63% for MI-TLIF compared with 1.93% and 0.80% for LLIF, respectively (p = 0.0003 and p = 0.034, respectively). No significant differences were noted for medical complications or reoperation. CONCLUSIONS While there was a higher overall complication rate with LLIF, MI-TLIF and LLIF both have acceptable complication profiles. LLIF had higher rates of sensory as well as temporary and permanent neurological symptoms, although rates of intraoperative and wound complications were less than MI-TLIF. Larger, prospective comparative studies are needed to confirm these findings as the current literature is of relative poor quality.
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Affiliation(s)
- Jacob R Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Frank La Marca
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Oliveira ORGD, Martins SPR, Lima WGD, Gomes MM. The use of bone morphogenetic proteins (BMP) and pseudarthrosis, a literature review. Rev Bras Ortop 2016; 52:124-140. [PMID: 28409128 PMCID: PMC5380784 DOI: 10.1016/j.rboe.2016.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/07/2016] [Indexed: 11/29/2022] Open
Abstract
Bone morphogenetic proteins (BMP) are multi-functional growth factors to promote bone healing with the proposal of less morbidity compared to the usual methods of bone graft harvest. Pseudoarthrosis occur when the fusion attempt fails, a solid fusion is not achieved, or there is motion across the segment leading to it, and it can be clinically symptomatic as pain, deformity, neurocompression, or hardware failure. BMPs are used at spinal fusion as a tool for the treatment of degenerative, traumatic, neoplastic and infectious conditions of the spine. This review shows that the use of BMPS is effective and secure when compared with iliac crest bone graft (ICGB); however, depending of the location of usage (cervical spine, lumbar spine or sacrum) and the medical status of the patient (presence of comorbidities, tobacco usage), it is more likely to exhibit complications. Therefore, the use of these proteins must be an informed decision of patient and physician preferences.
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James AW, LaChaud G, Shen J, Asatrian G, Nguyen V, Zhang X, Ting K, Soo C. A Review of the Clinical Side Effects of Bone Morphogenetic Protein-2. TISSUE ENGINEERING PART B-REVIEWS 2016; 22:284-97. [PMID: 26857241 DOI: 10.1089/ten.teb.2015.0357] [Citation(s) in RCA: 658] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Bone morphogenetic protein-2 (BMP-2) is currently the only Food and Drug Administration (FDA)-approved osteoinductive growth factor used as a bone graft substitute. However, with increasing clinical use of BMP-2, a growing and well-documented side effect profile has emerged. This includes postoperative inflammation and associated adverse effects, ectopic bone formation, osteoclast-mediated bone resorption, and inappropriate adipogenesis. Several large-scale studies have confirmed the relative frequency of adverse events associated with the clinical use of BMP-2, including life-threatening cervical spine swelling. In fact, the FDA has issued a warning of the potential life-threatening complications of BMP-2. This review summarizes the known adverse effects of BMP-2, including controversial areas such as tumorigenesis. Next, select animal models that replicate BMP-2's adverse clinical effects are discussed. Finally, potential molecules to mitigate the adverse effects of BMP-2 are reviewed. In summary, BMP-2 is a potent osteoinductive cytokine that has indeed revolutionized the bone graft substitute market; however, it simultaneously has accrued a worrisome side effect profile. Better understanding of these adverse effects among both translational scientists and clinicians will help determine the most appropriate and safe use of BMP-2 in the clinical setting.
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Affiliation(s)
- Aaron W James
- 1 Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center, UCLA and Orthopaedic Hospital, University of California , Los Angeles, Los Angeles, California.,2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California.,3 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Gregory LaChaud
- 1 Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center, UCLA and Orthopaedic Hospital, University of California , Los Angeles, Los Angeles, California.,2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California.,3 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Jia Shen
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Greg Asatrian
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Vi Nguyen
- 3 Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
| | - Xinli Zhang
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Kang Ting
- 2 Section of Orthodontics, Division of Growth and Development, School of Dentistry, University of California , Los Angeles, Los Angeles, California
| | - Chia Soo
- 1 Department of Orthopaedic Surgery and the Orthopaedic Hospital Research Center, UCLA and Orthopaedic Hospital, University of California , Los Angeles, Los Angeles, California.,4 Division of Plastic and Reconstructive Surgery, Department of Surgery, David Geffen School of Medicine, University of California , Los Angeles, Los Angeles, California
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Makhni MC, Caldwell JME, Saifi C, Fischer CR, Lehman RA, Lenke LG, Lee FY. Tissue engineering advances in spine surgery. Regen Med 2016; 11:211-22. [DOI: 10.2217/rme.16.3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Autograft, while currently the gold standard for bone grafting, has several significant disadvantages including limited supply, donor site pain, hematoma formation, nerve and vascular injury, and fracture. Bone allografts have their own disadvantages including reduced osteoinductive capability, lack of osteoprogenitor cells, immunogenicity and risk of disease transmission. Thus demand exists for tissue-engineered constructs that can produce viable bone while avoiding the complications associated with human tissue grafts. This review will focus on recent advancements in tissue-engineered bone graft substitutes utilizing nanoscale technology in spine surgery applications. An evaluation will be performed of bone graft substitutes, biomimetic 3D scaffolds, bone morphogenetic protein, mesenchymal stem cells and intervertebral disc regeneration strategies.
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Affiliation(s)
- Melvin C Makhni
- Department of Orthopedic Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | - Jon-Michael E Caldwell
- Department of Orthopedic Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | - Comron Saifi
- The Spine Hospital, Department of Orthopedic Surgery, New York-Presbyterian Healthcare System, Columbia University Medical Center, 5141 Broadway, New York, NY 10034, USA
| | - Charla R Fischer
- The Spine Hospital, Department of Orthopedic Surgery, New York-Presbyterian Healthcare System, Columbia University Medical Center, 5141 Broadway, New York, NY 10034, USA
| | - Ronald A Lehman
- Department of Orthopedic Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | - Lawrence G Lenke
- The Spine Hospital, Department of Orthopedic Surgery, New York-Presbyterian Healthcare System, Columbia University Medical Center, 5141 Broadway, New York, NY 10034, USA
| | - Francis Y Lee
- Department of Orthopedic Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
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Use of Recombinant Human Bone Morphogenetic Protein-2 in the Treatment of Degenerative Spondylolisthesis. Spine (Phila Pa 1976) 2016; 41:445-9. [PMID: 26571176 DOI: 10.1097/brs.0000000000001228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A questionnaire survey. OBJECTIVE To report the current use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in lumbar fusion procedures for the treatment of degenerative spondylolisthesis (DS), and identify associated factors including fusion technique, surgeon location, surgeon specialty, or surgeon practice model. SUMMARY OF BACKGROUND DATA The prevalence of rhBMP-2 use in fusions increased dramatically from 0.7% in 2002 to 24.7% in 2006, however more recent studies have identified significant complications with its use. Furthermore, an independent review of the industry-sponsored trial data has demonstrated no significant difference in fusion rates or clinical results with the use of rhBMP-2 compared with iliac-crest autograft. METHODS In July 2014, a survey was sent requesting information on the usage of rhBMP-2 in the treatment of DS. Determinants included the fusion technique, geographic location, specialty, and associated practice models. No funding was received for this work. RESULTS Overall, 7.8% +/- 2.0% of surgeons reported using rhBMP-2 when performing an open L4-L5 posterolateral fusion for DS; 6.2% +/- 1.8% reported using rhBMP-2 for an open L4-L5 interbody fusion, and 12.1% +/- 2.5% reported using rhBMP-2 for a L4-L5 minimally invasive (MIS) interbody fusion. The variables that were statistically associated with the use of rhBMP-2 were North America surgeons (P < 0.0001) and the type of procedure (P = 0.0005). CONCLUSION Compared with historical data, there has been a dramatic decrease in the number of surgeons using rhBMP-2 in lumbar fusion procedures for the treatment of DS. Currently, rhBMP-2 is more commonly used by surgeons in North America and those performing MIS interbody fusions. LEVEL OF EVIDENCE N/A.
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Incidence of graft extrusion following minimally invasive transforaminal lumbar interbody fusion. J Clin Neurosci 2016; 24:88-93. [DOI: 10.1016/j.jocn.2015.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 09/21/2015] [Indexed: 01/03/2023]
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Hofstetter CP, Hofer AS, Levi AD. Exploratory meta-analysis on dose-related efficacy and morbidity of bone morphogenetic protein in spinal arthrodesis surgery. J Neurosurg Spine 2015; 24:457-75. [PMID: 26613283 DOI: 10.3171/2015.4.spine141086] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECT Bone morphogenetic protein (BMP) is frequently used for spinal arthrodesis procedures in an "off-label" fashion. Whereas complications related to BMP usage are well recognized, the role of dosage is less clear. The objective of this meta-analysis was to assess dose-dependent effectiveness (i.e., bone fusion) and morbidity of BMP used in common spinal arthrodesis procedures. A quantitative exploratory meta-analysis was conducted on studies reporting fusion and complication rates following anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterolateral lumbar fusion (PLF) supplemented with BMP. METHODS A literature search was performed to identify studies on BMP in spinal fusion procedures reporting fusion and/or complication rates. From the included studies, a database for each spinal fusion procedure, including patient demographic information, dose of BMP per level, and data regarding fusion rate and complication rates, was created. The incidence of fusion and complication rates was calculated and analyzed as a function of BMP dose. The methodological quality of all included studies was assessed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were analyzed using a random-effects model. Event rates are shown as percentages, with a 95% CI. RESULTS Forty-eight articles met the inclusion criteria: ACDF (n = 7), PCF (n = 6), ALIF (n = 9), TLIF/PLIF (n = 17), and PLF (n = 9), resulting in a total of 5890 patients. In ACDF, the lowest BMP concentration analyzed (0.2-0.6 mg/level) resulted in a fusion rate similar to the highest dose (1.1-2.1 mg/level), while permitting complication rates comparable to ACDF performed without BMP. The addition of BMP to multilevel constructs significantly (p < 0.001) increased the fusion rate (98.4% [CI 95.4%-99.4%]) versus the control group fusion rate (85.8% [CI 77.4%-91.4%]). Studies on PCF were of poor quality and suggest that BMP doses of ≤ 2.1 mg/level resulted in similar fusion rates as higher doses. Use of BMP in ALIF increased fusion rates from 79.1% (CI 57.6%-91.3%) in the control cohort to 96.9% (CI 92.3%-98.8%) in the BMP-treated group (p < 0.01). The rate of complications showed a positive correlation with the BMP dose used. Use of BMP in TLIF had only a minimal impact on fusion rates (95.0% [CI 92.8%-96.5%] vs 93.0% [CI 78.1%-98.0%] in control patients). In PLF, use of ≥ 8.5 mg BMP per level led to a significant increase of fusion rate (95.2%; CI 90.1%-97.8%) compared with the control group (75.3%; CI 64.1%-84.0%, p < 0.001). BMP did not alter the rate of complications when used in PLF. CONCLUSIONS The BMP doses used for various spinal arthrodesis procedures differed greatly between studies. This study provides BMP dosing recommendations for the most common spine procedures.
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Affiliation(s)
| | - Anna S Hofer
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | - Allan D Levi
- Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
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Ishack S, Mediero A, Wilder T, Ricci JL, Cronstein BN. Bone regeneration in critical bone defects using three-dimensionally printed β-tricalcium phosphate/hydroxyapatite scaffolds is enhanced by coating scaffolds with either dipyridamole or BMP-2. J Biomed Mater Res B Appl Biomater 2015; 105:366-375. [PMID: 26513656 DOI: 10.1002/jbm.b.33561] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/18/2015] [Accepted: 10/11/2015] [Indexed: 01/24/2023]
Abstract
Bone defects resulting from trauma or infection need timely and effective treatments to restore damaged bone. Using specialized three-dimensional (3D) printing technology we have created custom 3D scaffolds of hydroxyapatite (HA)/beta-tri-calcium phosphate (β-TCP) to promote bone repair. To further enhance bone regeneration we have coated the scaffolds with dipyridamole, an agent that increases local adenosine levels by blocking cellular uptake of adenosine. Nearly 15% HA:85% β-TCP scaffolds were designed using Robocad software, fabricated using a 3D Robocasting system, and sintered at 1100°C for 4 h. Scaffolds were coated with BMP-2 (200 ng mL-1 ), dypiridamole 100 µM or saline and implanted in C57B6 and adenosine A2A receptor knockout (A2AKO) mice with 3 mm cranial critical bone defects for 2-8 weeks. Dipyridamole release from scaffold was assayed spectrophotometrically. MicroCT and histological analysis were performed. Micro-computed tomography (microCT) showed significant bone formation and remodeling in HA/β-TCP-dipyridamole and HA/β-TCP-BMP-2 scaffolds when compared to scaffolds immersed in vehicle at 2, 4, and 8 weeks (n = 5 per group; p ≤ 0.05, p ≤ 0.05, and p ≤ 0.01, respectively). Histological analysis showed increased bone formation and a trend toward increased remodeling in HA/β-TCP- dipyridamole and HA/β-TCP-BMP-2 scaffolds. Coating scaffolds with dipyridamole did not enhance bone regeneration in A2AKO mice. In conclusion, scaffolds printed with HA/β-TCP promote bone regeneration in critical bone defects and coating these scaffolds with agents that stimulate A2A receptors and growth factors can further enhance bone regeneration. These coated scaffolds may be very useful for treating critical bone defects due to trauma, infection or other causes. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 366-375, 2017.
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Affiliation(s)
- Stephanie Ishack
- Department of Biomaterials and Biomimetics, NYU College of Dentistry, New York, New York
| | - Aranzazu Mediero
- Division of Translational Medicine, Department of Medicine, NYU-Langone Medical Center, New York, New York
| | - Tuere Wilder
- Division of Translational Medicine, Department of Medicine, NYU-Langone Medical Center, New York, New York
| | - John L Ricci
- Department of Biomaterials and Biomimetics, NYU College of Dentistry, New York, New York
| | - Bruce N Cronstein
- Division of Translational Medicine, Department of Medicine, NYU-Langone Medical Center, New York, New York
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Platelet concentrates in spine fusion: meta-analysis of union rates and complications in controlled trials. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1474-1483. [PMID: 26298478 DOI: 10.1007/s00586-015-4193-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 08/08/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Platelet concentrates in spine fusion gained increasing popularity among spine surgeons. They avoid morbidity of bone harvest and promise good union rates without additional device-related adverse events. Therefore, they seem to be a safe and effective alternative to common bone substitutes. This meta-analysis assesses the available evidence for union rate and overall complications with the use of platelet concentrates in spine fusion. METHODS We conducted an online search for relevant controlled trials and extracted data on union rates, complications, and revision rates. These data were synthesized in a meta-analysis using fixed-effects odds ratios (OR). To assess covariates, meta-regression was performed as well. RESULTS Our search produced 166 results, ten of which were eligible for inclusion. These studies report on a total of 763 patients (328 experimental, 435 controls) with a mean age of 50.3 ± 7.5 years. Mean follow-up was 1.9 ± 0.0.4 years. With the use of platelet concentrates, union rate decreased significantly, OR 0.53 (95 % CI 0.35-0.79, p = 0.002), compared with the control group. There was no statistically significant difference in complication rates OR 1.34 (95 % CI 0.62-2.90, p = 0.46) or in revision rates OR 3.0 (95 % CI 0.90-10.00, p = 0.74). Meta-regression showed no statistically significant influence of randomization, Jadad score, or assessment of fusion. CONCLUSION The use of platelet concentrates in spine fusion shows significantly decreased union rates compared with the control group. However, complication and revision rates were not significantly increased. The current data do not recommend the use of platelet concentrate in spine fusion.
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Polyelectrolyte Complex Carrier Enhances Therapeutic Efficiency and Safety Profile of Bone Morphogenetic Protein-2 in Porcine Lumbar Interbody Fusion Model. Spine (Phila Pa 1976) 2015; 40:964-73. [PMID: 25893351 DOI: 10.1097/brs.0000000000000935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Porcine lumbar interbody fusion model. OBJECTIVE This study evaluates the effect of polyelectrolyte complex (PEC) carrier in enhancing the therapeutic efficiency and safety profile of bone morphogenetic protein-2 (BMP-2) in a large animal model. SUMMARY OF BACKGROUND DATA Extremely large amounts of BMP-2 are administered to achieve consistent spinal fusion, which has led to complications. Heparin-modified PEC carrying reduced BMP-2 doses of 0.5 μg was demonstrated to achieve consistent spinal fusion with reduction of complications in rodent model. The purpose of this study was to evaluate whether PEC could improve the therapeutic efficiency of BMP-2 in porcine model. METHODS Three-segment (L3-L6) anterior lumbar interbody fusions with instrumentation were performed on 6 pigs using 3 different doses of BMP-2, namely, (1) 50 μg, (2) 150 μg, and (3) 300 μg. The BMP-2 was delivered using heparin-modified alginate microbeads loaded into biodegradable cage. Fusion performance was evaluated after 3 months. RESULTS Manual palpation and micro-computed tomography showed consistent fusion in all experimental groups. Heterotopic bone formation beyond the cage implant area was more evident in group 2 and group 3 than in group 1. Similarly, superior bone microstructure was observed in the new bone with the lowered BMP-2 dose. Biomechanical evaluation revealed enhanced stiffness of the operated segments compared with nonoperated segments (P < 0.05). Mechanical stability was maintained despite dose reduction of BMP-2. Although the mineral apposition rate was higher in group 3, unsatisfactory bony microstructure with decreased trabecular number was observed in group 3 compared with group 1. CONCLUSION PEC carrying low doses of BMP-2 achieved consistent interbody fusion. We observed dose-related reduction in heterotopic ossification without compromising the stability of the fused segments. PEC carrier reduces the efficacious doses of BMP-2. This could enhance the safety profile of BMP-2 and reduce dose- and carrier-related complications. LEVEL OF EVIDENCE N/A.
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Vavken J, Mameghani A, Vavken P, Schaeren S. Complications and cancer rates in spine fusion with recombinant human bone morphogenetic protein-2 (rhBMP-2). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:3979-3989. [PMID: 25772092 DOI: 10.1007/s00586-015-3870-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/05/2015] [Accepted: 03/08/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE To quantitatively synthesize the available best evidence for general complications, heterotopic ossification (HO), retrograde ejaculation, cervical swelling, and cancer rates with the use of rhBMP-2 in lumbar and cervical spine fusion. METHODS We conducted an online search for relevant controlled trials and extracted data on the abovementioned endpoints. Studies were eligible for inclusion if they reported on spinal fusion with rhBMP-2 in humans. Publication bias and heterogeneity were assessed mathematically. These data were synthesized in a meta-analysis using DerSimonian-Laird random effects modeling to calculate pooled odds ratios. RESULTS We identified 26 studies reporting on a total of 184,324 patients (28,815 experimental, 155,509 controls) with a mean age of 51.1 ± 1.8 years. There was a significantly higher risk of general complications with rhBMP-2 compared to iliac crest bone graft (ICBG) with an odds ratio (OR) of 1.78 (95 %CI 1.20-2.63), (p = 0.004). The odds ratio for HO was 5.57 (95 %CI 1.90-16.36), (p = 0.002), for retrograde ejaculation 3.31 (95 %CI 1.20-9.09), (p = 0.020), and for cervical swelling 4.72 (95 %CI 1.42-15.67), (p = 0.011), all significantly higher in the rhBMP-2 group. The pooled odds ratio for new onset of tumor was 1.35 (95 %CI 0.93-1.96), which represents no statistically significant difference between the groups (p = 0.111). CONCLUSION rhBMP-2 is associated with a higher rate of general complications as well as retrograde ejaculation, HO, and cervical tissue swelling in spine fusion. There is a slightly increased risk of new onset of tumors, however, without statistical significance.
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Affiliation(s)
- Julia Vavken
- Spine Surgery, University Hospital of Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Alexander Mameghani
- Spine Surgery, University Hospital of Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Patrick Vavken
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Population and Development Studies, Harvard School of Public Health, Boston, MA, USA
| | - Stefan Schaeren
- Spine Surgery, University Hospital of Basel, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
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Minimally invasive spinal surgery for the treatment of traumatic thoracolumbar burst fractures. J Clin Neurosci 2015; 22:42-7. [DOI: 10.1016/j.jocn.2014.05.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/21/2014] [Accepted: 05/04/2014] [Indexed: 11/22/2022]
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Oryan A, Alidadi S, Moshiri A, Bigham-Sadegh A. Bone morphogenetic proteins: a powerful osteoinductive compound with non-negligible side effects and limitations. Biofactors 2014; 40:459-81. [PMID: 25283434 DOI: 10.1002/biof.1177] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/21/2014] [Accepted: 07/26/2014] [Indexed: 12/29/2022]
Abstract
Healing and regeneration of large bone defects leading to non-unions is a great concern in orthopedic surgery. Since auto- and allografts have limitations, bone tissue engineering and regenerative medicine (TERM) has attempted to solve this issue. In TERM, healing promotive factors are necessary to regulate the several important events during healing. An ideal treatment strategy should provide osteoconduction, osteoinduction, osteogenesis, and osteointegration of the graft or biomaterials within the healing bone. Since many materials have osteoconductive properties, only a few biomaterials have osteoinductive properties which are important for osteogenesis and osteointegration. Bone morphogenetic proteins (BMPs) are potent inductors of the osteogenic and angiogenic activities during bone repair. The BMPs can regulate the production and activity of some growth factors which are necessary for the osteogenesis. Since the introduction of BMP, it has added a valuable tool to the surgeon's possibilities and is most commonly used in bone defects. Despite significant evidences suggesting their potential benefit on bone healing, there are some evidences showing their side effects such as ectopic bone formation, osteolysis and problems related to cost effectiveness. Bone tissue engineering may create a local environment, using the delivery systems, which enables BMPs to carry out their activities and to lower cost and complication rate associated with BMPs. This review represented the most important concepts and evidences regarding the role of BMPs on bone healing and regeneration from basic to clinical application. The major advantages and disadvantages of such biologic compounds together with the BMPs substitutes are also discussed.
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Affiliation(s)
- Ahmad Oryan
- Department of Pathology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
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