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Song H, Edwards C, Curto R, Perez A, Cruess C, Schell A, Park J. Does Epidural Corticosteroid Application During Spinal Surgery Reduce Postoperative Pain?: An Adjunct to Multimodal Analgesia. Clin Spine Surg 2024; 37:E354-E363. [PMID: 38446588 PMCID: PMC11421561 DOI: 10.1097/bsd.0000000000001586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/22/2024] [Indexed: 03/08/2024]
Abstract
STUDY DESIGN A prospective, randomized, placebo-controlled, double-blinded study. OBJECTIVE To examine the effect of intraoperative epidural administration of Depo-Medrol on postoperative back pain and radiculitis symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). SUMMARY OF BACKGROUND DATA Postoperative pain is commonly experienced by patients undergoing spinal fusion surgery. Adequate management of intense pain is necessary to encourage early ambulation, increase patient satisfaction, and limit opioid consumption. Intraoperative steroid application has been shown to improve postoperative pain in patients undergoing lumbar decompression surgeries. There have been no studies examining the effect of epidural steroids on both back pain and radicular pain in patients undergoing TLIF. METHOD In all, 151 patients underwent TLIF surgery using rh-BMP2 with 3 surgeons at a single institution. Of those, 116 remained in the study and were included in the final analysis. Based on a 1:1 randomization, a collagen sponge saturated with either Saline (1 cc) or Depo-Medrol (40 mg/1 cc) was placed at the annulotomy site on the TLIF level. Follow-up occurred on postoperative days 1, 2, 3, 7, and postoperative months 1, 2, and 3. Lumbar radiculopathy was measured by a modified symptom- and laterality-specific Visual Analog Scale (VAS) regarding the severity of back pain and common radiculopathy symptoms. RESULTS The patients who received Depo-Medrol, compared with those who received saline, experienced significantly less back pain on postoperative days 1, 2, 3, and 7 ( P <0.05). There was no significant difference in back pain beyond day 7. Radiculopathy-related symptoms such as leg pain, numbness, tingling, stiffness, and weakness tended to be reduced in the steroid group at most time points. CONCLUSION This study provides Level 1 evidence that intraoperative application of Depo-Medrol during a TLIF surgery with rh-BMP2 significantly reduces back pain for the first week after TLIF surgery. The use of epidural Depo-Medrol may be a useful adjunct to multimodal analgesia for pain relief in the postoperative period.
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Affiliation(s)
- Hyun Song
- Maryland Spine Center, Mercy Medical Center, Baltimore, MD
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Kim SH, Park Y, Shin JW, Ha JW, Choi HM, Kim HS, Moon SH, Suk KS, Park SY, Lee BH, Kwon JW. Accelerated fusion dynamics by recombinant human bone morphogenetic protein-2 following transforaminal lumbar interbody fusion, particularly in osteoporotic conditions. Spine J 2024:S1529-9430(24)00302-4. [PMID: 38909911 DOI: 10.1016/j.spinee.2024.06.010] [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: 02/21/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND CONTEXT Early fusion is crucial in interbody procedures to minimize mechanical complications resulting from delayed union, especially for patients with osteoporosis. Bone morphogenetic proteins (BMPs) are used in spinal fusion procedures; however, limited evaluation exists regarding time-to-fusion for BMP use, particularly in patients with osteoporosis. PURPOSE To evaluate the difference in time-to-fusion after single-level transforaminal lumbar interbody fusion (TLIF) surgery between recombinant human bone morphogenetic protein-2 (rhBMP-2) usage and nonusage groups according to bone density. STUDY DESIGN Retrospective single-center cohort study. PATIENT SAMPLE This study enrolled 132 patients (mean age, 65.25±8.66; male patients, 40.9%) who underwent single-level TLIF for degenerative disorders between February 2012 and December 2021, with pre and postoperative computed tomography (CT). OUTCOME MEASURE The interbody fusion mass and bone graft status on postoperative CT scans was obtained annually, and time-to-fusion was recorded for each patient. METHODS The patients were divided into 2 groups based on rhBMP-2 use during the interbody fusion procedure. Patients were further divided into osteoporosis, osteopenia, and normal groups based on preoperative L1 vertebral body attenuation values, using cutoffs of 90 and 120 Hounsfield units. It was strictly defined that fusion is considered complete when a trabecular bone bridge was formed, and therefore, the time-to-fusion was measured in years. Time-to-fusion was statistically compared between BMP group and non-BMP groups, followed by further comparison according to bone density. RESULTS The time-to-fusion differed significantly between BMP and non-BMP groups, with half of the patients achieving fusion within 2.5 years in the BMP group compared with 4 years in the non-BMP group (p<.001). The fusion rate varied based on bone density, with the maximum difference observed in the osteoporosis group, when half of the patients achieved fusion within 3 years in the BMP group compared to 5 years in the non-BMP group (p<.001). Subgroup analysis was conducted, revealing no significant associations between time-to-fusion and factors known to influence the fusion process, including age, gender, medical history, smoking and alcohol use, and medication history, except for rh-BMP2 use and bone density. CONCLUSIONS RhBMP-2 usage significantly reduced time-to-fusion in single-level TLIF, especially in patients with osteoporosis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sang-Ho Kim
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea; Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Yung Park
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea.
| | - Jae-Won Shin
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea; Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Joong-Won Ha
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea
| | - Hee-Min Choi
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, 100 Ilsan-ro, Ilsandong-gu, Goyang 10444, Korea
| | - Hak-Sun Kim
- Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Kyung-Soo Suk
- Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Si-Young Park
- Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Byung-Ho Lee
- Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
| | - Ji-Won Kwon
- Department of Orthopedic Surgery, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea
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Singh V, Oppermann M, Evaniew N, Soroceanu A, Nicholls F, Jacobs WB, Thomas K, Swamy G. Lateral Lumbar Interbody Fusion With rhBMP-2 can Achieve High Fusion Rates in Adult Spine Deformity Surgeries. Global Spine J 2024; 14:244-256. [PMID: 35586905 PMCID: PMC10676168 DOI: 10.1177/21925682221103512] [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] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN An ambispective, observational study of the prospective, institutional adult spine deformity (ASD) database. OBJECTIVES The study investigates the clinical and radiographic fusion rates with lateral interbody approach and rhBMP-2 in multiple-level lumbar fusion in the ASD population. Previous studies have reported over 10% pseudoarthrosis rate with multiple segment fusions. Lateral lumbar interbody fusion (LLIF) allows multiple-level, less-invasive access to the anterior lumbar spine. We hypothesized that fusion rates with lateral approach with rhBMP-2 use are superior to the published data on lumbar fusion in ASD patients. METHODS The institutional ASD database was searched to identify eligible patients with two or more levels of LLIF (T12-L5), >4 levels of posterior instrumentations and >2 years of follow-up between the years 2010 and 2018. Antero-posterior and lateral 36-inch standing radiographs for each patient and computed tomography scans in select patients were studied to ascertain fusion status and patients were divided into two groups based on fusion status. RESULTS The study included 179 patients with a mean age of 65.3 years and 74% female patients. The median number of interbody fusions was performed at 3 (IQR 3-4) levels. The mean follow-up duration was 4.4 years (SD = 1.9). 169 patients (94.5%) had successful arthrodesis, while 10 patients (5.5%) had radiological pseudoarthrosis at one level. Of the 10 patients, 8 (4.4%) were either clinically asymptomatic or had manageable back pain. Two patients (1.1%) required revision surgery for symptomatic pseudoarthrosis. CONCLUSION This is the largest known series of ASD patients investigating the fusion rates with multiple-level LLIFs. LLIF along with rhBMP-2 can achieve high fusion success across interbody fusion levels in multi-segmental ASD surgeries.
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Affiliation(s)
- Vishwajeet Singh
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Marcelo Oppermann
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan Evaniew
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alex Soroceanu
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Fred Nicholls
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - W. Bradley Jacobs
- Division of Neurosurgery Spine Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Ken Thomas
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ganesh Swamy
- Division of Orthopedic Surgery Spine Program, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Park S, Jeong YH, Ha BJ, Yoo BS, Kim SH, Lee CK, Yi S, Ha Y, Kim KN, Shin DA. Fusion rate of Escherichia coli-derived recombinant human bone morphogenetic protein-2 compared with local bone autograft in posterior lumbar interbody fusion for degenerative lumbar disorders. Spine J 2023; 23:1877-1885. [PMID: 37516282 DOI: 10.1016/j.spinee.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND CONTEXT The use of recombinant human bone morphogenetic proteins-2 (rhBMP-2) for spinal fusion has been reported to be effective. However, most studies have focused on posterolateral and anterior lumbar interbody fusion, and few have investigated posterior lumbar interbody fusion (PLIF). PURPOSE This study aimed to determine the effectiveness and safety of the delivery of Escherichia coli-derived rhBMP-2 (E.BMP-2) with hydroxyapatite (HA) and β-tricalcium phosphate (β-TCP) poloxamer hydrogel composite carriers for PLIF. STUDY DESIGN A retrospective study. PATIENT SAMPLE Patients who underwent 1 to 3 levels of PLIF for lumbar degenerative disc disorders between 2015 and 2020 with a follow-up of ≥1 year were enrolled. In total, 254 patients (357 levels) were included in the analysis. The evaluation was performed at each segment level. In the E.BMP-2 group, 160 patients (221 levels) received autologous local bone with E.BMP-2 (maximum 0.5 mg/level), and in the control group, 94 patients (136 levels) received only local bone graft. OUTCOME MEASURES The primary outcome of this study was to compare the X-ray and CT fusion rates between the two groups. Secondary outcomes included analysis of the patients' clinical outcomes and postoperative complications on CT scans. METHODS Clinical evaluations were performed using a visual analog scale for back pain, the Oswestry Disability Index for disability, and physical and mental component summaries of the Short Form 36-Item Form Health Survey to assess functional effects and quality of life. The fusion was evaluated using radiography and CT. On radiography, solid fusion was defined when the difference between extension and flexion was less than 5°. On CT, solid fusion was defined when the upper and lower vertebral bodies were connected by the trabecular bone (bone bridge formation). In addition, complications such as osteolysis, cage subsidence, and screw loosening were investigated using CT. RESULTS All clinical results for low back pain, disability, and quality of life in both groups were excellent and showed statistically significant improvements compared with baseline (p<.0001). According to the X-ray evaluations, fusion was achieved in 92.31% (204/221) of the patients in the E.BMP-2 group and 82.35% (112/136) of the patients in the control group (p=.0041). According to the CT evaluations, the fusion rates were 93.21% (206/221) and 88.24% (120/136) in the E.BMP-2 and control groups (p=.1048), respectively. Except for screw loosening, which had a significantly higher incidence in the control group (p=.0014), the rates of most postoperative complications were not significantly different between the groups. CONCLUSIONS This study demonstrated that the adjunctive use of a low dose of E.BMP-2 with HA and β-TCP hydrogel can effectively promote bone fusion, making it a promising option for patients with limited autograft availability or compromised bone quality in PLIF.
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Affiliation(s)
- Sangman Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yeong Ha Jeong
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Byeong Jin Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Beom Seok Yoo
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Soo-Heon Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Chang Kyu Lee
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea.
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Xiao Y, Xiu P, Yang X, Wang L, Li T, Gong Q, Liu L, Song Y. Does Preoperative Modic Changes Influence the Short-term Fusion Rate of Single Level Transforaminal Lumbar Interbody Fusion?-a Matched-pair Case Control Study. Orthop Surg 2023; 15:2309-2317. [PMID: 37439298 PMCID: PMC10475667 DOI: 10.1111/os.13795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/12/2023] [Accepted: 05/21/2023] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE At present, the influence of Modic changes (MCs) on postoperative fusion rate of lumbar interbody fusion (LIF) is mainly focused on the medium- and long-term fusion rate, while the short-term fusion rate has not been reported. The aim of this study was to compare the short-term fusion rate of lumbar degenerative disease patients with and without MCs after single level transforaminal lumbar interbody fusion (TLIF). METHODS In this retrospective and matched-pair case control study, we included 100 patients who underwent TLIF from January 2017 to January 2020 and had at least two follow-up visits over a two-year period. Fifty patients with MCs (MCs group) were matched with 50 patients without MCs (non MCs group) for age, sex, surgical level, diagnosis, operative time, and intraoperative blood loss. We collected the X-ray and computed tomography (CT) data of patients from 3 months to 2 years after the operation to assess bony fusion and the cage union ratio. According to the type of cage, the MCs group was further divided into the nano-hydroxyapatite/polyamide 66 (n-HA/PA66) group and polyetheretherketone (PEEK) group, and the fusion performance between the two groups was compared. Finally, age, sex, body mass index (BMI), smoking and cage type were included in the logistic regression model for risk factor analysis. RESULTS The bony fusion rates in the MCs group at 3 months, 6 months, 1 year and 2 years after surgery were significantly lower than those in the non MCs group (P < 0.05) (23.8% vs 62.5%, 52.6% vs 78.9%, 61.1% vs 83.3%, 74.0% vs 90.0%). The average coronal cage union ratios of the upper and lower endplates in the MCs group were significantly lower than those in the non MCs group (54.3% ± 17.5% vs 75.0% ± 17.2%, P < 0.05; 73.3% ± 12.0% vs 84.9% ± 8.0%, P < 0.05). Similarly, analogous results were obtained by comparing the MCs and non MCs groups' three-dimensional CT sagittal plane images (62.5% ± 16.5% vs 76.1% ± 12.4%, P < 0.05; 67.0% ± 13.9% vs 79.8% ± 11.5%, P < 0.05). CONCLUSION Short-term fusion rates were lower in the MCs group than in the non MCs group. The coronal and sagittal cage union ratio in the MCs group was lower than that in the non MCs group. The fusion performance of n-HA/PA66 and PEEK cages in the MCs group was comparable.
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Affiliation(s)
- Yang Xiao
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
| | - Peng Xiu
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
| | - Xi Yang
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
| | - Liang Wang
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
| | - Tao Li
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
| | - Quan Gong
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
| | - Limin Liu
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
| | - Yueming Song
- Department of Orthopaedic, Orthopaedic Research InstituteWest China Hospital, Sichuan UniversityChengduChina
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Wijaya JH, Tjahyanto T, Alexi R, Purnomo AE, Rianto L, Arjuna YYE, Tobing JFL, Yunus Y, Faried A. Application of rhBMP in spinal fusion surgery: any correlation of cancer incidence? A systematic review and meta-analysis. 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 2023; 32:2020-2028. [PMID: 37133762 DOI: 10.1007/s00586-023-07730-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE Safety concerns regarding the application of bone morphogenetic proteins (BMPs) have been highlighted in recent years. It is noted that both BMP and their receptors being identified as a trigger for cancer growth. Here, we aimed to determine the safety and efficacy of BMP for spinal fusion surgery. METHODS We conducted this systematic review on topics of spinal fusion surgery with rhBMP application from three database (PubMed, EuropePMC, and Clinicaltrials.gov) with MeSH phrases such as "rh-BMP," "rhBMP," "spine surgery," "spinal arthrodesis," and "spinal fusion" were searched (using the Boolean operators "and" and "or"). Our research includes all articles, as long as published in English language. In the face of disagreement between the two reviewers, we discussed it together until all authors reached a consensus. The primary key outcome of our study is the incidence of cancer following rhBMP implantation. RESULTS Our study included a total of 8 unique studies (n = 37,682). The mean follow-up varies among all studies, with the longest follow-up is 66 months. Our meta-analysis showed that exposure to rhBMP in spinal surgery did increase the risk of cancers (RR 1.85, 95%CI [1.05, 3.24], p = 0.03). CONCLUSIONS Our study found that rhBMP was not associated with the increased risk of cancer incidence within the rhBMP cohort. Still, we did face several limitations, in which further studies are needed to confirm the result of our meta-analysis.
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Affiliation(s)
- Jeremiah Hilkiah Wijaya
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia.
| | - Teddy Tjahyanto
- Department of Medicine, Tarumanagara University, Jakarta, Indonesia
| | - Roberto Alexi
- Department of Medicine, Santo Vincentius Hospital, Singkawang, West Kalimantan, Indonesia
| | - Alexander Erick Purnomo
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia
| | - Louis Rianto
- Department of Orthopedics, Universitas Pelita Harapan, Karawaci, Tangerang, Banten, Indonesia
| | - Yang Yang Endro Arjuna
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia
| | | | - Yesaya Yunus
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia
| | - Ahmad Faried
- Department of Neurosurgery, Universitas Padjajaran, Bandung, West Java, Indonesia
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Patel HA, Wellington IJ, Lubonja K, Stelzer JW, Antonacci CL, Coskun E, Cote MP, Singh H, Mallozzi SS, Moss IL. Current Trends in Recombinant Human Bone Morphogenetic Protein 2 (rhBMP2) Usage for Spinal Fusion Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050878. [PMID: 37241110 DOI: 10.3390/medicina59050878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/25/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
(1) Background: Since first approved by the FDA, on-label and off-label usage of recombinant human bone morphogenetic protein 2 (rhBMP2) for spinal fusion surgeries has become widespread. While many studies have investigated the safety and efficacy of its use, as well as its economic impact, few have looked at the current trends in its on- and off-label use. The goal of this study is to evaluate the current trends of on- and off-label rhBMP2 use for spinal fusion surgery. (2) Methods: A deidentified survey was created and electronically distributed to members of two international spine societies. Surgeons were asked to report their demographic information, surgical experience, and current usage of rhBMP2. They were then presented with five spinal fusion procedures and asked to report if they use rhBMP2 for these indications in their current practice. Responses were stratified between rhBMP2 users vs. non-users and on-label vs. off-label use. Data were analyzed using chi-square with Fisher's exact test for categorical data. (3) Results: A total of 146 respondents completed the survey with a response rate of 20.5%. There was no difference in overall rhBMP2 usage based on specialty, experience, or number of cases per year. Fellowship-trained surgeons and those who practice in the United States were more likely to use rhBMP2. Surgeons who were trained in the Southeast and Midwest regions reported the highest usage rates. rhBMP2 use was more common among fellowship-trained and US surgeons for ALIFs; non-US surgeons for multilevel anterior cervical discectomy and fusions; and fellowship-trained and orthopedic spine surgeons for lateral lumbar interbody fusions. Non-US surgeons were more likely to use rhBMP2 for off-label indications compared to surgeons from the US. (4) Conclusions: While various demographics of surgeons report different rates of rhBMP2 use, off-label use remains relatively commonplace amongst practicing spine surgeons.
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Affiliation(s)
- Harshadkumar A Patel
- Westchester Medical Center, Department of Orthopaedic Surgery, Valhalla, NY 10595, USA
| | - Ian J Wellington
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT 06108, USA
| | - Klair Lubonja
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT 06108, USA
| | - John W Stelzer
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT 06108, USA
| | | | - Ergin Coskun
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT 06108, USA
| | - Mark P Cote
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Hardeep Singh
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT 06108, USA
| | - Scott S Mallozzi
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT 06108, USA
| | - Isaac L Moss
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT 06108, USA
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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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9
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Choi JY, Park HJ, Park SM, Kang CN, Song KS. Evaluation of the efficacy and safety of Escherichia coli-derived recombinant human bone morphogenetic protein-2 in transforaminal lumbar interbody fusion to treat degenerative spinal disease: a protocol of prospective, randomized controlled, assessor-blinded, open-label, multicenter trial. J Orthop Surg Res 2022; 17:397. [PMID: 36045371 PMCID: PMC9429459 DOI: 10.1186/s13018-022-03289-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been widely used as an alternative bone graft in spine fusion surgery. However, clinical outcome such as effects and complications has not yet been revealed for transforaminal lumbar interbody fusion (TLIF). Although previous studies have reported some results, the evidence is weak. Therefore, the purpose of this trial is to evaluate the effectiveness and safety of Escherichia coli-derived rhBMP-2 combined with hydroxyapatite (HA) in TLIF. Methods This trial is designed as a prospective, assessor-blinded, open-label, multicenter, randomized controlled study. Participants will be recruited from six tertiary teaching hospitals. All randomized participants will be undergoing one- or two-level TLIF with rhBMP-2 (77 participants) as the active experimental group or with an auto-iliac bone graft (77 participants) as the control group. The primary interbody fusion rate outcome will be evaluated using computed tomography (CT) 12 months after surgery. The secondary outcomes will be as follows: clinical outcomes (visual analog scale score, EuroQol-5-dimensions-5-level score, Oswestry Disability Index score, and some surgery-related variables) and adverse effects (radiculitis, heterotrophic ossification, endplate resorption, and osteolysis). Radiological outcomes will be evaluated using simple radiography or CT. All outcomes will be measured, collected, and evaluated before surgery and at 12, 24, and 52 weeks postoperatively.
Discussion This study will be the primary of its kind to evaluate the effectiveness and safety of E. coli-derived rhBMP-2 with HA in one- or two-level TLIF. It is designed to evaluate the equivalence of the results between rhBMP-2 with HA and auto-iliac bone graft using an appropriate sample size, assessor-blinded analyses, and prospective registration to avoid bias. This study will set up clear conclusions for using E. coli-derived rhBMP-2 with HA in TLIF. Trial registration: This study protocol was registered at Korea Clinical Research Information Service (https://cris.nih.go.kr; number identifier: KCT0005610) on 19 November 2020. And protocol version is v1.1, January 2022.
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Affiliation(s)
- Jun-Young Choi
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Seongnam, Republic of Korea
| | - Hyun-Jin Park
- Department of Orthopedic Surgery, Spine Center, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sang-Min Park
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Seongnam, Republic of Korea.
| | - Chang-Nam Kang
- Department of Orthopedic Surgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Sup Song
- Department of Orthopedic Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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10
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Im SK, Lee JH, Lee KY, Yoo SJ. Effectiveness and Feasibility of Injectable Escherichia coli-Derived Recombinant Human Bone Morphogenetic Protein-2 for Anterior Lumbar Interbody Fusion at the Lumbosacral Junction in Adult Spinal Deformity Surgery: A Clinical Pilot Study. Orthop Surg 2022; 14:1350-1358. [PMID: 35633034 PMCID: PMC9251273 DOI: 10.1111/os.13303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To explore the effectiveness and feasibility of injectable Escherichia coli‐derived recombinant human bone morphogenetic protein‐2 (injectable E‐rhBMP‐2, a combination of E. coli‐derived recombinant human bone morphogenic protein‐2 and a hydrogel type beta‐tricalcium phosphate carrier) as a bone substitute for anterior lumbar interbody fusion (ALIF) of the lumbosacral junction in adult spinal deformity (ASD) patients. Methods A prospective single‐institution therapeutic exploratory trial was conducted. Twenty patients (average age: 69.1 years; 19 female and one male; average fusion level: 7.95) diagnosed with ASD with sagittal imbalance who underwent surgical treatment including ALIF at the lumbosacral junction from December 2017 to January 2019 were evaluated. Injectable E‐rhBMP‐2 was prepared by dissolving 3 mg of E. coli‐derived recombinant human bone morphogenetic protein‐2 in 1.5 ml H2O and mixing in situ with 9 g hydrogel type beta‐tricalcium phosphate. This bone graft substitute was loaded onto a metal ALIF cage and L5–S1 ALIF was performed in routine manner. Then posterior column osteotomy with multilevel oblique lumbar interbody fusion or pedicle subtraction osteotomy with accessory rod technique was performed to restore sagittal balance. Patients were followed up for 12 months. CT‐based fusion rates were examined at 6 and 12 months after surgery. Also, clinical outcomes (Oswestry Disability Index [ODI], Visual Analog Scale [VAS] score of the back and leg) were evaluated at 6 and 12 months after surgery. All postoperative adverse events were evaluated for the association with injectable E.BMP‐2. Results Of the 20 patients, loss to follow‐up occurred with one patient at 6 months after surgery and one patient at 12 months after surgery, resulting in a total of 18 patients who were available for follow‐up. Six months after surgery, 68.4% patients achieved solid fusion. Twelve months after surgery, 100% fusion rate was achieved. Compared to baseline values, ODI scores improved to 45.8% and 63.7%, VAS (back) improved to 69.2% and 72.8%, and VAS (leg) improved to 49.2% and 64.8%, respectively, at 6 and 12 months after surgery (p < 0.001 for all). Ten cases of adverse events occurred. But no adverse events were associated with injectable E‐rhBMP‐2. Conclusion Injectable E‐rhBMP‐2 will be an effective bone graft substitute when achieving solid interbody fusion in the lumbosacral junction.
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Affiliation(s)
- Sang-Kyu Im
- Department of Orthopedic Surgery, Graduate School, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Jung-Hee Lee
- Department of Orthopedic Surgery, Graduate School, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Ki Young Lee
- Department of Orthopedic Surgery, Graduate School, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Seung-Jin Yoo
- Department of Radiology, College of Medicine, Hanyang University, Seoul, South Korea
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11
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Zhang H, Wang Z, Wang Y, Li Z, Chao B, Liu S, Luo W, Jiao J, Wu M. Biomaterials for Interbody Fusion in Bone Tissue Engineering. Front Bioeng Biotechnol 2022; 10:900992. [PMID: 35656196 PMCID: PMC9152360 DOI: 10.3389/fbioe.2022.900992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/21/2022] [Indexed: 12/04/2022] Open
Abstract
In recent years, interbody fusion cages have played an important role in interbody fusion surgery for treating diseases like disc protrusion and spondylolisthesis. However, traditional cages cannot achieve satisfactory results due to their unreasonable design, poor material biocompatibility, and induced osteogenesis ability, limiting their application. There are currently 3 ways to improve the fusion effect, as follows. First, the interbody fusion cage is designed to facilitate bone ingrowth through the preliminary design. Second, choose interbody fusion cages made of different materials to meet the variable needs of interbody fusion. Finally, complete post-processing steps, such as coating the designed cage, to achieve a suitable osseointegration microstructure, and add other bioactive materials to achieve the most suitable biological microenvironment of bone tissue and improve the fusion effect. The focus of this review is on the design methods of interbody fusion cages, a comparison of the advantages and disadvantages of various materials, the influence of post-processing techniques and additional materials on interbody fusion, and the prospects for the future development of interbody fusion cages.
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Affiliation(s)
- Han Zhang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhonghan Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
| | - Yang Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zuhao Li
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
- Orthopaedic Research Institute of Jilin Province, Changchun, China
| | - Bo Chao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Shixian Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Wangwang Luo
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Jianhang Jiao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Minfei Wu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
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12
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Zhang Y, Jiang Y, Zou D, Yuan B, Ke HZ, Li W. Therapeutics for enhancement of spinal fusion: A mini review. J Orthop Translat 2021; 31:73-79. [PMID: 34934624 DOI: 10.1016/j.jot.2021.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022] Open
Abstract
Objective With the advances in biological technologies over the past 20 years, a number of new therapies to promote bone healing have been introduced. Particularly in the spinal surgery field, more unprecedented biological therapeutics become available to enhance spinal fusion success rate along with advanced instrumentation approaches. Yet surgeons may not have been well informed about their safety and efficacy profiles in order to improve clinical practices. Therefore there is a need to summarize the evidence and bring the latest progress to surgeons for better clinical services for patients. Methods We comprehensively reviewed the literatures in regard to the biological therapeutics for enhancement of spinal fusion published in the last two decades. Results Autograft bone is still the gold standard for bone grafting in spinal fusion surgery due to its good osteoconductive, osteoinductive, and osteogenic abilities. Accumulating evidence suggests that adding rhBMPs in combination with autograft effectively promotes the fusion rate and improves surgical outcomes. However, the stimulating effect on spinal fusion of other growth factors, including PDGF, VEGF, TGF-beta, and FGF, is not convincing, while Nell-1 and activin A exhibited preliminary efficacy. In terms of systemic therapeutic approaches, the osteoporosis drug Teriparatide has played a positive role in promoting bone healing after spinal surgery, while new medications such as denosumab and sclerostin antibodies still need further validation. Currently, other treatment, such as controlled-release formulations and carriers, are being studied for better releasing profile and the administration convenience of the active ingredients. Conclusion As the world's population continues to grow older, the number of spinal fusion cases grows substantially due to increased surgical needs for spinal degenerative disease (SDD). Critical advancements in biological therapeutics that promote spinal fusion have brought better clinical outcomes to patients lately. With the accumulation of higher-level evidence, the safety and efficacy of present and emerging products are becoming more evident. These emerging therapeutics will shift the landscape of perioperative therapy for the enhancement of spinal fusion.
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Affiliation(s)
- Yidan Zhang
- Angitia Biopharmaceuticals, Guangzhou, China
| | - Yu Jiang
- Orthopaedic Department, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China.,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Da Zou
- Orthopaedic Department, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China.,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Baozhi Yuan
- Angitia Biopharmaceuticals, Guangzhou, China
| | - Hua Zhu Ke
- Angitia Biopharmaceuticals, Guangzhou, China
| | - Weishi Li
- Orthopaedic Department, Peking University Third Hospital, Beijing, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China.,Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
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13
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Liang W, Dong Y, Shen H, Shao R, Wu X, Huang X, Sun B, Zeng B, Zhang S, Xu F. Materials science and design principles of therapeutic materials in orthopedic and bone tissue engineering. POLYM ADVAN TECHNOL 2021. [DOI: 10.1002/pat.5445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Wenqing Liang
- Department of Orthopedics Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University Zhoushan China
| | - Yongqiang Dong
- Department of Orthopedics Xinchang People's Hospital Shaoxing China
| | - Hailiang Shen
- Department of Orthopedics Affiliated Hospital of Shaoxing University Shaoxing China
| | - Ruyi Shao
- Department of Orthopedics Zhuji People's Hospital Shaoxing China
| | - Xudong Wu
- Department of Orthopedics Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University Zhoushan China
| | - Xiaogang Huang
- Department of Orthopedics Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University Zhoushan China
| | - Bin Sun
- Department of Orthopedics Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University Zhoushan China
| | - Bin Zeng
- Department of Orthopedics Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University Zhoushan China
| | - Songou Zhang
- College of Medicine Shaoxing University Shaoxing China
| | - Fangming Xu
- Department of Orthopedics Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University Zhoushan China
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14
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Xu Z, Chen S, Feng D, Liu Y, Wang Q, Gao T, Liu Z, Zhang Y, Chen J, Qiu L. Biological role of heparan sulfate in osteogenesis: A review. Carbohydr Polym 2021; 272:118490. [PMID: 34420746 DOI: 10.1016/j.carbpol.2021.118490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 12/14/2022]
Abstract
Heparan sulfate (HS) is extensively expressed in cells, for example, cell membrane and extracellular matrix of most mammalian cells and tissues, playing a key role in the growth and development of life by maintaining homeostasis and implicating in the etiology and diseases. Recent studies have revealed that HS is involved in osteogenesis via coordinating multiple signaling pathways. The potential effect of HS on osteogenesis is a complicated and delicate biological process, which involves the participation of osteocytes, chondrocytes, osteoblasts, osteoclasts and a variety of cytokines. In this review, we summarized the structural and functional characteristics of HS and highlighted the molecular mechanism of HS in bone metabolism to provide novel research perspectives for the further medical research.
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Affiliation(s)
- Zhujie Xu
- Department of Orthopedics, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, PR China
| | - Shayang Chen
- Department of Orthopedics, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, PR China
| | - Dehong Feng
- Department of Orthopedics, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, PR China
| | - Yi Liu
- Department of Orthopedics, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, PR China.
| | - Qiqi Wang
- Department of Orthopedics, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, PR China
| | - Tianshu Gao
- Department of Orthopedics, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, PR China
| | - Zhenwei Liu
- Department of Orthopedics, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, PR China
| | - Yan Zhang
- School of Pharmaceutical Sciences, Jiangnan University, Wuxi 214122, PR China
| | - Jinghua Chen
- School of Pharmaceutical Sciences, Jiangnan University, Wuxi 214122, PR China
| | - Lipeng Qiu
- School of Pharmaceutical Sciences, Jiangnan University, Wuxi 214122, PR China.
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15
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Roh YH, Lee JC, Cho HK, Jang HD, Choi SW, Shin BJ. Comparative Study of Radiological and Clinical Outcomes in Patients Undergoing Minimally Invasive Lateral Lumbar Interbody Fusion Using Demineralized Bone Matrix Alone or with Low-Dose Escherichia coli-Derived rhBMP-2. World Neurosurg 2021; 158:e557-e565. [PMID: 34775087 DOI: 10.1016/j.wneu.2021.11.028] [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] [Received: 07/30/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the results of interbody fusion in patients undergoing minimally invasive lateral lumbar interbody fusion (LLIF) using demineralized bone matrix (DBM) alone versus DBM+recombinant human bone morphogenetic protein-2 (rhBMP2). METHODS This retrospective case-controlled study was conducted in patients undergoing minimally invasive LLIF (n = 54) for lumbar interbody fusion; they were divided into 2 groups: DBM-only group and DMB+rhBMP2 group. The improvements of segmental and lumbar lordosis and restoration of disc height were measured, and the interbody fusion rates were determined using a modified Bridwell grading system. Clinical outcomes after surgery, such as visual analog scale scores of back pain and leg pain, and Oswestry disability index were compared. RESULTS There were no significant differences in disc height, lumbar and segmental lordosis, or interbody fusion rate between the 2 groups. However, the proportion of Bridwell grade 1 as complete interbody bridging was higher in the DBM+rhBMP2 group than in the DBM-only group at both 6 and 12 months (P < 0.001). Clinical parameters showed equally significant improvement during follow-up in both groups, with no significant differences between the groups. CONCLUSION In minimally invasive LLIF, adding Escherichia coli-derived rhBMP2 to DBM did not affect clinical outcomes or radiation parameters, but increased the speed of fusion and interbody bony bridging rate.
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Affiliation(s)
- Young-Ho Roh
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju-si, Jeju-do, Republic of Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Yongsan-gu, Seoul, Republic of Korea.
| | - Hyung-Ki Cho
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Yongsan-gu, Seoul, Republic of Korea
| | - Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Bucheon Hospital, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Yongsan-gu, Seoul, Republic of Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University Seoul Hospital, Yongsan-gu, Seoul, Republic of Korea
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16
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Virk S, Vaishnav AS, Sheha E, Urakawa H, Sato K, Othman Y, Chaudhary C, Lee R, Cong GT, Chaudhary S, Qureshi SA. Combining Expandable Interbody Cage Technology With a Minimally Invasive Technique to Harvest Iliac Crest Autograft Bone to Optimize Fusion Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery. Clin Spine Surg 2021; 34:E522-E530. [PMID: 34224423 DOI: 10.1097/bsd.0000000000001228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/01/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort review. OBJECTIVE The objective of this study was to determine the rate of fusion associated with an expandable cage and iliac crest bone graft in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery. SUMMARY OF BACKGROUND DATA MI-TLIF is a commonly performed procedure, but challenges inherent in MI-TLIF technique can make achieving an interbody fusion difficult. METHODS A retrospective review was performed on consecutive patients treated with an MI-TLIF for degenerative lumbar pathology. Patients that completed patient-reported outcome measures and 1-year computed tomography (CT)-scans for fusion analysis were included. Fusion morphology was analyzed by evaluating CT scans for location of bridging trabecular bone in relation to the cage. Patients with bridging bone were considered fused. Preoperative and postoperative health-related quality of life scores were compared. A Kolmogrov-Smirnoff test was used to determine normality of health-related outcome scores. A Friedman 2-way analysis of variance by ranks with pairwise comparisons to determine statistical significance of differences between the date of a follow-up examination and preoperative examination was done. RESULTS Of 75 patients evaluated 23 patients were excluded due to loss to follow-up, adjacent segment degeneration, inability to obtain a CT scan, or reoperation for nonfusion related symptoms. Of 61 disk spaces that were included, 55 had bridging bone through the intervertebral cage, resulting in an overall fusion rate of 90.2%. There was a higher rate of fusion at L5-S1 as compared to L4-L5. There was mean improvement in patient-reported outcome measures for Oswestry Disability Index, Short Form-12 Physical Component Score, Visual Analog Scale Back/Leg pain, and Patient-Reported Outcome Measurement Information System Physical Function. There were no complications associated with iliac crest bone graft harvesting. CONCLUSION Combining an expandable cage with iliac crest autograft bone harvested through a minimally invasive technique can allow for improved fusion rates without graft-site complications in MI-TLIF surgery.
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Affiliation(s)
| | | | - Evan Sheha
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | | | | | | | | | | | | | | | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
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17
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Zhu S, Zhang X, Chen X, Wang Y, Li S, Qiu G, Qian W. Nano-Hydroxyapatite Scaffold Based on Recombinant Human Bone Morphogenetic Protein 2 and Its Application in Bone Defect Repair. J Biomed Nanotechnol 2021; 17:1330-1338. [PMID: 34446136 DOI: 10.1166/jbn.2021.3110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The best way in which to prepare scaffolds with good biological properties is an urgent problem in the field of tissue engineering. In this paper we discuss the preparation of nano-hydroxyapatite scaffold of recombinant human bone morphogenetic protein-2 (rhBMP-2) and its application in bone defect repair. rhBMP-2 reagent was dissolved in 1 mol/L sodium dihydrogen phosphate solution, and the rhBMP-2 solution was added to the nano-hydroxyapatite artificial bone with a 100 μL glass micro dropper at the rate of 10 drops/min to obtain Nano-HA/rhBMP-2 composite artificial bone. In in vivo experiments, rabbits were fixed on an operating table, a 2 cm longitudinal incision was made in the middle part of the radial forearm, and the radius was cut with a wire saw and periosteum, 2.5 cm away from the distal radius. After washing the wound with normal saline, Adv-hBMP-2/MC3T3-E1 nano-HA composite artificial bone, MC3T3-E1 nan-HA composite artificial bone, or Nano-HA artificial bone were implanted in different groups. The artificial bone scaffold prepared in this study has a stronger ability to repair bone defects than the alternatives, and is a promising prospect for the clinical treatment of bone defects.
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Affiliation(s)
- Shibai Zhu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Xiaotian Zhang
- Department of General Surgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Peking Union Medical College Hospital, Beijing 100730, PR China
| | - Xi Chen
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Yiou Wang
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Shanni Li
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Guixing Qiu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
| | - Wenwei Qian
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, PR China
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18
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Zhang H, Dial B, Brown C. Early Fusion Rates After Direct Lateral Lumbar Interbody Fusion With Bone-Morphogenetic Protein. Int J Spine Surg 2021; 15:423-428. [PMID: 33963022 DOI: 10.14444/8063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Direct lateral (transpsoas) lumbar interbody fusion (LLIF) reportedly achieves union by 1 year postoperatively, but how soon fusion occurs after these minimally invasive procedures is unclear. This study investigated LLIF fusion progression at 6 months and 1 year in a large-scale cohort using bone morphogenetic protein (BMP) graft and examined risk factors associated with failed fusion. METHODS Patients undergoing primary LLIF with a single surgical team from 2015 through 2016 with polyetheretherketone (PEEK) iimplants and BMP graft were identified. Retrospective chart review included demographics and medical history, construct length and location, and concurrent L5-S1 fusion. Inclusion criteria included minimum 1-year follow-up and postoperative lumbar computed tomography at 6 months and 1 year, which was independently assessed for bony union at each level. RESULTS 166 patients underwent LLIF at a total of 312 levels. Seventy-nine patients (48%) underwent 1-level fusion; 45 (27%), 2 levels; and 42 (25%), 3 or more levels. At 6 months, 160 (51%) levels showed fusion. At 1 year, 70% of the remainder were fused, and total fusion rate was 85%. Fusion rates from L1 through L4 were similar (84%-87%). Nonunion was not significantly associated with construct length (P = .19), concurrent anterior L5-S1 interbody fusion (P = .50), age (P = .70), BMI (P = .15), or comorbidities such as diabetes (P = .86) or thyroid disease (P = .46). CONCLUSIONS This large retrospective cohort study corroborates prior 1-year LLIF fusion rate reports (85%) independent of construct length or location or medical comorbidities. Significantly, half showed fusion by 6 months, earlier than previously described and validating the efficacy of LLIF. LEVEL OF EVIDENCE 5. CLINICAL RELEVANCE This study presents a large cohort of patients to support effective lumbar fusion after LLIF with BMP-2.
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Affiliation(s)
- Hanci Zhang
- Department of Orthopaedic Surgery, Duke University Medical Center; Durham, North Carolina
| | - Brian Dial
- Department of Orthopaedic Surgery, Duke University Medical Center; Durham, North Carolina
| | - Christopher Brown
- Department of Orthopaedic Surgery, Duke University Medical Center; Durham, North Carolina
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Lo WC, Tsai LW, Yang YS, Chan RWY. Understanding the Future Prospects of Synergizing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery with Ceramics and Regenerative Cellular Therapies. Int J Mol Sci 2021; 22:3638. [PMID: 33807361 PMCID: PMC8037583 DOI: 10.3390/ijms22073638] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022] Open
Abstract
Transforaminal lumber interbody fusion (TLIF) is the last resort to address the lumber degenerative disorders such as spondylolisthesis, causing lower back pain. The current surgical intervention for these abnormalities includes open TLIF. However, in recent years, minimally invasive TLIF (MIS-TLIF) has gained a high momentum, as it could minimize the risk of infection, blood loss, and post-operative complications pertaining to fusion surgery. Further advancement in visualizing and guiding techniques along with grafting cage and materials are continuously improving the safety and efficacy of MIS-TLIF. These assistive techniques are also playing a crucial role to increase and improve the learning curve of surgeons. However, achieving an appropriate output through TLIF still remains a challenge, which might be synergized through 3D-printing and tissue engineering-based regenerative therapy. Owing to their differentiation potential, biomaterials such as stem/progenitor cells may contribute to restructuring lost or damaged tissues during MIS-TLIF, and this therapeutic efficacy could be further supplemented by platelet-derived biomaterials, leading to improved clinical outcomes. Thus, based on the above-mentioned strategies, we have comprehensively summarized recent developments in MIS-TLIF and its possible combinatorial regenerative therapies for rapid and long-term relief.
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Affiliation(s)
- Wen-Cheng Lo
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Lung-Wen Tsai
- Department of Medical Education and Research, Taipei Medical University Hospital, Taipei 11031, Taiwan;
| | - Yi-Shan Yang
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
| | - Ryan Wing Yuk Chan
- Department of Surgery, Division of Neurosurgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (Y.-S.Y.); (R.W.Y.C.)
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei 11031, Taiwan
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20
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Injection of Calcium Phosphate Apatitic Cement/Blood Composites in Intervertebral Fusion Cages: A Simple and Efficient Alternative to Autograft Leading to Enhanced Spine Fusion. Spine (Phila Pa 1976) 2020; 45:E1288-E1295. [PMID: 32694485 DOI: 10.1097/brs.0000000000003598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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21
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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: 4] [Impact Index Per Article: 1.0] [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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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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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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Dang L, Zhu J, Liu Z, Liu X, Jiang L, Wei F, Song C. A new approach to the treatment of spinal instability: Fusion or structural reinforcement without surgery? Med Hypotheses 2020; 144:109900. [PMID: 32562916 DOI: 10.1016/j.mehy.2020.109900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
Spinal instability related low back pain is a common condition resulting from degeneration and loss of stiffness of the intervertebral joint. In order to restore stability, highly invasive surgical fusion is needed for patients who are not responding to conservative treatment. Given the risk and complications of surgery, there has been the urge for improvement with a less invasive solution. Formation of vertebral body osteophytes is a common observation that has been treated as a degenerative condition. However, recent studies have associated it with reduced motion of spinal segments. Unlike the traditional view, we regard it as adaptive reactions aiming to repair and hypothesize that the spinal segments could be stabilized or fused by intentionally induced osteophytes growth at the mobile parts of the intervertebral joint. This could be achieved by injecting Bone Morphogenetic Proteins to the anterior ends of the vertebral bodies and/or the facet joints on both sides of two consecutive vertebrae percutaneously. If verified, it would be the first time that fusion could be achieved without surgery. Hence it would provide a valuable alternative to current treatments of spinal instability. Preliminary test in favor of this hypothesis is presented and we recommend that a formal study with sufficient number of samples is needed for verification.
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Affiliation(s)
- Lei Dang
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Jinglin Zhu
- Department of Orthopedics, Beijing Shijitan Hospital, No. 10 Tieyi Rd., Yangfangdian Subdistrict, Haidian District, Beijing, PR China
| | - Zhongjun Liu
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Liang Jiang
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Feng Wei
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China
| | - Chunli Song
- Department of Orthopedics, Peking University 3rd Hospital, Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Rd., Haidian District, Beijing 100191, PR China.
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Formica M, Vallerga D, Zanirato A, Cavagnaro L, Basso M, Divano S, Mosconi L, Quarto E, Siri G, Felli L. Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review. Musculoskelet Surg 2020; 104:1-15. [PMID: 31894472 DOI: 10.1007/s12306-019-00634-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/21/2019] [Indexed: 12/20/2022]
Abstract
The aim of this meta-analysis and systematic review is to summarize and critically analyze the influence of surgery-related factors in lumbar interbody fusion for degenerative spine diseases. A systematic review of the literature was carried out with a primary search being performed on Medline through PubMed. The 2009 PRISMA flowchart and checklist were taken into account. Sixty-seven articles were included in the analysis: 48 studies were level IV of evidence, whereas 19 were level III. All interbody fusion techniques analyzed have proved to reach a good fusion rate. An overall mean fusion rate of 93% (95% CI 92-95%, p < 0.001) was estimated pooling the selected studies. The influence of sagittal parameters and cages features in fusion rate was not clear. Autograft is considered the gold standard material. The use of synthetic bone substitutes and biological factors alone or combined with bone graft have shown conflicting results. Low level of evidence studies and high heterogeneity (χ2 = 271.4, df = 72, p < 0.001; I2 = 73.5%, τ2 = 0.05) in data analysis could result in the risk of bias. Further high-quality studies would better clarify these results in the future.
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Affiliation(s)
- M Formica
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - D Vallerga
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy.
| | - A Zanirato
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - L Cavagnaro
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - M Basso
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - S Divano
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - L Mosconi
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - E Quarto
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - G Siri
- Department of Mathematics, University of Genoa, Via Dodecaneso 35, 16146, Genoa, GE, Italy
| | - L Felli
- Clinica Ortopedica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
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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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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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