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Keum BR, Kim HJ, Kim GH, Chang DG. Osteobiologies for Spinal Fusion from Biological Mechanisms to Clinical Applications: A Narrative Review. Int J Mol Sci 2023; 24:17365. [PMID: 38139194 PMCID: PMC10743675 DOI: 10.3390/ijms242417365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Degenerative lumbar spinal disease (DLSD), including spondylolisthesis and spinal stenosis, is increasing due to the aging population. Along with the disease severity, lumbar interbody fusion (LIF) is a mainstay of surgical treatment through decompression, the restoration of intervertebral heights, and the stabilization of motion segments. Currently, pseudoarthrosis after LIF is an important and unsolved issue, which is closely related to osteobiologies. Of the many signaling pathways, the bone morphogenetic protein (BMP) signaling pathway contributes to osteoblast differentiation, which is generally regulated by SMAD proteins as common in the TGF-β superfamily. BMP-2 and -4 are also inter-connected with Wnt/β-catenin, Notch, and FGF signaling pathways. With the potent potential for osteoinduction in BMP-2 and -4, the combination of allogenous bone and recombinant human BMPs (rhBMPs) is currently an ideal fusion material, which has equalized or improved fusion rates compared to traditional materials. However, safety issues in the dosage of BMP remain, so overcoming current limitations will provide significant advancement in spine surgery. In the future, translational research and the application of clinical study will be important to overcome the current limitations of spinal surgery.
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Affiliation(s)
- Byeong-Rak Keum
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju 28119, Republic of Korea;
| | - Hong Jin Kim
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
| | - Gun-Hwa Kim
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju 28119, Republic of Korea;
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
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Park J, Park SM, Han S, Jeon Y, Hong JY. Factors affecting successful immediate indirect decompression in oblique lateral interbody fusion in lumbar spinal stenosis patients. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100279. [PMID: 37869545 PMCID: PMC10587750 DOI: 10.1016/j.xnsj.2023.100279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/24/2023]
Abstract
Background Oblique lumbar interbody fusion (OLIF) offers indirect decompression of stenotic lesions of the spinal canal and foramen through immediate disc height restoration. Only a few studies have reported the effect of cage position and associated intraoperatively modifiable factors for successful immediate indirect decompression following OLIF surgery. This study aimed to investigate the intraoperatively modifiable factors for successful radiological outcomes of OLIF. Methods This study included 46 patients with 80 surgical levels who underwent OLIF without direct posterior decompression. Preoperative and postoperative radiological parameters were evaluated and intraoperatively modifiable radiologic parameters for successful immediate radiologic decompression on magnetic resonance image (MRI) were determined. Radiologic parameters were preoperative and postoperative radiological parameters including anterior disc height (ADH), posterior disc height (PDH) lumbar lordotic angle (LLA), segmental lordotic angle (SLA), foraminal height (FH), cage position, cross-sectional area (CSA) of the thecal sac, cross-sectional foraminal area (CSF), facet distance (FD). Results All radiologic outcomes significantly improved. Comparing preoperative and postoperative values, mean CSA increased from 99.63±40.21 mm2 to 125.02±45.90 mm2 (p<.0001), and mean left CSF increased from 44.54±12.90 mm2 to 69.91±10.80 mm2 (p<.0001). FD also increased from 1.40±0.44 to 1.92±0.71 mm (p<.0001). FH increased from 16.31±3.3 to 18.84±3.47 mm (p<.0001). ADH and PDH also significantly increased (p<.0001). Immediate postoperative CSF and FH improvement rate (%) were significantly correlated with posterior disc height restoration rate (%) (p=.0443, and p=.0234, respectively). In addition, the patients with a cage positioned in the middle of the vertebral body experienced a greater FH improvement rate (%) compared to the patients with a cage positioned anteriorly. Finally, Visual analogue scale (VAS) for leg pain was improved immediately. Conclusions OLIF provided satisfactory immediate indirect decompression in central and foraminal spinal stenosis. Moreover, intraoperative surgical technique for successful radiologic CSF and FH improvement included restoration of the PDH and placement of the cage in the middle.
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Affiliation(s)
- Jiwon Park
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Republic of 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, Republic of Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Yeong Jeon
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Republic of Korea
| | - Jae-Young Hong
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Republic of Korea
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Arcidiacono UA, Armocida D, Pesce A, Maiotti M, Proietti L, D’Andrea G, Santoro A, Frati A. Complex Regional Pain Syndrome after Spine Surgery: A Rare Complication in Mini-Invasive Lumbar Spine Surgery: An Updated Comprehensive Review. J Clin Med 2022; 11:7409. [PMID: 36556025 PMCID: PMC9781971 DOI: 10.3390/jcm11247409] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a postoperative, misdiagnosed condition highlighted only by pain therapists after numerous failed attempts at pain control by the treating surgeon in the case of prolonged pain after surgery. It only occurs rarely after spine surgery, causing the neurosurgeon's inappropriate decision to resort to a second surgical treatment. METHODS We performed a systematic review of the literature reporting and analyzing all recognized and reported cases of CRPS in patients undergoing spinal surgery to identify the best diagnostic and therapeutic strategies for this unusual condition. We compare our experience with the cases reported through a review of the literature. RESULTS We retrieve 20 articles. Most of the papers are clinical cases showing the disorder's rarity after spine surgery. Most of the time, the syndrome followed uncomplicated lumbar spine surgery involving one segment. The most proposed therapy was chemical sympathectomy and spinal cord stimulation. CONCLUSION CRPS is a rare pathology and is rarer after spine surgery. However, it is quite an invalidating disorder. Early therapy and resolution, however, require a rapid diagnosis of the syndrome. In our opinion, since CRPS occurs relatively rarely following spinal surgery, it should not have a substantial impact on the indications for and timing of these operations. Therefore, it is essential to diagnose this rare occurrence and treat it promptly and appropriately.
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Affiliation(s)
| | - Daniele Armocida
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, 00185 Rome, Italy
- IRCCS “Neuromed”, 86077 Pozzilli, Italy
| | - Alessandro Pesce
- Neurosurgery Unit, Santa Maria Goretti Hospital, Via Guido Reni 1, 04100 Latina, Italy
| | - Marco Maiotti
- Villa Stuart Hospital, Orthopedic Clinic, 00135 Roma, Italy
| | - Luca Proietti
- Division of Spinal Surgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Institute of Orthopaedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | | | - Antonio Santoro
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, 00185 Rome, Italy
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Chakravarthy VB, Laufer I, Amin AG, Cohen MA, Reiner AS, Vuong C, Persaud PS, Ruppert LM, Puttanniah VG, Afonso AM, Tsui VS, Brallier JW, Malhotra VT, Bilsky MH, Barzilai O. Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors. Cancer 2022; 128:4109-4118. [PMID: 36219485 PMCID: PMC10859187 DOI: 10.1002/cncr.34484] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence-based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center. METHODS The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0-5 cumulative opioid use (morphine milligram equivalent [MME]). RESULTS A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre-ERAS patients. Although the mean case durations were similar in the ERAS and pre-ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0-5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001). CONCLUSIONS The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.
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Affiliation(s)
- Vikram B. Chakravarthy
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ilya Laufer
- Neurological Surgery, New York University Medical Center, New York, New York, USA
| | - Anubhav G. Amin
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc A. Cohen
- Surgery (Head and Neck), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cindy Vuong
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Petal‐Ann S. Persaud
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa M. Ruppert
- Rehabilitation Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay G. Puttanniah
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Van S. Tsui
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jess W. Brallier
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vivek T. Malhotra
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark H. Bilsky
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ori Barzilai
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Gao G, Cao L, Du X, Xu B, Zhang P, Zhang X, Wang R, Quan Z. Comparison of Minimally Invasive Surgery Transforaminal Lumbar Interbody Fusion and TLIF for Treatment of Lumbar Spine Stenosis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:9389239. [PMID: 35126956 PMCID: PMC8808212 DOI: 10.1155/2022/9389239] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/30/2021] [Indexed: 01/29/2023]
Abstract
With the development of minimally invasive technology, minimally invasive surgery transforaminal lumbar interbody fusion has become an effective way to treat lumbar spinal stenosis. Lumbar spinal stenosis is one of the common diseases that cause backache or lumbago and sciatica. This article compares and analyzes the clinical efficacy of 60 patients with lumbar spinal stenosis surgery. It can be seen that the wound by MIS-TLIF is significantly less than that of traditional open surgery, and the postoperative recovery of MIS-TLIF is faster. So, MIS-TLIF is one of the concepts of minimally invasive surgery. The age distribution ranged from 56 to 78 years, with an average of 65.7 years. 31 cases were treated with MIS-TLIF (MIS-TLIF group), and 29 were treated with traditional posterior open surgery (TLIF group). The operation time, intraoperative blood loss, and postoperative drainage of the operation area were recorded. After statistical testing, the intraoperative blood loss, incision size, and postoperative drainage volume of the wound in the MIS-TLIF group were significantly less than those in the TLIF group. The results of JOA score, ODI score, and VAS score during the postoperative follow-up period were comparable to those of open surgery. Therefore, minimally invasive transforaminal lumbar interbody fusion is effective in treating lumbar spinal stenosis.
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Affiliation(s)
- Guodong Gao
- Department of Spinal Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Gansu 730000, China
| | - Linzhong Cao
- Department of Spinal Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Gansu 730000, China
| | - Xiaozheng Du
- Department of Spinal Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Gansu 730000, China
| | - Bin Xu
- Department of Spinal Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Gansu 730000, China
| | - Ping Zhang
- College of Electrical and Information Engineering, Lanzhou University of Technology, Gansu 730050, China
| | - Xiaogang Zhang
- Department of Spinal Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Gansu 730000, China
| | - Rong Wang
- Department of Spinal Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Gansu 730000, China
| | - Zhen Quan
- Department of Spinal Surgery, Affiliated Hospital of Gansu University of Chinese Medicine, Gansu 730000, China
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Han XG, Tang GQ, Han X, Xing YG, Zhang Q, He D, Tian W. Comparison of Outcomes between Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion and Oblique Lumbar Interbody Fusion in Single-Level Lumbar Spondylolisthesis. Orthop Surg 2021; 13:2093-2101. [PMID: 34596342 PMCID: PMC8528977 DOI: 10.1111/os.13151] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To compare the safety and effectiveness of robot‐assisted minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) and oblique lumbar interbody fusion (OLIF) for the treatment of single‐level lumbar degenerative spondylolisthesis (LDS). Methods This is a retrospective study. Between April 2018 and April 2020, a total of 61 patients with single‐level lumbar degenerative spondylolisthesis and treated with robot‐assisted OLIF (28 cases, 16 females, 12 males, mean age 50.4 years) or robot‐assisted Mis‐TLIF (33 cases, 18 females, 15 males, mean age 53.6 years) were enrolled and evaluated. All the pedicle screws were implanted percutaneously assisted by the TiRobot system. Surgical data included the operation time, blood loss, and length of postoperative hospital stay. The clinical and functional outcomes included Oswestry Disability Index (ODI), Visual Analog scores (VAS) for back and leg pain, complication, and patient's satisfaction. Radiographic outcomes include pedicle screw accuracy, fusion status, and disc height. These data were collected before surgery, at 1 week, 3 months, 6 months, and 12 months postoperatively. Results There were no significantly different results in preoperative measurement between the two groups. There was significantly less blood loss (142.4 ± 89.4 vs 291.5 ± 72.3 mL, P < 0.01), shorter hospital stays (3.2 ± 1.8 vs 4.2 ± 2.5 days, P < 0.01), and longer operative time (164.9 ± 56.0 vs 121.5 ± 48.2 min, P < 0.01) in OLIF group compared with Mis‐TLIF group. The postoperative VAS scores and ODI scores in both groups were significantly improved compared with preoperative data (P < 0.05). VAS scores for back pain were significantly lower in OLIF group than Mis‐TLIF group at 1 week (2.8 ± 1.2 vs 3.5 ± 1.6, P < 0.05) and 3 months postoperatively (1.6 ± 1.0 vs 2.1 ± 1.1, P < 0.05), but there was no significant difference at further follow‐ups. ODI score was also significantly lower in OLIF group than Mis‐TLIF group at 3 months postoperatively (22.3 ± 10.0 vs 26.1 ± 12.8, P < 0.05). There was no significant difference in the proportion of clinically acceptable screws between the two groups (97.3% vs 96.2%, P = 0.90). At 1 year, the OLIF group had a higher interbody fusion rate compared with Mis‐TLIF group (96.0% vs 87%, P < 0.01). Disc height was significantly higher in the OLIF group than Mis‐TLIF group (12.4 ± 3.2 vs 11.2 ± 1.3 mm, P < 0.01). Satisfaction rates at 1 year exceeded 90% in both groups and there was no significant difference (92.6% for OLIF vs 91.2% for Mis‐TLIF, P = 0.263). Conclusion Robot‐assisted OLIF and Mis‐TLIF both have similar good clinical outcomes, but OLIF has the additional benefits of less blood loss, less postoperative hospital stays, higher disc height, and higher fusion rates. Robots are an effective tool for minimally invasive spine surgery.
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Affiliation(s)
- Xiao-Guang Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Guo-Qing Tang
- Kunshan Hospital of Traditional Chinese Medicine, Kunshan, China
| | - Xiao Han
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Yong-Gang Xing
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Qi Zhang
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Da He
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
| | - Wei Tian
- Department of Spine Surgery, Beijing Jishuitan Hospital, Beijing, China.,Beijing Key Laboratory of Robotic Orthopaedics, Beijing, China
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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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