Complications associated with recombinant human bone morphogenetic protein use in pediatric craniocervical arthrodesis

Clinical article

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Object

Management of pediatric occipitocervical instability remains especially challenging. The off-label use of recombinant human bone morphogenetic protein (rhBMP)-2 for spinal fusion has increased with a well-documented increase in fusion rate in many case series. Unfortunately, recent reports have documented complications associated with rhBMP use in adult spinal fusions. Complications associated with the use of rhBMP in pediatric spinal surgery is less well understood. In this study the authors report on the fusion rate and complications associated with rhBMP in pediatric occipitocervical arthrodesis.

Methods

The authors reviewed the medical records of those patients 18 years old and younger who underwent dorsal occipitocervical fusion from January 2004 to December 2007 at the University of Iowa Hospitals and Clinics. Forty-eight patients were identified who received rhBMP-augmented fusion. The clinical outcome and complications of these fusions were analyzed.

Results

All 48 patients had fusion confirmed on lateral radiographs within 4–14 months with an average fusion time of 6.7 months. There were 6 complications, 5 of which included seroma formation. Two of 5 patients who developed postoperative seroma presented with symptoms suggesting brainstem compression and obstructive hydrocephalus requiring emergency reoperation. One patient developed heterotopic bone formation causing cervicomedullary compression requiring reoperation.

Conclusions

The use of rhBMP to augment autograft in occipitocervical fusion allows for a high rate of successful arthrodesis, but is associated with potentially life-threatening complications in pediatric patients.

Abbreviations used in this paper: BMP = bone morphogenetic protein; EVD = external ventricular drain; Oc = occiput; rhBMP = recombinant human BMP.

Article Information

Address correspondence to: Arnold H. Menezes, M.D., Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242. email: arnold-menezes@uiowa.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 1. An axial CT scan of the head obtained at the onset of apneic spells revealed epidural fluid in the posterior fossa and evidence of obstructive hydrocephalus (A). A sagittal MR image (B) revealed epidural fluid extending from the surgical site into the epidural space causing mass effect on the craniocervical junction. Case 2. An emergency axial CT scan of the head obtained at the onset of progressive somnolence revealed a large epidural fluid collection and obstructive hydrocephalus (C).

  • View in gallery

    Case 3. Preoperative 3D CT scans demonstrate posterior (A) and lateral (B) views of the previous suboccipital craniectomy and C-1 laminectomy. A repeat 3D CT was performed 15 months after the dorsal Oc–C2 fusion augmented with rhBMP. The posterior view (C) and superior view looking down through the foramen magnum (D) reveal extensive bone formation entirely occluding the prior decompression, causing recurrent symptoms.

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