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

Case report

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

Abbreviations used in this paper:ALIF = anterior lumbar interbody fusion; BMP = bone morphogenetic protein; rhBMP = recombinant human BMP; TGF-β = transforming growth factor–β; TLIF = transforaminal lumbar interbody fusion.

Article Information

Address correspondence to: Shaun Rodgers, M.D., Department of Neurosurgery, New York University Langone Medical Center, 462 First Avenue, Suite 7S4, New York, New York 10016. email: shaun.rodgers@nyumc.org.

Please include this information when citing this paper: published online April 5, 2013; DOI: 10.3171/2013.3.SPINE12377.

© AANS, except where prohibited by US copyright law.

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    Prior to the second surgery, a sagittal CT scan (left) and MR image (right) suggested fibrosis and scarring of the left iliac vein to the anterior L4–5 disc space (circled).

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    Sagittal MR image of virgin tissue obtained prior to any surgery showing a good fat plane and no evidence of fibrosis.

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    Sagittal CT scans showing extensive osteophyte formation with fibrosis between the 2 surgeries. Image on the left was obtained immediately after the first surgery, whereas the image on the right was obtained immediately prior to the second surgery.

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