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Bone Morphogenetic Protein-2 (BMP-2) in the Treatment of Pyogenic Vertebral Osteomyelitis

Allen, R Todd, MD, PhD; Lee, Yu-Po, MD; Stimson, Elizabeth, NP, MS; Garfin, Steven R., MD

doi: 10.1097/BRS.0b013e31815cde3e
Clinical Case Series
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Study Design. Retrospective case series.

Objective. To present results of recombinant human bone morphogenetic protein-2 (rhBMP-2) use in medically nonresponsive pyogenic vertebral osteomyelitis (PVO), treated by anterior/posterior debridement and instrumented fusion in the cervical, thoracic, and lumbosacral spine.

Summary of Background Data. Surgical options for PVO vary, as do their outcomes, and can be complicated by recurrence, pseudarthrosis, and death. Although rhBMP-2 use in spinal fusion is increasing, its utility in PVO is unknown. Additionally, use in areas of infection is listed as a contraindication, although this is not supported by laboratory (animal) studies or clinical studies in long bones.

Methods. Between 2003 and 2005, 14 patients who underwent circumferential fusion for PVO were included in this study. Average patient age was 54 years (range, 27–77 years). Eight (57%) patients had 3 or more vertebral bodies involved. Diagnostic studies included radiographs, CT, MRI, and markers of infection [(C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood count (WBC)]. All patients underwent anterior fusion with rhBMP-2 inserted in structural allograft (11 patients) or titanium cylindrical cages (3 patients), followed by posterior instrumented fusion with autogenous iliac crest graft (8 occurring on the same day). Follow-up averaged 22 months (range, 11–30 months). All were studied with plain radiographs, including flexion-extension lateral films and fine cut CT scans with reconstruction. Pain ratings were recorded by visual analog scores (VAS).

Results. Clinical resolution of infections, normalization of lab values, and bony fusion, based on dynamic radiographs and CT scans, were seen in all patients at latest follow-up. Staphylococcus aureus was the most frequently identified organism (8 patients). Four (29%) patients had positive blood cultures (all MRSA). Predisposing comorbidities were present in 12 patients. Six patients had epidural abscesses. Eight (57%) patients presented with neurologic deficits, ranging from paraparesis to quadriplegia. Complete recovery was seen in 7 (quadriplegia unchanged). At 1 year, mean VAS pain scores improved significantly (P < 0.05) from 7.9 (range, 3–10) to 2.8 (range, 0–6). Perioperative complications (non-BMP related) occurred in 2 patients. There were no surgically-related deaths.

Conclusion. rhBMP-2 use, in combination with antibiotics and circumferential instrumented fusion, provides a safe and successful surgical treatment of medically nonresponsive PVO, with solid fusions obtained, good clinical results, and no adverse side effects from the BMP.

Fourteen patients with mild to severe pyogenic vertebral osteomyelitis in all spinal regions were treated by circumferential instrumented fusion using rhBMP-2 (plus allograft or titanium cage) anteriorly. Bony fusion occurred quickly and at latest follow-up resolution of infection, normalized CRP, and significant VAS pain score and functional improvements have occurred.

From the Department of Orthopaedic Surgery, University of California-San Diego, San Diego, CA.

Acknowledgment date: February 2, 2007. Revision date: June 6, 2007. Acceptance date: June 7, 2007.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

No funds were received in support of this work. Although one or more of the author(s) has/have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript, benefits will be directed solely to a research fund, foundation, educational institution, or other nonprofit organization which the author(s) has/have been associated.

Address correspondence and reprint requests to Steven R. Garfin, MD, Department of Orthopaedic Surgery, University of California, San Diego, 350 Dickinson St., San Diego, CA 92103-8894; E-mail: sgarfin@ucsd.edu

© 2007 Lippincott Williams & Wilkins, Inc.