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Occipitocervical Fusion Using Recombinant Human Bone Morphogenetic Protein-2: Adverse Effects due to Tissue Swelling and Seroma

Shahlaie, Kiarash, MD, PhD; Kim, Kee D., MD

doi: 10.1097/BRS.0b013e318183971d
Literature Review

Study Design. Case presentation and literature review.

Objective. To review the safety of using INFUSE bone graft (recombinant human bone morphogenetic protein-2 applied to an absorbable collagen sponge) in occipitocervical (OC) fusion.

Summary of Background Data. Although INFUSE bone graft is currently approved for use in certain tibial fractures, oral maxillary procedures, and anterior lumbar interbody fusion, it has been extensively used “off-label” in posterolateral lumbar and anterior cervical fusions. INFUSE is highly effective in promoting cervical spine fusion via an anterior approach, but its potential role in promoting bony fusion in posterior cervical or OC fixation has not been studied.

Methods. A 53-year-old woman with basilar invagination underwent OC fixation using INFUSE bone graft. Three days after surgery she experienced neurologic decline associated with significant tissue swelling and a large postoperative seroma under significant pressure. She made excellent recovery after reoperation and drainage. An extensive review of the literature was performed to propose a modified approach to the use of INFUSE in OC fixation.

Results. Proper dosing and delivery of INFUSE for posterior cervical/OC fixation is not currently known. Previously published experience with anterior cervical fusion suggests that INFUSE can have potent inflammatory effects on paraspinal soft tissue.

Conclusion. INFUSE should only be used for OC fixation in patients at elevated risk of nonunion. To prevent complications due to soft tissue swelling, consideration should be given to preventing direct exposure of INFUSE to paraspinal musculature, prolonged soft tissue drainage, and prophylactic treatment with perioperative steroid therapy.

INFUSE (rh-BMP2) has been successfully used to promote lumbar and cervical fusion, but its potential role in occipitocervical fixation has not been previously studied. An illustrative case is presented, and an extensive literature review was performed to propose techniques for the safe use of INFUSE in occipitocervical fixation.

From the Department of Neurological Surgery, Davis School of Medicine, University of California, Sacramento, CA.

Acknowledgment date: January 23, 2008. Revision date: May 2, 2008. Acceptance date: May 5, 2008.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Kee D. Kim, MD, Department of Neurological Surgery, Davis School of Medicine, University of California, 4860 Y Street, Suite 3740, Sacramento, CA 95817; E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.