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Osteolysis in Transforaminal Lumbar Interbody Fusion with Bone Morphogenetic Protein-2

Knox, CPT Jeffrey B. MD; Dai, CPT Joseph M. III MD; Orchowski, LTC Joseph MD

doi: 10.1097/BRS.0b013e3181e030e0
Clinical Case Series

Study Design. Retrospective radiographic review.

Objective. To determine the incidence of osteolysis, graft subsidence, and cage migration after recombinant human bone morphogenetic protein-2 (rhBMP-2) use with transforaminal lumbar interbody fusion (TLIF).

Summary of Background Data. Osteolysis after TLIF is a recently described phenomenon associated with rhBMP-2 use. Although this is typically a self-limiting condition, complications such as graft subsidence and cage migration have been described. The incidence of this is not well defined and most studies use plain radiographs for diagnosis rather than more advanced imaging. This study serves to quantify the risk of osteolysis and its associated graft complications with routine use of computed tomography.

Methods. A total of 58 patients who underwent primary TLIF from a single surgeon between 2004 and 2007 underwent routine postoperative computed tomographic scan. Seventy-seven levels of fusion were evaluated for osteolysis. All patients received the same dose of rhBMP-2 of 5 mg per level. Imaging was performed immediately postoperative and again at an average of 4.3 months postoperative (range = 2.4–9.0 months). These images were evaluated for the presence of osteolysis, graft subsidence, and cage migration. These changes were then graded according to their severity.

Results. Osteolysis was found in 16 of the 58 (27.6%) patients and 19 of the 77 (24.7%) levels treated. No significant difference was found between single and two-level fusions. The degree of osteolysis ranged from 3 to 20 mm with an average of 12.5 mm. The osteolysis was characterized as severe (>1 cm) in 12 of the 19 levels. Of the patients with osteolysis, 31.6% demonstrated graft subsidence all of which occurred with severe osteolytic defects. Migration of the intervertebral cage was found in 8.8% of patients.

Conclusion. rhBMP-2 use with TLIF is associated with a significant risk of postoperative osteolysis. Patients who demonstrated postoperative osteolysis were associated with significant risk of subsidence or migration of the intervertebral cage. The clinical implications of these changes are not currently known.

Osteolysis is a recently described phenomenon found after recombinant human bone morphogenetic protein-2 use for spinal fusions. Bone morphogenetic protein-2 use is associated with a significant risk of osteolysis and may result in migration or subsidence of the intervertebral cage.

From the Orthopedic Surgery Service, Department of Surgery, Tripler Army Medical Center, Honolulu, HI.

Address correspondence and reprint requests to CPT Jeffrey B. Knox, MD, Orthopedic Surgery Department, Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI 96859; E-mail:

Acknowledgment date: January 11, 2010. Revision date: February 6, 2010. Acceptance date: February 8, 2010.

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.

The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

© 2011 Lippincott Williams & Wilkins, Inc.