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Comparison of TLIF With rhBMP-2 Versus No TLIF and Higher Posterolateral rhBMP-2 Dose At L5–S1 for Long Fusions to the Sacrum With Sacropelvic Fixation in Patients With Primary Adult Deformity

Rahman, Ra'Kerry K. MD*; Buchowski, Jacob M. MD; Stephens, Bradley MD; Dorward, Ian G. MD; Koester, Linda A. BS; Bridwell, Keith H. MD

doi: 10.1097/BRS.0000000000000045

Study Design. Comparvative case series. Data was prospectively entered and retrospectively analyzed.

Objective. To evaluate the need for distal lumbar interbody fusion when sufficient recombinant human bone morphogenetic protein-2 (rhBMP-2) is used posterolaterally at L5–S1 in long spinal constructs for adult deformity via costs and radiographical and patient-reported outcome comparisons.

Summary of Background Data. Many authors and investigators have suggested that an interbody fusion is mandatory at L5–S1 with long fusion to the sacrum with sacropelvic fixation. Past studies have shown competitive fusion rates using rhBMP-2 versus iliac crest bone graft for long fusions. There are various advocates for anterior lumbar interbody fusion versus posterior lumbar interbody fusion versus transforaminal lumbar interbody fusion (TLIF). The optimal strategy remains elusive.

Methods. Fifty-seven patients were studied at one institution. Thirty-one patients had no interbody fusion (NI group) with 20 mg of rhBMP-2 posterolaterally on 10 mL of carrier and 26 patients had TLIF at L5–S1 (TLIF group) with 6 mg of rhBMP-2 in the interbody space along with local bone graft and 6 mg of rhBMP-2 on carrier posterolaterally at L5–S1. Patients were followed for 24 to 87 months (mean follow-up, 3.92 yr). Demographics of the 2 groups were similar.

Results. There were no detected nonunions at L5–S1 in either group. By our limited cost analysis, the expense of performing a TLIF at L5–S1 is higher than that of using extra rhBMP-2 posterolaterally at that segment. Improvement in outcomes scores, namely Scoliosis Research Society-22 and Oswestry Disability Index, were the same statistically in both groups. Blood loss was greater in the TLIF group than the NI group. There were no identified rhBMP-2 adverse events in either group.

Conclusion. Utilization of 20 mg of rhBMP-2 at L5–S1 has the potential to be less expensive than an interbody fusion in most patients having a primary long fusion for adult spinal deformity. The apparent fusion rates at L5–S1 were identical in both groups. Both strategies were successful in regard to improving patient outcomes and achieving apparent solid arthrodesis at the lumbosacral junction, which was the focus of this study.

Level of Evidence: 2

For long fusions to the sacrum with sacropelvic fixation in patients with primary adult spinal deformity, transforaminal lumbar interbody fusion (TLIF group) with 6 mg of recombinant human bone morphogenetic protein (rhBMP)-2 anteriorly, and 6 mg of rhBMP-2 posterolaterally was compared with a no-TLIF group (NI group) with a higher dose of rhBMP-2 posterolaterally (20 mg). Nonunion rates at L5–S1, clinical outcomes and expense of the 2 approaches were similar. The extra rhBMP-2–without-TLIF (NI group) approach was not more expensive, nor did it result in more complications or blood loss or lower improvement in outcome scores when compared with the TLIF group.

*Division of Orthopaedics, Southern Illinois University School of Medicine, Springfield, IL; and

Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO.

Address correspondence and reprint requests to Keith H. Bridwell, MD, Department of Orthopedic Surgery, Washington University Orthopedics, 660 South Euclid Ave, Campus Box 8233, St. Louis, MO; E-mail:

Acknowledgment date: November 16, 2012. First revision date: April 10, 2013. Second revision date: August 12, 2013. Acceptance date: September 16, 2013.

The device(s)/drug(s) that is/are the subject of this manuscript is/are not FDA-approved for this indication and is/are not commercially available in the United States.

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, expert testimony, grants, payment for lecture, travel/accommodations, meeting expenses.

© 2013 by Lippincott Williams & Wilkins