Analysis of prevertebral soft-tissue swelling and dysphagia in multilevel anterior cervical discectomy and fusion with recombinant human bone morphogenetic protein–2 in patients at risk for pseudarthrosis

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The goal of this study was to demonstrate the incidence of fusion and soft-tissue swelling in multilevel anterior cervical discectomies and fusions (ACDFs) using polyetheretherketone (PEEK) spacers with recombinant human bone morphogenetic protein–2 (rhBMP-2) impregnated in a Type I collagen sponge and titanium plates.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A single surgeon performed 30 multilevel ACDFs using PEEK spacers with an rhBMP-2 impregnated collagen sponge (0.4 ml, or the equivalent of 0.6 mg rhBMP-2). Soft-tissue swelling was assessed using cervical spine radiographs on postoperative Day 1 and at 2, 6, and 10 weeks and 6 months after surgery. Incidence of dysphagia was assessed with the Cervical Spine Research Society Swallowing–Quality of Life tool. Clinical success was evaluated with the Neck Disability Index, neck pain scores, and arm pain scores. Final fusion was assessed with CT by an independent neuroradiologist.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Patients were followed for 6 months unless they had an incomplete fusion; those patients were reassessed at 9 months. Twenty-four patients underwent 2-level ACDFs and 6 underwent 3-level ACDFs were performed on patients with the following risk factors for pseudarthrosis: smoking (33%), diabetes (13%), and obesity (body mass index ≥ 30 [43%]). Seventeen percent of the patients had multiple risk factors. Soft-tissue swelling peaked at 2 weeks regardless of level of surgery or number of levels treated surgically and decreased to near preoperative levels by 6 months. At 2 weeks, Swallowing–Quality of Life evaluation showed 19% of patients frequently choking on food, 4.8% frequently choking when drinking, and 47.6% with frequent food sticking in the throat. Scores continued to improve, and at 6 months, 0% had frequent choking on food, 6.7% had frequent difficulty drinking, and 6.7% had frequent food sticking in the throat. The Neck Disability Index, neck pain, and arm pain scores all improved progressively over 6 months. Incidence of fusion was 95% at 6 months and 100% at 9 months. There were no rehospitalizations or reoperations for soft-tissue swelling or dysphagia.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Multilevel ACDF procedures using PEEK grafts and rhBMP-2 can be performed safely in patients with multiple risk factors for pseudarthrosis with excellent fusion outcomes.</jats:p></jats:sec>

Point-counter-point debate: the association between recombinant human bone morphogenetic protein utilization and complications in spine surgery

“…The authors also reported that while most patients complained of neck swelling there were no cases of reintubation due to airway compromise and no patients returned to the operating room for postoperative hematoma or seroma evacuation. Similarly, Stachniak et al reported a 95 % fusion rate at 6-months and a 100 % fusion rate at 9-months following a 2-or 3-level ACDF with rhBMP-2 in a group with substantial risk factors for pseudarthrosis (33 % smoking, 13 % diabetes, and 43 % obesity) [53]. In another retrospective cohort study comparing multilevel ACF with and without rhBMP-2, the authors demonstrated a 100 % fusion rate in the rhBMP-2 cohort vs an 82.6 % fusion rate in the group without rhBMP-2 [44].…”

“…Although multiple complications associated with BMP utilization in cervical fusion procedures have been reported, there is evidence that the complication rates are dose related and decrease with lower doses [53]. Importantly, Frankel et al reported no complications when the dosage of rhBMP-2 was less than 1.1 mg/level [44].…”

Local steroids and dysphagia in anterior cervical discectomy and fusion—does the employment of rhBMP-2 make their use a necessity?

“…Stachniak et al reported that only 6.7% of their patients had persistent dysphagia with low dose rhBMP-2, 6 months after their procedure (10). Similarly, Kukreja et al reported lower incidence of postoperative dysphagia with lower rhBMP-2 doses (11).…”

Reoperation rates for symptomatic nonunions in posterior cervicothoracic fusions with and without bone morphogenetic protein in a cohort of 450 patients

“…36 Controversy over its use, however, has also increased over the years 18,42 with several studies reporting complications. 3,8,10,30,41,[45][46][47][48]51,52,55 One of the justifications for its use has been its cost savings associated with prevention of fusion failures. 1,19,39 A few studies have advocated for its use in the posterior cervical spine because of its high fusion rates.…”