Contained-Delivery Route and the Administration of Postoperative Steroids Following Anterior Cervical Spinal Fusion With Low-dose rhBMP-2 Reduces the Magnitude of Respiratory Compromise

Abstract

Study Design: Retrospective chart review of patients who underwent anterior cervical discectomy and fusion (ACDF) using low-dose recombinant human bone morphogenic protein (rhBMP)-2. Objective: Determine whether severity and incidence of respiratory complications after ACDF surgery are decreased when using a low-dose BMP-infused sponge within a constrained carrier and postoperative IV and oral steroids. Summary of Background Data: Many physicians avoid using BMP in anterior cervical spine fusions because of concern for an increased incidence of dysphagia, significant prevertebral swelling, and airway edema compromise. Pilot studies have shown that the local application of steroids may decrease the incidence of postoperative airway edema and dysphagia. We performed a retrospective study to evaluate the safety of immediate postoperative tapered steroid use following low-dose rhBMP-2 completely contained inside either an allograft or PEEK cage in reducing the severity and incidence of respiratory complications following ACDF. Materials and Methods: Forty-seven patients between 33 and 74 years of age, undergoing 1-, 2-, 3-, or 4-level ACDFs augmented with a fraction of a small sponge of rhBMP-2 (0.525 mg/level) within an allograft or PEEK cage and prescribed IV and oral postoperative steroids between January 1, 2008 and November 1, 2016. The incidence of complications such as dyspnea, dysphagia, airway issues, edema ectopic bone osteolysis, radiculitis, and nonunion were collected using medical charts. Additional data regarding length of hospital stay and readmissions were also recorded. Results: No life-threatening respiratory events, such as prolonged intubation, re-intubation, or readmission for labored breathing, were observed. No complications referable to steroids such as delayed healing, uncontrollable blood sugar, or diabetes were encountered in this series. Conclusions: This study provides evidence that a tapered dose of steroids and a contained delivery route significantly decreases postoperative respiratory compromise incidence and magnitude following anterior cervical spine fusion using low-dose rhBMP-2.

Safety and efficacy of low-dose rhBMP-2 use for anterior cervical fusion

“…In our study we did not present a control group for comparison, but our rate of cervical swelling appeared to fall within the control group range of 0.0-13.9% in the aforementioned studies. Interestingly, Maza et al 30 showed that using a contained delivery device for rhBMP-2 significantly reduced postoperative swelling complications. For ACDF, J.P.M.…”

BMP and TGFβ use and release in bone regeneration

“…Although BMP is one of the most popular growth factors which are known as triggering / signaling molecules that regulate not only growth but also repair and regeneration [1,21] by promoting osteogenesis, chondrogenesis, vascularization and formation of fibrotic tissue to accelerate the maturation progress and callus formation while inhibiting osteoclastogenesis [8], decreasing blood loss, surgery time and hospital stay [20,21]; the use of BMPs is still avoided by many physicians because of their complications such as an increase incidence in dysphagia, significant prevertebral swelling, airway edema compromise [1,2,20,51], uncertain impacts in promoting tumorigenesis and tumor metastasis [45,52], ectopic bone formation, osteophyte production [1,20,43,44]. It is also reported that BMP-2 induces PPARγ activation in a dose dependent manner and promotes the commitment of MSCs to adipocyte lineage [20,53].…”

“…There are also various applications of BMPs and TGFβs in clinics with carrier molecules [51,[75][76][77][78][79][80][81][82][83][84]. However, the locally applied supraphysiological BMP-2 doses during surgery is reported to be connected with hematoma formation in soft tissue, increased inflammatory response, bone cysts and infection [85] which also increase the importance of clinical follow-up studies.…”

“…Since BMP is reported with side effects, Maza et al [51] observed the results of small sponge rhBMP-2 application either within an allograft or a PEEK cage in 47 patients between 33-74 years of age spectrum within 2010 January and 2016 November and reported no incidence of expected Mid-diaphysis full defect model in old vs young rats Increased expression of critical genes were observed to decrease to their baseline levels after 4 weeks in young rats while many genes including osteoblastic and osteoclastic genes, remained upregulated in old rats up to 6 weeks 1 µg BMP-2 exhibited prolonged inflammation compared to 10 µg groups which might be related with the poor healing of these groups. complications such as dyspnea, edema, ectopic bone formation, or life threatening respiratory events such as prolonged intubation or complications referred to steroid usage as delayed healing or diabetes.…”

Editorial. Anterior cervical fusion and rhBMP-2: a prospective study is needed to assess optimal dosing and delivery

“…However, more recent literature has demonstrated some evidence of safety in usage of lower rhBMP-2 doses and especially when these were delivered in contained devices. 1,11 Tumialán et al reviewed 200 patients who underwent a single-or multilevel ACDF with PEEK spacers filled with a collagen sponge impregnated with low-dose rhBMP-2. 1 In their report, the authors concluded that the incidence of symptomatic dysphagia may be reduced with lower doses of rhBMP-2 that are placed only within the PEEK spacer.…”