Comparison of transforaminal lumbar interbody fusion outcomes in patients receiving rhBMP-2 versus autograft

Spine J. 2018 Mar;18(3):439-446. doi: 10.1016/j.spinee.2017.08.230. Epub 2017 Aug 18.


Background context: Recombinant human bone morphogenetic protein 2 (rhBMP-2) plays a pivotal role in complex spine surgery. Despite its limited approval, the off-label use of rhBMP-2 is prevalent, particularly in transforaminal lumbar interbody fusions (TLIFs).

Purpose: To determine the effectiveness and safety of rhBMP-2 use in TLIF procedures versus autograft.

Study design: Retrospective cohort study.

Patient sample: Patients older than 18 years undergoing spine surgery for lumbar degenerative spine disease at a single academic institution.

Outcome measures: Clinical outcome was determined according to patient records. Radiographic outcome was determined according to plain X-rays and computed tomography (CT).

Methods: A retrospective study from 1997 to 2014 was conducted on 191 adults undergoing anterior-posterior instrumented spinal fusion with TLIF at a single academic institution. Patient data were gathered from operative notes, follow-up clinic notes, and imaging studies to determine complications and fusion rates. One hundred eighty-seven patients fit the criteria, which included patients with a minimum of one TLIF, and had a minimum 2-year radiographic and clinical follow-up. Patients were further classified into a BMP group (n=83) or non-BMP group (n=104). Three logistic regression models were run using rhBMP-2 exposure as the independent variable. The respective outcome variables were TLIF-related complications (radiculitis, seroma, osteolysis, and ectopic bone), surgical complications, and all complications.

Results: Bone morphogenetic protein (n=83) and non-BMP (n=104) groups had similar baseline demographics (sex, diabetes, pre-existing cancer). On average, the BMP and non-BMP groups were similarly aged (51.9 vs. 47.9 years, p>.05), but the BMP group had a shorter follow-up time (3.03 vs. 4.06 years; p<.001) and fewer smokers (8 vs. 21 patients; p<.048). The fusion rate for the BMP and non-BMP groups was 92.7% and 92.3%, respectively. The pseudoarthrosis rate was 7.5% (14 of 187 patients). Radiculitis was observed in seven patients in the BMP group (8.4%) and two patients in the non-BMP group (1.9%). Seroma was observed in two patients in the BMP group (2.4%) and none in the non-BMP group. No deep infections were observed in the BMP group, and in one patient in the non-BMP group (0.96%). Although patients exposed to BMP were at a significantlygreater risk of developing radiculitis and seroma (odds ratio [OR]=4.53, confidence interval [CI]=1.42-14.5), BMP exposure was not a significant predictor of surgical complications (OR=0.32, CI=0.10-1.00) or overall complications (OR=1.11, CI=0.53-2.34). The outcome of TLIF-related complications was too rare and the confidence interval too wide for practical significance of the first model.

Conclusion: Evidence supports the hypothesis that off-label use of rhBMP-2 in TLIF procedures is relatively effective for achieving bone fusion at rates similar to patients receiving autograft. Patients exhibited similar complication rates between the two groups, with the BMP group exhibiting slightly higher rates of radiculitis and seroma.

Keywords: BMP; Bone morphogenetic protein; Spine surgery; TLIF; Transforaminal lumbar interbody fusion; rhBMP-2.

Publication types

  • Comparative Study
  • Evaluation Study

MeSH terms

  • Adult
  • Aged
  • Bone Morphogenetic Protein 2 / administration & dosage
  • Bone Morphogenetic Protein 2 / adverse effects
  • Bone Morphogenetic Protein 2 / therapeutic use*
  • Female
  • Humans
  • Lumbosacral Region / surgery*
  • Male
  • Middle Aged
  • Postoperative Complications / diagnostic imaging
  • Postoperative Complications / epidemiology*
  • Radiography
  • Recombinant Proteins / administration & dosage
  • Recombinant Proteins / adverse effects
  • Recombinant Proteins / therapeutic use
  • Spinal Fusion / adverse effects
  • Spinal Fusion / methods*
  • Transforming Growth Factor beta / administration & dosage
  • Transforming Growth Factor beta / adverse effects
  • Transforming Growth Factor beta / therapeutic use*
  • Transplantation, Autologous / adverse effects
  • Transplantation, Autologous / methods


  • Bone Morphogenetic Protein 2
  • Recombinant Proteins
  • Transforming Growth Factor beta
  • recombinant human bone morphogenetic protein-2