Pseudarthrosis in Multilevel Anterior Cervical Fusion With rhBMP-2 and Allograft Analysis of One Hundred Twenty-Seven Cases With Minimum Two-Year Follow-up

Study Design. Consecutive case series. Objective. The purpose of this study was to analyze the pseudarthrosis rate in a large series of recombinant human bone morphogenetic protein-2 (rhBMP-2) augmented multilevel (>= 3 levels) anterior cervical fusions. Summary of Background Data. The reported pseudarthrosis rate following anterior cervical fusion varies from 0% to 20% for single-level and up to 50% for multilevel fusions. It has been postulated that the use of rhBMP-2 may decrease the pseudarthrosis rate. Methods. A consecutive series of patients with cervical spondylosis and/or disc herniation who underwent anterior cervical fusion with rhBMP-2, structural allograft, and plate fixation with a minimum 2-year follow-up were analyzed by experienced, independent spine surgeons. Results. A total of 127 patients (54 men and 73 women with mean age of 54 +/- 10 years [range, 32-79]) were examined. Seventy-five (59.1%) patients underwent a 3-level fusion, 34 (26.7%) underwent a 4-level fusion, and 18 (14.2%) underwent a 5-level fusion. Of the 451 fusion segments, 14 segments (3.1%) in 13 of 127 patients (10.2%) had evidence of pseudarthrosis at 6 months following surgery. Of the 13 patients with a pseudarthrosis, 3 had a 3-level fusion (3/75 patients [4.0%]), 6 had a 4-level fusion (6/34 patients [17.4%]), and 4 had a 5-level fusion (4/18 patients [22.2%]). Five patients were asymptomatic and were not revised, but the remaining 8 patients required additional surgery. In 12 of 13 patients with a pseudarthrosis, the nonunion occurred at the lowest fusion level and at the cervicothoracic junction. The only statistically significant risk factor for developing a pseudarthrosis was the number of fusion levels. Conclusion. In a large series of rhBMP-2 augmented multilevel fusions, the pseudarthrosis rate was 10.2% at 6 months following surgery. Since the risk of pseudarthrosis increases with the number of fusion levels, a long fusion lever arm may biomechanically overwhelm the biologic advantage of rhBMP-2. While rhBMP-2 is known to enhance fusion rates, it does not guarantee fusion in all situations.