Using the United States Nationwide Inpatient Sample, we identified national trends in revision spinal fusion along with a comprehensive comparison of comorbidities, inpatient complications and surgical factors of revision spinal fusion compared to primary spinal fusion. In 2009, there were 410 158 primary spinal fusion discharges and 22 128 revision spinal fusion discharges. Between 2002 and 2009, primary fusion increased at a higher rate compared with revision fusion (56.4% vs 51.0%; p < 0.001). In 2009, the mean length of stay and hospital charges were higher for revision fusion discharges than for primary fusion discharges (4.2 days vs 3.8 days, p < 0.001; USD $91 909 vs. $87 161, p < 0.001). In 2009, recombinant human bone morphogenetic protein (BMP) was used more in revision fusion than in primary fusion (39.6% vs 27.6%, p < 0.001), whereas interbody devices were used less in revision fusion (41.8% vs 56.6%, p < 0.001). . In the multivariable logistic regression model for all spinal fusions, depression (odds ratio (OR) 1.53, p < 0.001), psychotic disorders (OR 1.49, p < 0.001), deficiency anaemias (OR 1.35, p < 0.001) and smoking (OR 1.10, p = 0.006) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges, adjusting for other variables. In terms of complications, after adjusting for all significant comorbidities, this study found that dural tears (OR 1.41; p < 0.001) and surgical site infections (OR 3.40; p < 0.001) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges (p < 0.001). A p-value < 0.01 was considered significant in all final analyses. Cite this article: Bone Joint J 2014;96-B:807–16

Introduction:. Several reports showed superior fusion rates, as high as 100%, using rhBMP-2 with ALIF cages. This has led to the widespread off-label use of rhBMP-2 in several other lumbar fusion procedures. There is paucity of reports analysing the clinic-radiological outcome of using rhBMP-2 to promote bone union in cases of symptomatic pseudoarthosis following lumbar spine fusion. Methods:. 52 consecutive patients who underwent revision spinal surgery for symptomatic pseudoarthosis utilizing rhBMP-2 between 2008 and 2013 were included in the study. Demographic, and surgical data were collected from medical records. Functional outcomes were recorded using the ODI. All patients had preoperative fine-cut CT scan to confirm pseudoarthosis. Postoperative CT-scan at 6 months was routinely done to confirm fusion. Results:. Average age at time of revision surgery was 54years (range 28–73). Average follow up was 3 years 5 months (range 2–5 years). Overall fusion rate of 92.3% (48/52) was achieved. The average ODI has improved from 56% preoperatively to 49% postoperatively. We had 1 infection case, and 5 complications related to metalwork. One case with neuronal complications was recorded. No rhBMP-2 related complications. There was no record of heterotopic bone formation in the spinal canal or the neuroforamen. Conclusion:. Recombinant BMP-2 is a safe and effective adjunct to revision lumbar spinal fusion surgery to alleviate back pain symptoms from pseudoarthosis. The limitations of the study include: retrospective review, lack of matched cohort utilising iliac crest bone graft, and relatively short follow-up

Objectives. We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis. Methods. The MEDLINE, EMBASE and Cochrane Library databases were searched using defined search terms. The primary outcome measure was spinal fusion, assessed as success or failure in accordance with radiograph, MRI or CT scan review at 24-month follow-up. The secondary outcome measure was time to fusion. Results. A total of six studies (three prospective and three retrospective) reporting on the use of BMP2 met the inclusion criteria (203 patients). Of these, four provided a comparison of BMP2 and bone graft whereas the other two solely investigated the use of BMP2. The primary outcome was seen in 92.3% (108/117) of patients following surgery with BMP2. Although none of the studies showed superiority of BMP2 to bone graft for fusion, its use was associated with a statistically quicker time to achieving fusion. BMP2 did not appear to increase the risk of complication. Conclusion. The use of BMP2 is both safe and effective within the revision setting, ideally in cases where bone graft is unavailable or undesirable. Further research is required to define its optimum role. Cite this article: Mr P. Bodalia. Effectiveness and safety of recombinant human bone morphogenetic protein-2 for adults with lumbar spine pseudarthrosis following spinal fusion surgery: A systematic review. Bone Joint Res 2016;5:145–152. DOI: 10.1302/2046-3758.54.2000418