Guppy Kern H, Harris Jessica, Chen Jason, Paxton Elizabeth W, Alvarez Julie, Bernbeck Johannes
Department of Neurosurgery, Kaiser Permanente Medical Group, Sacramento;
Surgical Outcomes & Analysis Unit of Clinical Analysis, Kaiser Permanente, San Diego; and.
J Neurosurg Spine. 2016 Apr;24(4):556-64. doi: 10.3171/2015.7.SPINE15353. Epub 2016 Jan 1.
Bone morphogenetic protein (BMP) was first approved in 2002 for use in single-level anterior lumbar fusions as an alternative to iliac crest grafts. Subsequent studies have concluded that BMP provides superior fusions rates and therefore reduces reoperations for nonunions. The purpose of this study was to determine the reoperation rates for symptomatic nonunions in posterior cervical (subaxial) spinal fusions with and without the use of BMP and to determine if the nonunion rates are statistically significantly different between the two groups.
Between January 2009 and September 2013, the authors identified 1158 posterior cervical spinal fusion cases in the subaxial spine (C2-7) from a large spine registry (Kaiser Permanente). Patient characteristics, diagnoses, operative times, lengths of stay, and reoperations were extracted from the registry. Reoperations for symptomatic nonunions were adjudicated via chart review. Logistic regression was conducted to produce estimates of odds ratios (OR) and 95% confidence intervals (CIs). Kaplan-Meier curves for the non-BMP and BMP groups were generated and compared using the log-rank test.
In this cohort there were 1158 patients (19.3% with BMP) with a median follow up of 1.7 years (interquartile range [IQR] 0.7-2.9 years) and median duration to operative nonunion of 0.63 years (IQR 0.44-1.57 years). Kaplan-Meier curves showed no significant difference in reoperation rates for nonunions using the log-rank test (p = 0.179). In a subset of patients with more than 1 year of follow-up, 788 patients were identified (22.5% with BMP) with a median follow-up duration of 2.5 years (IQR 1.7-3.4 years) and a median time to operative nonunion of 0.73 years (IQR 0.44-1.57 years). There was no statistically significant difference in the symptomatic operative nonunion rates for posterior cervical (subaxial) fusions with BMP compared with non-BMP (1.1% vs. 0.7%; crude OR 1.73, 95% CI 0.32-9.55, p = 0.527) for more than 1 year of follow-up.
This study presents the largest series of patients using BMP in posterior cervical (subaxial) spinal fusions. Reoperation rates for symptomatic nonunions with more than 1 year of follow-up were found to be 1.1% with BMP and 0.7% without BMP. There was no significant difference in the reoperation rates for symptomatic nonunions with or without BMP.
骨形态发生蛋白（BMP）于2002年首次获批用于单节段前路腰椎融合术，作为髂嵴植骨的替代方法。随后的研究得出结论，BMP能提供更高的融合率，因此减少了因骨不连而进行的再次手术。本研究的目的是确定在有或没有使用BMP的下颈椎后路脊柱融合术中，有症状骨不连的再次手术率，并确定两组之间的骨不连率是否存在统计学上的显著差异。
2009年1月至2013年9月期间，作者从一个大型脊柱登记库（凯撒医疗集团）中识别出1158例下颈椎（C2-7）后路脊柱融合病例。从登记库中提取患者特征、诊断、手术时间、住院时间和再次手术情况。通过病历审查对有症状骨不连的再次手术进行判定。进行逻辑回归以得出优势比（OR）和95%置信区间（CI）的估计值。生成非BMP组和BMP组的Kaplan-Meier曲线，并使用对数秩检验进行比较。
在这个队列中，有1158例患者（19.3%使用BMP），中位随访时间为1.7年（四分位间距[IQR]为0.7 - 2.9年），手术至骨不连的中位持续时间为0.63年（IQR为0.44 - 1.57年）。Kaplan-Meier曲线显示，使用对数秩检验，骨不连再次手术率无显著差异（p = 0.179）。在随访超过1年的患者亚组中，识别出788例患者（22.5%使用BMP），中位随访时间为2.5年（IQR为1.7 - 3.4年），手术至骨不连的中位时间为0.73年（IQR为0.44 - 1.57年）。随访超过1年时，使用BMP的下颈椎后路（下颈椎）融合术与未使用BMP的有症状手术骨不连率无统计学显著差异（1.1%对0.7%；粗OR为1.73，95%CI为0.32 - 9.55，p = 0.527）。
本研究呈现了下颈椎后路脊柱融合术中使用BMP的最大规模患者系列。随访超过1年的有症状骨不连再次手术率，使用BMP为1.1%，未使用BMP为0.7%。有或没有使用BMP的有症状骨不连再次手术率无显著差异。
