The Rise and Fall of Bone Morphogenetic Protein 2 Throughout the United States.

STUDY DESIGN: Retrospective Database Study. OBJECTIVE: Investigate utilization of bone morphogenetic protein (BMP-2) between 2004 and 2014. SUMMARY OF BACKGROUND DATA: The utilization, particularly off-label utilization, of BMP-2 has been controversial and debated in the literature. Given the concerns regarding cancer and potential complications, the risk benefit profile of BMP must be weighed with each surgical case. The debate regarding the costs and potential side effects of BMP-2 compared with autologous iliac crest bone harvest has continued. METHODS: The National Inpatient Sample (NIS) database was queried for the use of BMP-2 (ICD-9-CM 84.52) between 2004 and 2014 across 44 states. The NIS database represents a 20% sample of discharges, weighted to provide national estimates. BMP-2 utilization rates in spine surgery fusion procedures were calculated as a fraction of the total number of thoracic, lumbar, and sacral spinal fusion surgeries performed each year. RESULTS: Between 2004 and 2014, BMP-2 was utilized in 927,275 spinal fusion surgeries. In 2004, BMP-2 was utilized in 28.3% of all cases (N=48,613). The relative use of BMP-2 in spine fusion surgeries peaked in 2008 at 47.0% (N=112,180). Since then, it has continued to steadily decline with an endpoint of 23.6% of cases in 2014 (N=60,863). CONCLUSIONS: Throughout the United States, the utilization of BMP-2 in thoracolumbar fusion surgeries increased from 28.3% to 47.0% between 2004 and 2008. However, from 2008 to 2014, the utilization of BMP-2 in thoracolumbar spine fusion surgeries decreased significantly from 47.0% to 23.4%. While this study provides information on the utilization of BMP-2 for the entire United States over an 11-year period, further research is needed to the determine the factors affecting these trends.

Pelvic fixation for adult scoliosis.

INTRODUCTION: Obtaining a fusion, especially to the sacrum for adult deformity correction remains a challenge. Prior to modern fixation techniques, the reported fusion rates for adult scoliotic deformities were low. However sacropelvic fixation techniques for adult deformity continue to evolve. As a result, modern day pelvic fixation techniques have improved fusion rates at the base of long constructs. The purpose of this article is to discuss the history, indications, and modern fixation techniques for pelvic fixation in the surgical management of adult scoliosis patients. METHODS: We searched PUBMED using the search terms pelvic fixation, deformity, lumbopelvic, sacropelvic, and iliac fixation. Linkage or association studies published in English and available full-text were analyzed specifically regarding techniques and innovations in pelvic fixation. RESULTS: Sacropelvic fixation should be considered in any patient with a long construct ending in the sacrum, those patients with associated risk factors for loss of distal fixation or high risk for pseudarthrosis at L5-S1, and those undergoing three column osteotomies or vertebral body resections in the low lumbar spine. Current pelvic fixation techniques with iliac screws, multiple screw/rod constructs, and S2-alar-iliac screws are all viable techniques for achieving pelvic fixation. CONCLUSIONS: There is growing evidence that pelvic fixation may become the standard for obtaining long fusions in adult scoliosis. Although technically challenging, in selected cases the use of four pelvic screws and/or four rods across the lumbosacral pelvis can help address pseudarthroses, implant breakage, and screw pullout secondary to osteoporosis. Ultimately, indications and techniques should be individualized to the patient and based on surgeon preference and experience.