Skip to main content

Bone union rate with recombinant human bone morphogenic protein-2 versus autologous iliac bone in PEEK cages for anterior lumbar interbody fusion



Autologous iliac crest bone graft (ICBG) is the gold standard material for spinal fusion. Bone graft substitutes, such as recombinant human bone morphogenic protein 2 (rhBMP-2) have been developed to promote spinal fusion and address morbidity issues related to ICBG harvesting. The objective of this study was to compare bone fusion rates after anterior lumbar interbody fusion (ALIF) between ICBG and rhBMP-2 by examining thin-cut computed tomography (CT) images at the one year follow-up.


Fifty one patients (62 levels) who underwent single- or two-level ALIF via the video-assisted minimally invasive anterior approach in our institution were assessed. Radiolucent cages were inserted in all cases. Each cage has a middle beam delimiting two chambers. Grafting was performed as follows: one chamber was filled with autologous ICBG, and the other chamber was filled with 6 mg of rhBMP-2. Thin-cut CT-scan multiplanar reconstruction analyses were performed to assess the rate and quality of bone fusion at one year of follow-up.


Fusion was observed in 55 levels (88.7 %), with significant differences in fusion rates with rhBMP-2 and ICBG (71 % vs. 88.7 %) (P=0.001). Osteogenesis in the rhBMP-2 chamber had a centripetal pattern in all cases, leaving a central void in 97.7 % of cases representing 38.3 % of the surface of its chamber (range 0–80.3 %). In ICBG chambers, graft resorption was present in 44.4 %, representing 9.8 % of the chamber surface (range 0–52.2 %).


RhBMP-2 was inferior to ICBG in terms of rate and quality of bone fusion in one- or two-level ALIF.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. Banwart JC, Asher MA, Hassanein RS (1995) Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine (Phila Pa 1976) 20(9):1055–1060

    Article  CAS  Google Scholar 

  2. Silber JS, Anderson DG, Daffner SD, Brislin BT, Leland JM, Hilibrand AS, Vaccaro AR, Albert TJ (2003) Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976) 28(2):134–139. doi:10.1097/01.BRS.0000041587.55176.67

    Article  Google Scholar 

  3. Summers BN, Eisenstein SM (1989) Donor site pain from the ilium. A complication of lumbar spine fusion J Bone Joint Surg Br 71(4):677–680

    CAS  Google Scholar 

  4. Sasso RC, LeHuec JC, Shaffrey C, Spine Interbody Research G (2005) Iliac crest bone graft donor site pain after anterior lumbar interbody fusion: a prospective patient satisfaction outcome assessment. J Spinal Disord Tech 18 Suppl:S77-81. doi:00024720-200502001-00011 [pii]

  5. Mroz TE, Wang JC, Hashimoto R, Norvell DC (2010) Complications related to osteobiologics use in spine surgery: a systematic review. Spine (Phila Pa 1976) 35(9 Supp):S86–104. doi:10.1097/BRS.0b013e3181d81ef2

    Article  Google Scholar 

  6. Carragee EJ, Hurwitz EL, Weiner BK (2011) A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. Spine J 11(6):471–491. doi:10.1016/j.spinee.2011.04.023

    Article  PubMed  Google Scholar 

  7. Simmonds MC, Brown JV, Heirs MK, Higgins JP, Mannion RJ, Rodgers MA, Stewart LA (2013) Safety and effectiveness of recombinant human bone morphogenetic protein-2 for spinal fusion: a meta-analysis of individual-participant data. Ann Intern Med 158(12):877–889. doi:10.7326/0003-4819-158-12-201306180-00005

    Article  PubMed  Google Scholar 

  8. Fu R, Selph S, McDonagh M, Peterson K, Tiwari A, Chou R, Helfand M (2013) Effectiveness and harms of recombinant human bone morphogenetic protein-2 in spine fusion: a systematic review and meta-analysis. Ann Intern Med 158(12):890–902. doi:10.7326/0003-4819-158-12-201306180-00006

    Article  PubMed  Google Scholar 

  9. Ong KL, Villarraga ML, Lau E, Carreon LY, Kurtz SM, Glassman SD (2010) Off-label use of bone morphogenetic proteins in the United States using administrative data. Spine (Phila Pa 1976) 35(19):1794–1800. doi:10.1097/BRS.0b013e3181ecf6e4

    Article  Google Scholar 

  10. Lad SP, Nathan JK, Boakye M (2011) Trends in the use of bone morphogenetic protein as a substitute to autologous iliac crest bone grafting for spinal fusion procedures in the United States. Spine (Phila Pa 1976) 36(4):E274–281. doi:10.1097/BRS.0b013e3182055a6b

    Article  Google Scholar 

  11. Epstein NE (2011) Pros, cons, and costs of INFUSE in spinal surgery. Surg Neurol Int 2:10. doi:10.4103/2152-7806.76147

    Article  PubMed Central  PubMed  Google Scholar 

  12. Brantigan JW, Steffee AD, Lewis ML, Quinn LM, Persenaire JM (2000) Lumbar interbody fusion using the Brantigan I/F cage for posterior lumbar interbody fusion and the variable pedicle screw placement system: two-year results from a Food and Drug Administration investigational device exemption clinical trial. Spine (Phila Pa 1976) 25(11):1437–1446

    Article  CAS  Google Scholar 

  13. Thalgott JS, Fogarty ME, Giuffre JM, Christenson SD, Epstein AK, Aprill C (2009) A prospective, randomized, blinded, single-site study to evaluate the clinical and radiographic differences between frozen and freeze-dried allograft when used as part of a circumferential anterior lumbar interbody fusion procedure. Spine (Phila Pa 1976) 34(12):1251–1256. doi:10.1097/BRS.0b013e3181a005d7

    Article  Google Scholar 

  14. Boden SD, Zdeblick TA, Sandhu HS, Heim SE (2000) The use of rhBMP-2 in interbody fusion cages. Definitive evidence of osteoinduction in humans: a preliminary report. Spine (Phila Pa 1976) 25(3):376–381

    Article  CAS  Google Scholar 

  15. Burkus JK, Transfeldt EE, Kitchel SH, Watkins RG, Balderston RA (2002) Clinical and radiographic outcomes of anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2. Spine (Phila Pa 1976) 27(21):2396–2408. doi:10.1097/01.BRS.0000030193.26290.DD

    Article  Google Scholar 

  16. Burkus JK, Gornet MF, Dickman CA, Zdeblick TA (2002) Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech 15(5):337–349

    Article  PubMed  Google Scholar 

  17. Vaidya R, Weir R, Sethi A, Meisterling S, Hakeos W, Wybo CD (2007) Interbody fusion with allograft and rhBMP-2 leads to consistent fusion but early subsidence. J Bone Joint Surg Br 89(3):342–345. doi:10.1302/0301-620X.89B3.18270

    Article  CAS  PubMed  Google Scholar 

  18. Pradhan BB, Bae HW, Dawson EG, Patel VV, Delamarter RB (2006) Graft resorption with the use of bone morphogenetic protein: lessons from anterior lumbar interbody fusion using femoral ring allografts and recombinant human bone morphogenetic protein-2. Spine (Phila Pa 1976) 31(10):E277–284. doi:10.1097/01.brs.0000216442.12092.01

    Article  Google Scholar 

  19. Itoh K, Udagawa N, Katagiri T, Iemura S, Ueno N, Yasuda H, Higashio K, Quinn JM, Gillespie MT, Martin TJ, Suda T, Takahashi N (2001) Bone morphogenetic protein 2 stimulates osteoclast differentiation and survival supported by receptor activator of nuclear factor-kappaB ligand. Endocrinology 142(8):3656–3662

    CAS  PubMed  Google Scholar 

  20. Poynton AR, Lane JM (2002) Safety profile for the clinical use of bone morphogenetic proteins in the spine. Spine (Phila Pa 1976) 27(16 Suppl 1):S40–48

    Article  Google Scholar 

  21. Burkus JK, Sandhu HS, Gornet MF (2006) Influence of rhBMP-2 on the healing patterns associated with allograft interbody constructs in comparison with autograft. Spine (Phila Pa 1976) 31(7):775–781. doi:10.1097/01.brs.0000206357.88287.5a

    Article  Google Scholar 

  22. McKay B, Sandhu HS (2002) Use of recombinant human bone morphogenetic protein-2 in spinal fusion applications. Spine (Phila Pa 1976) 27(16 Suppl 1):S66–85

    Article  Google Scholar 

  23. Vaidya R, Sethi A, Bartol S, Jacobson M, Coe C, Craig JG (2008) Complications in the use of rhBMP-2 in PEEK cages for interbody spinal fusions. J Spinal Disord Tech 21(8):557–562. doi:10.1097/BSD.0b013e31815ea897

    Article  PubMed  Google Scholar 

Download references

Conflict of interest and funding source

None of the authors has, currently or in the past, financial activity for the work under consideration.

CH F-L is receiving travel expenses from LDR Medical, Medtronic and DePuy Synthes.

AG declares no conflict of interest.

JA is currently receiving honoraria, royalties, payment for lectures or travel support from Medtronic, DePuy Synthes, LDR Medical.

PH declares no conflict of interest.

AP has received travel support from LDR Medical.

CB has received travel support from LDR Medical, DePuy Synthes and Medtronic

Author information

Authors and Affiliations


Corresponding author

Correspondence to Charles-Henri Flouzat-Lachaniette.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Flouzat-Lachaniette, CH., Ghazanfari, A., Bouthors, C. et al. Bone union rate with recombinant human bone morphogenic protein-2 versus autologous iliac bone in PEEK cages for anterior lumbar interbody fusion. International Orthopaedics (SICOT) 38, 2001–2007 (2014).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: