Transforaminal Lumbar Interbody Fusion With rhBMP-2 in Spinal Deformity, Spondylolisthesis, and Degenerative Disease–Part 1: Large Series Diagnosis Related Outcomes and Complications With 2- to 9-Year Follow-up

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Study Design.

Retrospective review of prospectively collected data.


To evaluate long-term clinical outcomes and complications of the transforaminal lumbar interbody fusion (TLIF) procedure from a large consecutive series, without industry funding. Clinical outcomes and complications are analyzed by diagnosis and primary versus revision surgery to assess whether TLIF with bone morphogenic protein (BMP) is appropriate for common use in deformity, spondylolisthesis, and degenerative disease.

Summary of Background Data.

A common method for achieving spinal arthrodesis includes TLIF with a cage and off-label interbody BMP-2, supported by posterior arthrodesis and a pedicle screw construct. There are no large studies analyzing outcomes and complications after TLIF in different diagnoses, for primary and revision surgery, leading some to question the widespread use of TLIF.


A total of 509 consecutive adults underwent open posterior instrumented fusion, augmented with TLIF at 872 discs using a cage and rhBMP-2, with minimum 2-year follow-up. Cohort diagnoses included 179 degenerative, 207 spondylolisthesis, and 123 deformity patients. Patient age averaged 61 years, 207 had undergone prior decompression or fusion surgery. All patients underwent posterior instrumented fusion and pedicle screw instrumentation at average 3.6 levels (range, 1–16); all patients had TLIF 1.7 levels (range, 1–4 levels) with BMP and autograft, stabilized with an interbody cage.


At average 59 months follow-up, 12 patients developed pseudoarthrosis, 8 at TLIF levels (8/872 discs, 0.92%) most commonly at L5–S1 (6/8). Significant clinical improvement was noted in patients with deformity, spondylolisthesis, and degenerative disease undergoing primary and revision surgery. Overall, visual analogue scale preoperative score was 6.6, at 1 year 3.8, at 2 years 3.5 (P < 0.001) and the preoperative ODI was 50.9, at 1 year 36.1, and at 2 years 35.0 (P < 0 0.001). Pain medication requirements also declined.


The efficacy of TLIF with BMP is supported in this large series with long-term follow-up, independent of industry. Reliable fusion and improved outcomes can be expected in adults undergoing TLIF for deformity, spondylolisthesis, and degenerative disease. Most complications occurred in patients with deformity.


Level of Evidence: 3

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