SURGICAL TECHNIQUE
BMP-2-induced Neuroforaminal Bone Growth in the
Setting of a Minimally Invasive Transforaminal Lumbar
Interbody Fusion
Junyoung Ahn, BS, Ehsan Tabaraee, MD, and Kern Singh, MD
Abstract: Minimally invasive transforaminal lumbar interbody fu-
sion (MIS-TLIF) has become a popular alternative to traditional
methods of lumbar decompression and fusion. When compared
with the open technique, the minimally invasive approach can result
in decreased pain and blood loss as well as a shorter length of
hospitalization. However, the narrower working channel through
the tubular retractor increases the difficulty of decortication and
bone grafting. Therefore, recombinant human bone morphogenetic
proteins (rhBMP-2) is often utilized (although this is off-label) to
create a more favorable interbody fusion environment. Recently,
the use of rhBMP-2 has been associated with excessive bone growth
in an MIS-TLIF. If this bone growth compresses the neighboring
neural structures, patients may present with either new or recurrent
radicular pain. Computed tomographic (CT) imaging can demon-
strate heterotopic bone growth extending from the disk space into
either the ipsilateral neuroforamen or lateral recess, which may
result in the compression of the exiting or traversing root, re-
spectively. The purpose of this article and the accompanying video
is to demonstrate a technique for defining and resecting rhBMP-2-
induced heterotopic bone growth following a previous MIS-TLIF.
Key Words: minimally invasive, transforaminal, lumbar fusion,
BMP, bone growth
(J Spinal Disord Tech 2015;28:186–188)
INDICATIONS
The indication for resection of rhBMP-2-induced
neuroforaminal bone growth after an MIS-TLIF includes
intractable radicular symptoms with correlating radio-
graphic (CT) evidence of lateral recess, foraminal, or
central stenosis.
Received for publication March 23, 2015; accepted April 13, 2015.
From the Department of Orthopaedic Surgery, Rush University Medical
Center, Chicago, IL.
The authors declare no conflict of interest.
Reprints: Kern Singh, MD, Department of Orthopaedic Surgery, Rush
University Medical Center, 1611W. Harrison St, Suite #300,
Chicago, IL 60612 (e-mail: kern.singh@rushortho.com).
Supplemental Digital Content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
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OPERATING ROOM SET-UP
Instruments/Materials Required
 Curved microcurette
 Expandable versus fixed tubular retractors (22–26 mm)
 High-speed burr
 Intraoperative fluoroscopy (C-arm)
 Jackson table
 Kerrison rongeurs
 Surgical loupes or microscope
Positioning
Endotracheal intubation is performed with the pa-
tient in supine position. Following successful intubation,
the patient is positioned prone on a Jackson table. The
shoulders should be abducted and the elbows flexed to 90
degrees. The pressure points are padded. The intra-
operative fluoroscopy C-arm should be positioned across
from the surgeon and side of pathology (Fig. 1).
SURGICAL TECHNIQUE
Step 1: Localization
 The target level is identified with fluoroscopic imaging.
Dependent on the extent of the previous decompres-
sion and fusion, the respective spinous processes and
endplates may not be well visualized. Therefore, proper
rotation should be determined by positioning the left
and right pedicles equidistant from the midline on
anteroposterior view.
Step 2: Incision
 The previous paramedian incision can be used. This
incision should be lateral to the pedicle on the side of
FIGURE 1. Intraoperative photograph demonstrating prone
positioning of patient on a Jackson table with appropriate
padding.
J Spinal Disord Tech  Volume 28, Number 5, June 2015
J Spinal Disord Tech  Volume 28, Number 5, June 2015
FIGURE 2. Tubular retractor image demonstrating the bony
overgrowth (outlined by dashed line). Note the location of the
L4 pedicle (7 o’clock position) and the L5 pedicle (5 o’clock
position).
the pathology and at least 2–3 cm in length. The
scarred subcutaneous tissue and fascia should be
incised with electrocautery to achieve hemostasis.
Step 3: Exposure and Visualization
 Previous decompressive surgeries and variable patterns
of heterotopic bone growth in the setting of a revision
MIS-TLIF may pose significant risks and challenges.
 Previous instrumentation should be palpated as the
pedicle tulips and connecting rods are superficial to any
previous decompression. Sequential dilation over this
hardware may allow for placement of a self-retaining
tubular retractor.
FIGURE 3. Tubular retractor image demonstrating the high-
speed burr placement on the L4 pedicle (cross) and the re-
sidual L4 pars interarticularis. Note the location of the L5
pedicle indicated by the X sign.
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BMP-2 Induced Neuroforaminal Bone Growth
 The soft tissue over the connecting rod and set screws
are cleared.
 The set screws are then loosened. The connecting rods
and pedicle screws are also removed.
Step 4: Orientation
 The bony pedicle tracts above and below the operative
level should be referenced for orientation in the setting
of variable anatomy and the lack of protective
structures such as the ligamentum flavum (Fig. 2).
Step 5: Skeletonization of the Superior Pedicle,
Pars Interarticularis, and Inferior Pedicle
 A high-speed burr is utilized to create troughs along the
inferior aspect of the superior pedicle (L4 as demonstrated
in the Supplementary Video, http://links.lww.com/JSDT/
A5; Fig. 3) and the superior aspect of the inferior pedicle
(L5 in the Supplementary Video, http://links.lww.com/
JSDT/A5).
 By deepening the trough inferior to the superior
pedicle, one can decompress the bone overlying the
exiting nerve root.
J This step must be approached with caution as it
exposes the dorsal surface of the exiting nerve
without a protective overlying ligamentum flavum.
Step 6: Establishment of the Floor of the Spinal
Canal
 Under lateral fluoroscopic guidance, a high-speed burr
is used to deepen the dorsal aspect of the bone growth
until the floor of the spinal canal (posterior vertebral
body) is established.
J This step can be best accomplished at the site
immediately superior to the trough located
proximal to the inferior pedicle.
Step 7: Defining the Resection of the Bony
Overgrowth
 A plane between the dorsomedial margins of the bone
growth and the dura can be defined as this bony
overgrowth often occurs in proximity to the trans-
foraminal discectomy.
 Once the margins of the bone growth are identified, the
bone can be thinned and resected with the use of a
high-speed burr and rongeurs (Kerrison or pituitary).
Step 8: Decompression of the Traversing Nerve
Root
 Identification and resection of the ventral bony over-
growth medially is essential to the complete decom-
pression of the traversing nerve root.
J This bone growth can be the source of failed
revision decompression and radiculopathy after
an MIS-TLIF.
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Ahn et al
FIGURE 4. Tubular retractor image demonstrating the com-
pletion of neurolysis and ventral decompression resulting in the
mobilization of the L4 exiting nerve root (arrow). The decom-
pressed transforaminal space is outlined (dashed line).
Step 9: Full Decompression of the Exiting Nerve
Root
 The decompression of this ventral bony overgrowth
extends in the lateral direction to fully decompress the
undersurface of the exiting nerve root following
visualization.
Step 10: Neurolysis of the Exiting Nerve Root
 Angled microcurettes are utilized to remove residual
bone growth fragments and adhesions are from the
exiting nerve root.
J During this portion of the procedure, micro-
curette should be directed away from the dural
sac to prevent an incidental durotomy.
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J Spinal Disord Tech  Volume 28, Number 5, June 2015
Step 11: Mobilization of the Nerve Roots
 Complete decompression is best assessed when the
nerve roots can be mobilized without residual tethering
or kinking of the dural coverings (Fig. 4).
POSTOPERATIVE PROTOCOL
Complications
 Violation of the dural sac (durotomy) may present as
headaches (posture dependent) accompanied by nausea
and/or vomiting.
J Most cases of durotomy may be adequately
treated with a collagen sponge and fibrin glue.
’ If the patient is asymptomatic, early post-
operative mobilization is recommended.
’ If patient is symptomatic (headaches, photo-
phobia), 23 hours of bed rest is recommended
followed by mobilization.
PEARLS AND PITFALLS
 Following removal of previous instrumentation, the
borders of the pedicles should be referenced to orient
oneself to the mediolateral and superoinferior margins
of the revision decompression.
 Fluoroscopic guidance in the lateral view is important
in identifying the floor of the spinal canal to avoid
neural injury.
 During the neurolysis of the exiting nerve root,
directing the microcurette distally helps avoid dural
injury.
 Decompression of the ventral aspect of the exiting
nerve root is crucial to free the root from any residual
bone growth extending from the floor of the canal to
the nerve root.
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