The Use of rhBMP-2 in Cervical Fusion: A Systematic Review

Background Context: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used off-label in anterior and posterior cervical spine fusion (ACF and PCF) as an alternative to autologous or allogenic grafts, enhancing fusion potential. However, concerns regarding complications such as neck swelling and dysphagia have been raised. Purpose Therefore, this study aims to assess complication profiles of rhBMP-2 in cervical fusions, comparing anterior and posterior approaches and examining the impact of dosage, patient-specific risk factors, and preventive strategies. Study Design: Systematic review Methods We conducted a systematic literature search in June 2025 in accordance with PRISMA guidelines. PubMed and Embase were queried with keywords involving rhBMP-2 and cervical fusion. Eligible studies included clinical studies reporting outcomes of anterior or posterior cervical fusion with rhBMP-2. Data on fusion rates, complications, and their relevant factors were extracted and analyzed. Results Thirty-four studies, 26 ACF and 8 PCF, met our inclusion criteria. Fusion rates with rhBMP-2 were consistently high, ranging from 81.8–100% in ACF and 82.4–100% in PCF. Comparative data generally demonstrated superior fusion rates with rhBMP-2 compared to controls, with some evidence of accelerated fusion times. However, use of rhBMP-2 was also associated with more severe cases of cervical swelling and dysphagia in ACF. rhBMP-2 groups in PCF generally did not demonstrate significantly higher incidence of complications compared to control groups. Conclusions Our systematic review suggests that rhBMP-2 successfully augments cervical fusion; however, it also increases the risk of certain complications, particularly in anterior cervical surgery. Dosing, specific levels fused, number of levels fused, and patient-specific factors all significantly influence the risk of complications. Importantly, prophylactic measures, such as containment, drain placement, and local steroid administration, show potential in reducing the severity of adverse outcomes. Ultimately, careful patient selection and complication prevention strategies may enable rhBMP-2 to provide its intended benefits while minimizing risks.