title: Multiple myeloma exacerbation following utilization of bone morphogenetic protein-2 in lateral lumbar interbody fusion: a case report and review of the literature.
abstract: BACKGROUND
  Recent studies generated antithetic results regarding the safety of bone morphogenetic protein-2 (BMP-2) use in spine surgery, and the effect of this biologic adjunct on myeloma cells remains to be fully elucidated.
  
  
  OBJECTIVE
  The purpose of this study was to present a case of multiple myeloma (MM) exacerbation after BMP-2 implantation in the setting of lateral lumbar interbody fusion (LLIF).
  
  
  METHODS
  Case report and literature review.
  
  
  METHODS
  The medical records, laboratory findings, and radiographic imaging studies of an 86-year-old female patient with exacerbation of previously undiagnosed MM were reviewed.
  
  
  RESULTS
  The patient presented with a 10-year history of debilitating lower back pain and bilateral lower extremity claudication. Radiographic studies depicted lumbar scoliosis and lateral spondylolisthesis. Preoperative serum immunofixation electrophoresis showed a serum immunoglobulin A kappa paraprotein-peak; however, the patient had never been diagnosed with MM or reported any unexplained fever, night sweats, or weight loss indicative of MM. The patient underwent LLIF from L1-L5 supplemented by BMP-2. On postoperative day 1, the patient was evaluated by the hematology department for paraproteinemia. Serum electrophoresis showed decreased albumin, hypogammaglobulinemia, and suspicious broadening of the complement component in the beta region. Postoperative imaging studies (19 weeks) depicted progression of a previously visible intraosseous lesion, and anterior cortical breakthrough (L5), in addition to a soft tissue mass at the T10 level. Histological examination of iliac crest and T10 vertebral biopsies showed fatty marrow infiltration by plasma cells and plasma cell dyscrasia, proving the diagnosis of MM. The patient died 10 months after surgery due to complications related to a methicillin-resistant Staphylococcus aureus infection.
  
  
  CONCLUSIONS
  Based on the present case, perhaps one should consider that in patients with abnormal electrophoresis results, even in the absence of a prior diagnosis of MM as well as in the absence of symptoms indicative of MM, BMPs should be administered only after preoperative exclusion of neoplastic disease.
authors.affiliation: Department of Orthopaedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, 535 E. 70th St, New York, NY 10021, USA. Electronic address: HughesA@HSS.EDU.
authors.forename: Alexander P
authors.initials: AP
authors.lastname: Hughes
authors.affiliation: Department of Orthopaedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, 535 E. 70th St, New York, NY 10021, USA.
authors.forename: Fadi
authors.initials: F
authors.lastname: Taher
authors.affiliation: Department of Orthopaedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, 535 E. 70th St, New York, NY 10021, USA.
authors.forename: Mazda
authors.initials: M
authors.lastname: Farshad
authors.affiliation: Department of Orthopaedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, 535 E. 70th St, New York, NY 10021, USA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Aichmair
mesh_terms: D000369:Aged, 80 and over; D055396:Bone Morphogenetic Protein 2 / Q000009:adverse effects* / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D009101:Multiple Myeloma / Q000175:diagnosis / Q000209:etiology*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D055396:Bone Morphogenetic Protein 2
keywords: Bone morphogenetic protein-2; Complication; LLIF; Lateral lumbar interbody fusion; Multiple myeloma; XLIF