Clinical and Cost-Effectiveness of Lumbar Interbody Fusion Using Tritanium Posterolateral Cage (vs. Propensity-Matched Cohort of PEEK Cage)

A comparison of transforaminal lumbar interbody fusion (TLIF) cage material on fusion rates: A systematic review and network meta-analysis

Background

A wide variety of materials are used for lumbar interbody fusion, but there is no unified consensus on the superiority of one material over another. The aim of this systematic review and network meta-analysis (NMA) is to compare and rank the various TLIF interbody materials based on fusion rates.

Methods

We queried PubMed, EMBASE and Scopus from inception until August 2023, in which 2135 studies were identified. Inclusion criteria were applied based on the PRISMA guidelines. The fusion assessment employed the Bridwell's criteria with a length of follow-up of at least 12 months. The NMA was conducted to compare multiple approaches from multiple studies using the frequentist framework with STATA16.

Results

In total, 13 TLIF studies involving 1919 patients with 1981 lumbar interbody levels fulfilled our eligibility criteria. Seven different cage materials were utilized: polyetheretherketone (PEEK, as the reference), allograft, autograft, PEEK with titanium coating (TiPEEK), titanium, carbon/carbon fiber reinforced polymer (CFRP) and 3D-printed titanium. The average patient age was 60.9 (SD = 7.5) years old. When compared to PEEK, the other six materials did not have a significantly different rate of lumbar fusion. However, the SUCRA number of the 3D-printed titanium, TiPEEK, Ti, allograft, autograft, CFRP, and PEEK were 0.8, 0.6, 0.5, 0.5, 0.4, 0.4, and 0.3 consecutively.

Conclusions

Based on a network meta-analysis within the confines of our clinical study, 3D-printed titanium interbody cage may promote the highest success rate of fusion while PEEK may be the material with the least success rate of fusion in TLIF.

The Effectiveness of Tritanium Cages in Preventing Osteolytic Vertebral Endplate Cysts After Lumbar Interbody Fusion

OBJECTIVE

Lumbar interbody fusion (LIF) is a common surgical procedure, but postoperative complications, such as osteolytic vertebral endplate cysts, can adversely affect patient outcomes. This study aims to investigate whether tritanium cages (Stryker, Mahwah, New Jersey, USA) are effective in preventing osteolytic vertebral endplate cysts after LIF.

METHODS

Clinical data from 8 years (2013-2020) of LIF procedures at our hospital were analyzed. Computed tomography was used to assess the formation of osteolytic vertebral endplate cysts 6 months after surgery. Clinical factors potentially associated with cyst formation were compared among 3 different interbody spacer materials: tritanium, titanium, and polyetheretherketone.

RESULTS

LIF was performed for 169 patients at 205 spinal levels, employing tritanium cages in 56 levels (48 patients), titanium in 103 levels (86 patients), and polyetheretherketone in 46 levels (35 patients). At 6 months after LIF, 27.3% of patients showed worsening of osteolytic vertebral endplate cysts. Multivariate logistic regression analysis showed that tritanium cages (odds ratio [OR], 3.86; 95% confidence interval [CI], 1.46-10.21) and titanium (OR, 2.55; 95% CI, 1.13-5.75), and posterior LIF (OR, 5.74; 95% CI, 2.24-14.74) were associated with a reduced risk of postoperative osteolytic vertebral endplate cysts.

CONCLUSIONS

Tritanium cages have shown promise in preventing postoperative osteolytic vertebral endplate cysts, suggesting their potential as a stable and effective choice in LIF procedures. These findings have significant implications for improving patient outcomes and warrant further investigation to optimize surgical techniques and materials.

Fundamentals of Mechanobiology and Potential Applications in Spinal Fusion

BACKGROUND

Mechanobiology can help optimize spinal fusion by providing insights into the mechanical environment required for bone healing and fusion. This includes understanding the optimal loading conditions, the mechanical properties of implanted materials, and the effects of mechanical stimuli on the cells involved in bone formation. The present article reviews the evidence for surface technologies and implant modification of spinal cages in enhancing spinal fusion.

METHODS

Databases used included Embase, MEDLINE, Springer, and Cochrane Library. Relevant articles were identified using specific keywords and search fields. Only systematic reviews, meta-analyses, review articles, and original research articles in English were included. Two researchers independently performed the search and selection process. A flowchart of the search strategy and study selection method is provided in the article.

RESULTS

The studies indicate that surface modification can significantly enhance osseointegration and interbody fusion by promoting cellular adhesion, proliferation, differentiation, and mineralization. Various surface modification techniques such as coating, etching, nanotopography, and functionalization achieve this. Similarly, implant material modification can improve implant stability, biocompatibility, and bioactivity, leading to better fusion outcomes. Mechanobiology plays a vital role in this process by influencing the cellular response to mechanical cues and promoting bone formation.

CONCLUSIONS

The studies reviewed indicate that surface technologies and implant material modification are promising approaches for improving the success of spinal cage fusion. Mechanobiology is critical in this process by influencing the cellular response to mechanical signals and promoting bone growth.