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Shukla G, Matur AV, Tao X, Khalid S, Garner R, Gibson J, Cass D, Wu A, Street S, Garcia-Vargas J, Mehta J, Childress K, Duah HO, Motley B, Cheng J, Adogwa O. Synthetic Interbody Devices and Traditional Bone Graft Are Associated With a Similar Rate of Surgical Complications After 1-2 Level Anterior Cervical Discectomy and Fusions. Spine (Phila Pa 1976) 2024; 49:615-620. [PMID: 37661823 DOI: 10.1097/brs.0000000000004819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To compare the rates of all-cause surgical complications of synthetic interbody devices versus allograft or autograft in patients undergoing 1-2 levels anterior cervical discectomy and fusion (ACDF) procedures. SUMMARY OF BACKGROUND DATA Cervical degenerative disorders affect up to 60% of older adults in the United States. Both traditional allograft or autograft and synthetic interbody devices (polyetheretherketone or titanium) are used for decompression and arthrodesis, with increasing utilization of the latter. However, the differences in their postsurgical complication profiles are not well-characterized. PATIENTS AND METHODS Patients who underwent 1-2 level ACDFs for cervical radiculopathy or myelopathy between 2010 and 2022 were identified using the PearlDiver Mariner all-claims insurance database. Patients undergoing surgery for nondegenerative pathologies, such as tumors, trauma, or infection, were excluded. 1:1 exact matching was performed based on factors that were significant predictors of all-cause surgical complications in a linear regression model. The primary outcome measure was the development of all-cause surgical complications after 1-2 level ACDFs. The secondary outcome was all-cause medical complications. RESULTS 1:1 exact matching resulted in two equal groups of 11,430 patients who received treatment with synthetic interbody devices or allograft/autograft. No statistically significant difference in all-cause surgical complications was found between the synthetic cohort and the allograft or autograft cohort after 1-2 level ACDFs (Relative Risk: 0.86, 95% confidence interval: 0.730-1.014, P = 0.079). No significant differences were observed regarding any specific surgical complications except for pseudoarthrosis (Relative Risk: 0.73, 95% confidence interval: 0.554-0.974, P = 0.037), which was higher in the allograft/autograft cohort. CONCLUSION After 1:1 exact matching to control for confounding variables, the findings of this study suggest that all-cause surgical complications are similar in patients undergoing ACDFs with synthetic interbody devices or allograft/autographs. However, the rate of pseudarthrosis appears to be higher in patients with allograft/autographs. Future prospective studies are needed to corroborate these findings.
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Affiliation(s)
- Geet Shukla
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Abhijith V Matur
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Xu Tao
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Syed Khalid
- Department of Neurosurgery, University of Illinois, Chicago, IL
| | - Rebecca Garner
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Justin Gibson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daryn Cass
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew Wu
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Seth Street
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Julia Garcia-Vargas
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jay Mehta
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH
| | - Kelly Childress
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Henry O Duah
- Institute for Nursing Research and Scholarship, University of Cincinnati College of Nursing, Cincinnati, OH
| | - Benjamin Motley
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Peng Q, Yang S, Zhang Y, Liu H, Meng B, Zhao W, Hu M, Zhang Y, Chen L, Sun H, Zhang L, Wu H. Effects of Structural Allograft versus Polyetheretherketone Cage in Patients Undergoing Spinal Fusion Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 178:162-171.e7. [PMID: 37442540 DOI: 10.1016/j.wneu.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Inter body spacers have been widely used in patients undergoing spinal fusion surgery; however, it is not clear whether one implant shows superior clinical outcomes compared with the other. This systematic review and meta-analysis comprehensively evaluated the radiologic outcomes and patient-reported outcomes of structural allograft versus polyetheretherketone (PEEK) implants in patients undergoing spinal fusion surgery. METHODS Extensive literature searches were conducted on online databases, including MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Library, until January 2023. The present study adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and the Newcastle-Ottawa Scale and Cochrane Collaboration Risk of Bias tool were used to assess the quality of the included studies. RESULTS Fifteen studies, encompassing 8020 patients, met the eligibility criteria. The results indicate that structural allografts show a higher fusion rate compared with PEEK implants (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.05-3.37; P =0.03; I2 = 71%). In addition, the structural allograft group also had a lower pseudarthrosis rate (OR, 0.40; 95% CI, 0.20-0.80; P = 0.009; I2 = 75%) and reoperation rate (OR, 0.46; 95% CI, 0.26-0.81; P = 0.007; I2 = 38%). CONCLUSIONS Our systematic review and meta-analysis show that structural allograft has a higher fusion rate compared with PEEK implants in patients undergoing spinal fusion surgery. In addition, structural allograft has a lower pseudarthrosis rate and reoperation rate.
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Affiliation(s)
- Qing Peng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Sheng Yang
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Yu Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Huanxiang Liu
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Bo Meng
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Wenjie Zhao
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Man Hu
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Yongbo Zhang
- Department of Orthopedics, Graduate School of Dalian Medical University, Dalian, China
| | - Liuyang Chen
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hua Sun
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Liang Zhang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Haisheng Wu
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Rodrigues AJ, Varshneya K, Stienen MN, Schonfeld E, Than KD, Veeravagu A. Clinical Outcomes and Cost Profiles for Cage and Allograft Anterior Cervical Discectomy and Fusion Procedures in the Adult Population: A Propensity Score-Matched Study. Asian Spine J 2023; 17:620-631. [PMID: 37226385 PMCID: PMC10460669 DOI: 10.31616/asj.2022.0261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/04/2022] [Accepted: 09/13/2022] [Indexed: 05/27/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE To characterize the postoperative outcomes and economic costs of anterior cervical discectomy and fusion (ACDF) procedures using synthetic biomechanical intervertebral cage (BC) and structural allograft (SA) implants. OVERVIEW OF LITERATURE ACDF is a common spine procedure that typically uses an SA or BC for the cervical fusion. Previous studies that compared the outcomes between the two implants were limited by small sample sizes, short-term postoperative outcomes, and procedures with single-level fusion. METHODS Adult patients who underwent an ACDF procedure in 2007-2016 were included. Patient records were extracted from MarketScan, a national registry that captures person-specific clinical utilization, expenditures, and enrollments across millions of inpatient, outpatient, and prescription drug services. Propensity-score matching (PSM) was employed to match the patient cohorts across demographic characteristics, comorbidities, and treatments. RESULTS Of 110,911 patients, 65,151 (58.7%) received BC implants while 45,760 (41.3%) received SA implants. Patients who underwent BC surgeries had slightly higher reoperation rates within 1 year after the index ACDF procedure (3.3% vs. 3.0%, p=0.004), higher postoperative complication rates (4.9% vs. 4.6%, p=0.022), and higher 90-day readmission rates (4.9% vs. 4.4%, p =0.001). After PSM, the postoperative complication rates did not vary between the two cohorts (4.8% vs. 4.6%, p=0.369), although dysphagia (2.2% vs. 1.8%, p<0.001) and infection (0.3% vs. 0.2%, p=0.007) rates remained higher for the BC group. Other outcome differences, including readmission and reoperation, decreased. Physician's fees remained high for BC implantation procedures. CONCLUSIONS We found marginal differences in clinical outcomes between BC and SA ACDF interventions in the largest published database cohort of adult ACDF surgeries. After adjusting for group-level differences in comorbidity burden and demographic characteristics, BC and SA ACDF surgeries showed similar clinical outcomes. Physician's fees, however, were higher for BC implantation procedures.
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Affiliation(s)
- Adrian John Rodrigues
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Martin Nikolaus Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St.Gallen, St. Gallen,
Switzerland
| | - Ethan Schonfeld
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Khoi Duc Than
- Department of Neurosurgery, Duke University, Durham, NC,
USA
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
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Wei Z, Zhang Z, Zhu W, Weng X. Polyetheretherketone development in bone tissue engineering and orthopedic surgery. Front Bioeng Biotechnol 2023; 11:1207277. [PMID: 37456732 PMCID: PMC10345210 DOI: 10.3389/fbioe.2023.1207277] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023] Open
Abstract
Polyetheretherketone (PEEK) has been widely used in the medical field as an implant material, especially in bone tissue engineering and orthopedic surgery, in recent years. This material exhibits superior stability at high temperatures and is biosecured without harmful reactions. However, the chemical and biological inertness of PEEK still limits its applications. Recently, many approaches have been applied to improve its performance, including the modulation of physical morphology, chemical composition and antimicrobial agents, which advanced the osteointegration as well as antibacterial properties of PEEK materials. Based on the evolution of PEEK biomedical devices, many studies on the use of PEEK implants in spine surgery, joint surgery and trauma repair have been performed in the past few years, in most of which PEEK implants show better outcomes than traditional metal implants. This paper summarizes recent studies on the modification and application of biomedical PEEK materials, which provides further research directions for PEEK implants.
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Affiliation(s)
- Zhanqi Wei
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Ze Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Wei Zhu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Speed and quality of interbody fusion in porous bioceramic Al 2O 3 and polyetheretherketone cages for anterior cervical discectomy and fusion: a comparative study. J Orthop Surg Res 2023; 18:165. [PMID: 36869376 PMCID: PMC9983253 DOI: 10.1186/s13018-023-03625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/17/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND The objective of this prospective randomized monocentric study is to compare the speed and quality of interbody fusion of implanted porous Al2O3 (aluminium oxide) cages with PEEK (polyetheretherketone) cages in ACDF (anterior cervical discectomy and fusion). MATERIALS AND METHODS A total of 111 patients were enrolled in the study, which was carried out between 2015 and 2021. The 18-month follow-up (FU) was completed in 68 patients with an Al2O3 cage and 35 patients with a PEEK cage in one-level ACDF. Initially, the first evidence (initialization) of fusion was evaluated on computed tomography. Subsequently, interbody fusion was evaluated according to the fusion quality scale, fusion rate and incidence of subsidence. RESULTS Signs of incipient fusion at 3 months were detected in 22% of cases with the Al2O3 cage and 37.1% with the PEEK cage. At 12-month FU, the fusion rate was 88.2% for Al2O3 and 97.1% for PEEK cages, and at the final FU at 18 months, 92.6% and 100%, respectively. The incidence of subsidence was observed to be 11.8% and 22.9% of cases with Al2O3 and PEEK cages, respectively. CONCLUSIONS Porous Al2O3 cages demonstrated a lower speed and quality of fusion in comparison with PEEK cages. However, the fusion rate of Al2O3 cages was within the range of published results for various cages. The incidence of subsidence of Al2O3 cages was lower compared to published results. We consider the porous Al2O3 cage as safe for a stand-alone disc replacement in ACDF.
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A Five-Year Cost-Utility Analysis Comparing Synthetic Cage Versus Allograft Use in Anterior Cervical Discectomy and Fusion Surgery for Cervical Spondylotic Myelopathy. Spine (Phila Pa 1976) 2023; 48:330-334. [PMID: 36730850 DOI: 10.1097/brs.0000000000004526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/12/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective cost-utility analysis. OBJECTIVE To conduct a cost-analysis comparing synthetic cage (SC) versus allograft (Allo) over a five-year time horizon. SUMMARY OF BACKGROUND DATA SC and Allo are two commonly used interbody choices for anterior cervical discectomy and fusion (ACDF) surgery. Previous analyses comparative analyses have reached mixed conclusions regarding their cost-effectiveness, yet recent estimates provide high-quality evidence. MATERIALS AND METHODS A decision-analysis model comparing the use of Allo versus SC was developed for a hypothetical 60-year-old patient with cervical spondylotic myelopathy undergoing single-level ACDF surgery. A comprehensive literature review was performed to estimate probabilities, costs (2020 USD) and quality-adjusted life years (QALYs) gained over a five-year period. A probabilistic sensitivity analysis using a Monte Carlo simulation of 1000 patients was carried out to calculate incremental cost-effectiveness ratio and net monetary benefits. One-way deterministic sensitivity analysis was performed to estimate the contribution of individual parameters to uncertainty in the model. RESULTS The use of Allo was favored in 81.6% of the iterations at a societal willing-to-pay threshold of 50,000 USD/QALY. Allo dominated (higher net QALYs and lower net costs) in 67.8% of the iterations. The incremental net monetary benefits in the Allo group was 2650 USD at a willing-to-pay threshold of 50,000 USD/QALY. One-way deterministic sensitivity analysis revealed that the cost of the index surgery was the only factor which significantly contributed to uncertainty. CONCLUSION Cost-utility analysis suggests that Allo maybe a more cost-effective option compared with SCs in adult patients undergoing ACDF for cervical spondylotic myelopathy.
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Bakare AA, Smitherman AD, Fontes RBV, O'Toole JE, Deutsch H, Traynelis VC. Comparison of Fusion versus Nonunion After 4-Level and 5-Level Anterior Cervical Diskectomy and Fusion With Anterior Plate Fixation. Neurosurgery 2022; 91:764-774. [PMID: 35951736 DOI: 10.1227/neu.0000000000002108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nonunion remains a concern in multilevel anterior cervical discectomy and fusion (ACDF), yet there are limited data on nonunion after 4 to 5-level ACDF. In fact, the largest series on 4-level or 5-level ACDF focused specifically on the swallowing outcomes. OBJECTIVE To assess nonunion after 4 to 5-level ACDF. METHODS Forty-one patients treated with 4 to 5-level ACDF with minimum of 12-month radiographic follow-up were retrospectively reviewed. Nonunion was found in 25 patients (61%) and 42 levels (25%) and complete fusion in 16 (39%) patients and 126 levels (75%). The 2 groups were further compared. RESULTS One-level nonunion was by far the most common pattern compared with multilevel nonunion. Nonunion occurred more frequently at the caudal than the cranial or middle segments ( P < .0001). There were significantly more subsidence ( P < .0001) and screw fractures/pullouts ( P < .0001) in the nonunion compared with the fusion group. The symptomatic patients were significantly younger than the asymptomatic patients ( P = .044). The symptomatic levels were significantly more than asymptomatic levels ( P = .048). Equal proportion of patients implanted with allograft and polyetheretherketone had nonunion. However, there were markedly more nonunion than fused levels with allograft and more fused than nonunion levels with polyetheretherketone ( P = .023). The reoperation rate was 24.4% and mostly due to nonunion. There were no reoperations within 90 days of the primary surgery. CONCLUSION The nonunion rate for 4-level and 5-level ACDF may be higher than previously reported. Symptomatic nonunion remains a major reason for reoperation after multilevel ACDF. Baseline characteristics that negatively affect fusion may be obviated by careful patient selection.
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Affiliation(s)
- Adewale A Bakare
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Adam D Smitherman
- Baxter Regional Neurosurgery & Spine Clinic, Mountain Home, Arkansas, USA
| | - Ricardo B V Fontes
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Harel Deutsch
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Vincent C Traynelis
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
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Prospective, Randomized, Blinded Clinical Trial Comparing PEEK and Allograft Spacers in Patients Undergoing Anterior Cervical Discectomy and Fusion Surgeries. Spine (Phila Pa 1976) 2022; 47:1043-1054. [PMID: 35881014 DOI: 10.1097/brs.0000000000004361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 03/17/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, randomized, blinded clinical trial. OBJECTIVE To examine clinical and radiological outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF) surgeries randomized to receive either polyether-ether-ketone (PEEK) or structural bone allografts. SUMMARY OF BACKGROUND DATA The biomechanical qualities as well as osteoconductive, osteogenic, and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however, as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. METHODS Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. Radiographic and clinical outcomes were assessed at 3, 6, 12, and 24 months with an additional postoperative radiographic assessment. RESULTS A total of 120 patients were enrolled and randomized. Comparing clinical outcomes, no differences in arm or neck pain scores were noted; however, there was a statistically significant (≤0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency toward lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (P = 0.72) in the PEEK and allograft groups, respectively. At 24 months' follow-up time, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24 months' follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. CONCLUSION Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK versus allograft-assisted ACDF surgeries. Although MCID comparisons suggest that allograft and PEEK-treated patients have similar clinical outcomes, testing that incorporates the magnitude of the change suggests that there may be a statistically significant greater magnitude of improvement for the allograft group patients, but further studies with a larger sample size would be helpful to determine if a true effect exists.
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Muthiah N, Yolcu YU, Alan N, Agarwal N, Hamilton DK, Ozpinar A. Evolution of polyetheretherketone (PEEK) and titanium interbody devices for spinal procedures: a comprehensive review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2547-2556. [PMID: 35689111 DOI: 10.1007/s00586-022-07272-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/22/2022] [Accepted: 05/18/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Interbody fusion is commonly utilized for arthrodesis and stability among patients undergoing spine surgery. Over the last few decades, interbody device materials, such as titanium and polyetheretherketone (PEEK), have been replacing traditional autografts and allografts for interbody fusion. As such, with the exponential growth of bioengineering, a large variety cage surface technologies exist. Different combinations of cage component materials and surface modifications have been created to optimize interbody constructs for surgical use. This review aims to provide a comprehensive overview of common surface technologies, their performance in the clinical setting, and recent modifications and material combinations. MATERIALS AND METHODS We performed a comprehensive review of the literature on titanium and PEEK as medical devices between 1964 and 2021. We searched five major databases, resulting in 4974 records. Articles were screened for inclusion manually by two independent reviewers, resulting in 237 articles included for review. CONCLUSION Interbody devices have rapidly evolved over the last few decades. Biomaterial and biomechanical modifications have allowed for continued design optimization. While titanium has a high osseointegrative capacity, it also has a high elastic modulus and is radio-opaque. PEEK, on the other hand, has a lower elastic modulus and is radiolucent, though PEEK has poor osseointegrative capacity. Surface modifications, material development advancements, and hybrid material devices have been utilized in search of an optimal spinal implant which maximizes the advantages and minimizes the disadvantages of each interbody material.
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Affiliation(s)
- Nallammai Muthiah
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | | | - Nima Alan
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - David Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA
| | - Alp Ozpinar
- Department of Neurosurgery, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA, 15213, USA.
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Abstract
Pseudarthrosis of the cervical spine represents a common and challenging problem for spine surgeons. Rates vary greatly from as low as 0%-20% to >60% and depend heavily on patient factors, approach, and number of levels. While some patients remain asymptomatic from pseudarthrosis, many require revision surgery due to instability, continued neck pain, or radiculopathy/myelopathy. We aimed to provide a practical, narrative review of cervical pseudarthrosis to address the following areas: (1) definitions, (2) incidence, (3) risk factors, (4) presentation and workup, (5) treatment decision-making, and (6) postoperative care. It is our hope the current review provides a concise summary for how to diagnose and treat challenging cervical nonunions.
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Affiliation(s)
- Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Clinton J Devin
- Steamboat Orthopedic and Spine Institute, Steamboat Springs, CO
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Onyedimma C, Jallow O, Yolcu YU, Alvi MA, Goyal A, Ghaith AK, Bhatti AUR, Abode-Iyamah K, Quinones-Hinojosa A, Freedman BA, Bydon M. Comparison of Outcomes Between Cage Materials Used for Patients Undergoing Anterior Cervical Discectomy and Fusion with Standalone Cages: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 158:e38-e54. [PMID: 34838765 DOI: 10.1016/j.wneu.2021.10.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Interbody cages are currently being used to address diseases of the vertebra requiring surgical stabilization. Titanium cages were first introduced in 1988. Polyetheretherketone (PEEK) cages are used frequently as one of the alternatives to titanium cages in current practice. This study aimed to compare available cage materials by reviewing the surgical and radiographic outcomes following anterior cervical discectomy and fusion. METHODS A comprehensive search of several electronic databases was conducted following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Baseline characteristics, operative outcomes, arthrodesis rates, subsidence rates, and complications were collected from included studies. Collected outcomes were further stratified according to the procedure type, the number of levels operated, and graft used to compare cage materials. RESULTS Following the screening for inclusion criteria, a total of 37 studies with 2363 patients were included. The median age was 49.5 years and the median follow-up was 26 months. Overall, no significant differences were found between PEEK and titanium cages regarding fusion, neurologic deficit, subsidence rates, or "good and excellent" outcome according to Odom criteria. However, the standalone comparison between PEEK, titanium, and poly-methyl-methacrylate (PMMA) cages showed a significantly lower fusion rate for PMMA (PEEK: 94%, PMMA: 56%, titanium: 95%, P < 0.01). CONCLUSIONS In the present systematic review and meta-analysis, a comparison of the long-term patient-reported and the radiographic outcomes associated with the use of titanium and PEEK, intervertebral body cages showed similar findings. However, there were significantly lower fusion rates for PMMA cages when using a standalone cage without graft material.
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Affiliation(s)
- Chiduziem Onyedimma
- Meharry Medical College, Nashville, Tennessee, USA; Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Yagiz U Yolcu
- Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammed Ali Alvi
- Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anshit Goyal
- Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Abdul Karim Ghaith
- Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Atiq Ur Rehman Bhatti
- Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Diagnosis of reoperated cervical non-union: Multicenter retrospective study about 45 patients. Orthop Traumatol Surg Res 2021; 107:102924. [PMID: 33845177 DOI: 10.1016/j.otsr.2021.102924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/04/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Non-union is one of the main complications of single- or multi-level cervical spine fusion, considerably impairing functional results. The aim of this study was to evaluate the respective contributions of imaging examinations in the diagnostic process, the challenge being to avoid inappropriate surgery and unnecessary complementary examinations. MATERIAL AND METHOD A retrospective multicenter study included all patients managed for cervical spine non-union between 2008 and 2018. We evaluated the imaging examinations performed on each patient and determined signs of non-union in each image. RESULTS The study included 45 patients in 4 centers: 55% female; mean age, of 48±8.0 years; 57% smokers. Systematic static radiography showed signs of non-union in 55% of cases. Dynamic X-ray was performed in 34% of patients, and showed hypermobility of the level in 80% of cases. CT supported diagnosis of non-union in 97% of cases, and MRI in 48%. SPECT-CT was positive in all cases of non-union. DISCUSSION Dynamic X-ray is rarely prescribed, but frequently provided an objective measure of hypermobility of the level in non-union, justifying first-line use. Millimetric-slice CT was reliable for diagnosis. MRI is relevant only once diagnosis has been made, as part of preoperative work-up. Nuclear imaging can be useful in order to solve doubtful cases. CONCLUSION In suspected cervical spine non-union, we recommend dynamic X-rays (flexion/extension) and CT-scan as first-line diagnosis examinations. LEVEL OF EVIDENCE IV.
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Menon N, Turcotte J, Patton C. Structural Allograft Versus Synthetic Interbody Cage for Anterior Cervical Discectomy and Fusion: A Comparison of 1-Year Outcomes From a National Database. Global Spine J 2021; 11:1215-1222. [PMID: 32748651 PMCID: PMC8453680 DOI: 10.1177/2192568220942217] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Observational cohort study. OBJECTIVE To compare 1-year perioperative complications between structural allograft (SA) and synthetic cage (SC) for anterior cervical discectomy and fusion (ACDF) using a national database. METHODS The TriNetX Research Network was retrospectively queried. Patients undergoing initial single or multilevel ACDF surgery between October 1, 2015 and April 30, 2019 were propensity score matched based on age and comorbidities. The rates of 1-year revision ACDF surgery and reported diagnoses of pseudoarthrosis, surgical site infection (SSI), and dysphagia were compared between structural allograft and synthetic cage techniques. RESULTS A comparison of 1-year outcomes between propensity score matched cohorts was conducted on 3056 patients undergoing single-level ACDF and 3510 patients undergoing multilevel ACDF. In single-level ACDF patients, there was no difference in 1-year revision ACDF surgery (P = .573), reported diagnoses of pseudoarthrosis (P = .413), SSI (P = .620), or dysphagia (P = .529) between SA and SC groups. In multilevel ACDF patients, there was a higher rate of revision surgery (SA 3.8% vs SC 7.3%, odds ratio = 1.982, P < .001) in the SC group, and a higher rate of dysphagia in the SA group (SA 15.9% vs SC 12.9%). CONCLUSION While the overall revision and complication rate for single-level ACDF remains low despite interbody graft selection, SC implant selection may result in higher rates of revision surgery in multilevel procedures despite yielding lower rates of dysphagia. Further prospective study is warranted.
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Affiliation(s)
- Nandakumar Menon
- Anne Arundel Medical Center, Annapolis, MD, USA,Nandakumar Menon, AAMC Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 101, Annapolis, MD 21401, USA.
| | | | - Chad Patton
- Anne Arundel Medical Center, Annapolis, MD, USA
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14
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Murthy NK, Dahdaleh NS. Commentary: Nonunion Rates After Anterior Cervical Discectomy and Fusion: Comparison of Polyetheretherketone vs Structural Allograft Implants. Neurosurgery 2021; 89:E13-E14. [PMID: 33822188 DOI: 10.1093/neuros/nyab102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nikhil K Murthy
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
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15
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Wang TY, Mehta VA, Sankey EW, Shaffrey CI, Abd-El-Barr MM, Than KD. The Impact of Instrumentation and Implant Surface Technology on Cervical and Thoracolumbar Fusion. Oper Neurosurg (Hagerstown) 2021; 21:S12-S22. [PMID: 34128071 DOI: 10.1093/ons/opaa321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/23/2020] [Indexed: 11/12/2022] Open
Abstract
Spinal fusion has undergone significant evolution and improvement over the past 50 yr. Historically, spine fusion was noninstrumented and arthrodesis was based entirely on autograft. Improved understanding of spinal anatomy and materials science ushered in a new era of spinal fusion equipped with screw-based technologies and various interbody devices. Osteobiologics is another important realm of spine fusion, and the evolution of various osteobiologics has perhaps undergone the most change within the past 20 yr. A new element to spinal instrumentation has recently gained traction-namely, surface technology. New data suggest that surface treatments play an increasingly well-recognized role in inducing osteogenesis and successful fusion. Until now, however, there has yet to be a unified resource summarizing the existing data and a lack of consensus exists on superior technology. Here, authors provide an in-depth review on surface technology and its impact on spinal arthrodesis.
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Affiliation(s)
- Timothy Y Wang
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Vikram A Mehta
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Eric W Sankey
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Christopher I Shaffrey
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Muhammad M Abd-El-Barr
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
| | - Khoi D Than
- Duke University Medical Center Department of Neurological Surgery, Durham, North Carolina, USA
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16
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Bergin SM, Wang TY, Park C, Rajkumar S, Goodwin CR, Karikari IO, Abd-El-Barr MM, Shaffrey CI, Yarbrough CK, Than KD. Pseudarthrosis rate following anterior cervical discectomy with fusion using an allograft cellular bone matrix: a multi-institutional analysis. Neurosurg Focus 2021; 50:E6. [PMID: 34062497 DOI: 10.3171/2021.3.focus2166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of osteobiologics, engineered materials designed to promote bone healing by enhancing bone growth, is becoming increasingly common for spinal fusion procedures, but the efficacy of some of these products is unclear. The authors performed a retrospective, multi-institutional study to investigate the clinical and radiographic characteristics of patients undergoing single-level anterior cervical discectomy with fusion performed using the osteobiologic agent Osteocel, an allograft mesenchymal stem cell matrix. METHODS The medical records across 3 medical centers and 12 spine surgeons were retrospectively queried for patients undergoing single-level anterior cervical discectomy and fusion (ACDF) with the use of Osteocel. Pseudarthrosis was determined based on CT or radiographic imaging of the cervical spine. Patients were determined to have radiographic pseudarthrosis if they met any of the following criteria: 1) lack of bridging bone on CT obtained > 300 days postoperatively, 2) evidence of instrumentation failure, or 3) motion across the index level as seen on flexion-extension cervical spine radiographs. Univariate and multivariate analyses were then performed to identify independent preoperative or perioperative predictors of pseudarthrosis in this population. RESULTS A total of 326 patients met the inclusion criteria; 43 (13.2%) patients met criteria for pseudarthrosis, of whom 15 (34.9%) underwent revision surgery. There were no significant differences between patients with and those without pseudarthrosis, respectively, for patient age (54.1 vs 53.8 years), sex (34.9% vs 47.4% male), race, prior cervical spine surgery (37.2% vs 33.6%), tobacco abuse (16.3% vs 14.5%), chronic kidney disease (2.3% vs 2.8%), and diabetes (18.6% vs 14.5%) (p > 0.05). Presence of osteopenia or osteoporosis (16.3% vs 3.5%) was associated with pseudarthrosis (p < 0.001). Implant type was also significantly associated with pseudarthrosis, with a 16.4% rate of pseudarthrosis for patients with polyetherethereketone (PEEK) implants versus 8.4% for patients with allograft implants (p = 0.04). Average lengths of follow-up were 27.6 and 23.8 months for patients with and those without pseudarthrosis, respectively. Multivariate analysis demonstrated osteopenia or osteoporosis (OR 4.97, 95% CI 1.51-16.4, p < 0.01) and usage of PEEK implant (OR 2.24, 95% CI 1.04-4.83, p = 0.04) as independent predictors of pseudarthrosis. CONCLUSIONS In patients who underwent single-level ACDF, rates of pseudarthrosis associated with the use of the osteobiologic agent Osteocel are higher than the literature-reported rates associated with the use of alternative osteobiologics. This is especially true when Osteocel is combined with a PEEK implant.
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Fang CH, Li M, Zhang YF, Liu H. Extra-articular migration of PEEK interference screw after anterior cruciate ligament reconstruction: a report of two cases. BMC Musculoskelet Disord 2021; 22:498. [PMID: 34051767 PMCID: PMC8164745 DOI: 10.1186/s12891-021-04387-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 05/19/2021] [Indexed: 11/27/2022] Open
Abstract
Background The interference screw is the most popular device that fixes the graft for anterior cruciate ligament reconstruction, reducing the incidence of windshield effect and bungee effect. For the screw, either metallic, “bioresorbable,” or polyetheretherketone (PEEK) material is available. PEEK is popular and extensively used due to its stability, biocompatibility, radiolucency, and elastic modulus. Rare relevant complications were reported, but here, we report two cases of extra-articular migrations of PEEK interference screw from the tibial tunnel after anterior cruciate reconstruction. Case report An 18-year-old boy and a 56-year-old woman underwent anterior cruciate ligament reconstruction using a PEEK interference screw to fix the graft in the tibial tunnel. They suffered from screw extrusion from the tibial tunnel after 40 days and six months, respectively, with an incision rupture or palpable subcutaneous mass. They underwent a second operation and recovered well. Conclusions The exact incidence of extra-articular migrations of PEEK interference screws is unknown, but it seems to be quite low; despite this and its uncertain cause, the negative effects caused by the PEEK material need to be considered.
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Affiliation(s)
- Chao-Hua Fang
- Department of Joint Surgery, Ningbo No.6 Hospital, No.1059 Zhongshan road, Yinzhou District, Zhejiang, 315000, Ningbo, People's Republic of China.,School of Biomedical Engineering, Shanghai Jiao Tong University, No.1954 Huashan Road, Xuhui District, 200240, Shanghai, People's Republic of China
| | - Ming Li
- Department of Joint Surgery, Ningbo No.6 Hospital, No.1059 Zhongshan road, Yinzhou District, Zhejiang, 315000, Ningbo, People's Republic of China
| | - Yun-Feng Zhang
- Department of Joint Surgery, Ningbo No.6 Hospital, No.1059 Zhongshan road, Yinzhou District, Zhejiang, 315000, Ningbo, People's Republic of China
| | - Hua Liu
- Department of Joint Surgery, Ningbo No.6 Hospital, No.1059 Zhongshan road, Yinzhou District, Zhejiang, 315000, Ningbo, People's Republic of China.
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18
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Ryu WHA, Richards D, Kerolus MG, Bakare AA, Khanna R, Vuong VD, Deutsch H, Fontes R, O'Toole JE, Traynelis VC, Fessler RG. Nonunion Rates After Anterior Cervical Discectomy and Fusion: Comparison of Polyetheretherketone vs Structural Allograft Implants. Neurosurgery 2021; 89:94-101. [PMID: 33733682 DOI: 10.1093/neuros/nyab079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 01/20/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although advances in implant materials, such as polyetheretherketone (PEEK), have been developed aimed to improve outcome after anterior cervical discectomy and fusion (ACDF), it is essential to confirm whether these changes translate into clinically important sustained benefits. OBJECTIVE To compare the radiographic and clinical outcomes of patients undergoing up to 3-level ACDF with PEEK vs structural allograft implants. METHODS In this cohort study, radiographic and symptomatic nonunion rates were compared in consecutive patients who underwent 1 to 3 level ACDF with allograft or PEEK implant. Prospectively collected clinical data and patient-reported outcome (PRO) scores were compared between the allograft and PEEK groups. Regression analysis was performed to determine the predictors of nonunion. RESULTS In total, 194 of 404 patients met the inclusion criteria (79% allograft vs 21% PEEK). Preoperative demographic variables were comparable between the 2 groups except for age. The rate of radiographic nonunion was higher with PEEK implants (39% vs 27%, P = .0035). However, a higher proportion of nonunion in the allograft cohort required posterior instrumentation (14% vs 3%, P = .039). Patients with multilevel procedures and PEEK implants had up to 5.8 times the risk of radiographic nonunion, whereas younger patients, active smokers, and multilevel procedures were at higher risk of symptomatic nonunion. CONCLUSION Along with implant material, factors such as younger age, active smoking status, and the number of operated levels were independent predictors of fusion failure. Given the impact of nonunion on PRO, perioperative optimization of modifiable factors and surgical planning are essential to ensure a successful outcome.
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Affiliation(s)
- Won Hyung A Ryu
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | - Dominick Richards
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | - Mena G Kerolus
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | - Adewale A Bakare
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | - Ryan Khanna
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | - Victoria D Vuong
- Department of General Surgery, Rush University, Chicago, Illinois, USA
| | - Harel Deutsch
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | - Ricardo Fontes
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | - John E O'Toole
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
| | | | - Richard G Fessler
- Department of Neurological Surgery, Rush University, Chicago, Illinois, USA
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Marrache M, Bronheim R, Harris AB, Puvanesarajah V, Raad M, Lee S, Skolasky R, Jain A. Synthetic Cages Associated With Increased Rates of Revision Surgery and Higher Costs Compared to Allograft in ACDF in the Nonelderly Patient. Neurospine 2020; 17:896-901. [PMID: 33401868 PMCID: PMC7788413 DOI: 10.14245/ns.2040216.108] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/20/2020] [Indexed: 11/19/2022] Open
Abstract
Objective The aim of this study was to compare all-cause reoperation rates and costs in nonelderly patients treated with anterior cervical discectomy and fusion (ACDF) with structural allograft versus synthetic cages for degenerative pathology.
Methods We queried a private claims database to identify adult patients (≤ 65 years) who underwent single-level ACDF in a hospital setting using either structural allograft or a synthetic cage (polyetheretherketone, metal, or hybrid device), from 2010 to 2016. The rate of all-cause reoperations at 2 years were compared between the 2 groups. Index hospitalization costs and 90-day complication rates were also compared. Significance was set at p < 0.05.
Results A total of 26,754 patients were included in the study. 11,514 patients (43%) underwent ACDF with structural allograft and 15,240 (57%) underwent ACDF with a synthetic cage. The patients in the allograft group were younger and more likely to be male. There was no significant difference between the 2 groups with respect to 90-day complications including: wound dehiscence, dysphagia, dysphonia, and hematoma/seroma. In the 2-year postoperative period, the synthetic cage group had a significantly higher rate of allcause reoperation compared to the allograft group (9.1% vs. 8.0%, p = 0.002). Index hospitalization costs were significantly higher in the synthetic cage group compared to those in the allograft group ($23,475 vs. $20,836, p < 0.001).
Conclusion Structural allograft is associated with lower all-cause reoperation rates and lower index costs in nonelderly patients undergoing ACDF surgery for degenerative pathology. It is important to understand this data as we transition toward value-based care.
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Affiliation(s)
- Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel Bronheim
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sang Lee
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Buyuk AF, Onyekwelu I, Gaffney CJ, Mehbod AA, Dawson JM, Garvey TA, Mueller B, Schwender JD. Symptomatic pseudarthrosis requiring revision surgery after 1- or 2-level ACDF with plating: peek versus allograft. JOURNAL OF SPINE SURGERY 2020; 6:670-680. [PMID: 33447669 DOI: 10.21037/jss-19-419] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Polyetheretherketone (PEEK) and machined allograft interbody spacers are among devices used as fusion adjuncts in anterior cervical discectomy and fusion (ACDF). Most results are good to excellent but some patients develop pseudarthrosis. We compared the reoperation rates for pseudarthrosis following 1- or 2-level ACDF with PEEK or allograft cages. Methods This was a retrospective cohort study. We reviewed patients who underwent 1- or 2-level ACDF. The rate of subsequent surgery for pseudarthrosis was calculated for cases confirmed by computerized tomography. Patient-reported outcomes were collected at post-index surgery follow-up and post-revision ACDF follow-up. Radiographic parameters were assessed at a minimum of 1-year post-op on all patients. Results Two hundred and nine patients were included: 167 received allograft and 42 received PEEK. Subsidence was demonstrated in 31% of allograft and 29% of PEEK patients. There were no significant differences in clinical outcomes between allograft and PEEK groups. Clinical outcomes were not adversely affected by subsidence. Reoperation for pseudarthrosis was performed in 8% of allograft patients and 14% of PEEK patients (not statistically different). Improvement in patient-reported outcome was significantly better for patients without symptomatic post-operative pseudarthrosis. Conclusions Both allograft and PEEK spacers are acceptable options for ACDF surgery. Similar clinical outcomes and rates of radiographic subsidence were found. Subsidence was not a factor in clinical outcomes. Reoperation for pseudarthrosis was associated with poor outcomes. A higher incidence of revision for symptomatic pseudarthrosis occurred in the PEEK group, but this was not statistically significant.
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Anterior Cervical Arthrodesis With Polyetheretherketone Spacers: What is the Role of the Grafting Material? Clin Spine Surg 2020; 33:E539-E544. [PMID: 32324673 DOI: 10.1097/bsd.0000000000000995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective study of 2 surgeons' use of a single polyetheretherketone (PEEK) device. OBJECTIVE Our objective was to investigate the fusion adjunct placed within PEEK devices to examine the likelihood of an arthrodesis, regardless of the PEEK interbody device itself. SUMMARY OF BACKGROUND DATA The effectiveness of PEEK interbody devices in anterior cervical arthrodesis has been questioned. METHODS The authors retrospectively reviewed the results of 121 patients with demineralized bone matrix (DBM) and 96 with local autograft bone placed within identical PEEK devices for anterior cervical arthrodesis (from 2011 to 2018); 1 surgeon used DBM and another local autograft bone. Arthrodesis was determined independently by a surgeon and 2 blinded neuroradiologists. RESULTS For DBM versus autograft; mean age was 60 versus 61 years, smoking status 42.1% versus 31%, diabetes mellitus 18.2% versus 28%, mean body mass index 31 versus 30, and follow up averaged 17 months in both groups. For DBM versus autograft; a radiographic arthrodesis was observed in 22.3% versus 76% of patients. Refusion at the index level was required in 5.8% of the DBM and 0% of the autograft patients. CONCLUSIONS A PEEK interbody device filled with local autograft resulted in a higher radiographic fusion rate and a lower need for reoperation at the index level than an identical device filled with DBM. Caution is warranted in assigning fusion failure to the PEEK device alone in anterior cervical discectomy and fusion surgery.
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Ashour AM, Abdelmohsen I, Sawy ME, Toubar AF. Stand-alone polyetheretherketone cages for anterior cervical discectomy and fusion for successive four-level degenerative disc disease without plate fixation. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:118-123. [PMID: 32904887 PMCID: PMC7462137 DOI: 10.4103/jcvjs.jcvjs_62_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 11/21/2022] Open
Abstract
Background: Anterior cervical discectomy with fusion became the most frequently performed technique for the treatment of symptoms related to cervical disc prolapse. Multilevel anterior cervical discectomy has been combined with anterior cervical plate application to help maintain the cervical lordosis and enhance fusion. This was associated with more soft-tissue separation and retraction with increased incidence of surgically related complications and postoperative dysphagia. Aim of the Study: The aim of this study is to evaluate the safety and efficacy of the stand-alone cervical polyetheretherketone (PEEK) cages in four-level discectomy and to determine if it is possible to avoid anterior plate fixation and to achieve satisfactory outcomes. Methodology: This is a retrospective study which was performed between June 2011 and December 2018 at one institute. The clinical and radiological data were collected from patients who underwent successive four-level anterior cervical discectomy and fusion with PEEK cages for degenerative cervical disc disease without plate fixation. Results: This study included 66 patients, 35 males and 31 females. The follow-up period was 24 months. Mean Japanese Orthopedic Association scores were 13.3 ± 1.41 preoperative and 15.9 ± 0.86 postoperative (P = 0.046). The cervical curvature index “Ishihara” (ICI) was 9.9 ± 5.90 preoperative and the mean of ICI was 10.5 ± 6.65 postoperative, which is insignificant, P = 0.7). The lordotic curvature according to these results was preserved till the end of the year and half of the follow-up period postoperative. Conclusion: Consecutive four-level anterior discectomy with PEEK cage interbody fusion without plate and screw is a safe and effective procedure in the absence of instability, and it may be a reliable alternative for the treatment of multilevel cervical disc.
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Affiliation(s)
- Ahmed M Ashour
- Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | | | - Medhat El Sawy
- Department of Neurosurgery, El-Menia University, Menia, Egypt
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Moo IH, Kam CJW, Lai MWS, Yeo W, Soh RCC. A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up. BMC Musculoskelet Disord 2020; 21:331. [PMID: 32466749 PMCID: PMC7257195 DOI: 10.1186/s12891-020-03325-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 04/30/2020] [Indexed: 11/18/2022] Open
Abstract
Background Allografts and polyetheretherketone (PEEK) cages are the two most commonly used materials in anterior cervical discectomy and fusion (ACDF). However, their effectiveness in two-level ACDF remains controversial. The primary aim of this retrospective study was to compare the clinical and radiological outcomes of two-level ACDF with plate fixation using either a structural allograft or a PEEK cage. Methods From 2010 to 2015, 88 consecutive patients underwent two-level ACDF, of whom 53 received an allograft and 35 patients received a PEEK cage. All PEEK cages were filled with local autografts. All clinical outcomes were prospectively collected before and six months and two years after surgery. Clinical efficacy was evaluated using a visual analogue scale for neck pain and limb pain, the Neck Pain and Disability Score, the Neck Disability Index, the Neurogenic Symptom Score, and the Japanese Orthopedic Association score. Radiological outcomes were assessed preoperatively, immediately after surgery, and at the final follow-up. Results A preoperative comparison revealed no difference between the two patient groups in terms of age, sex, body mass index, smoking status, preoperative symptoms, operation level, or follow-up (mean = 42.8 months). No differences in the improvements in clinical outcomes were observed between the two groups. Both groups showed significant improvement in mean disc height, segmental height, and segmental lordosis postoperatively. The fusion rate for the PEEK cage was 100% at both levels, while the fusion rate for the allograft group was 98.1% at the cephalad level and 94.2% at the caudad level (p > 0.05). Subsidence at the cephalad level occurred in 22.9% (8/35) of segments in the PEEK group and 7.7% (4/52) of segments in the allograft group (p = 0.057). At the caudal level, a higher incidence of cage subsidence was noted in the PEEK group than in the allograft group [37.1% (13/35) versus 15.4% (8/52)] (p = 0.02). Overall, subsidence was noted in 30% (21/70) of the PEEK group and in 11% (12/104) of the allograft group (p < 0.05). Conclusion The use of PEEK cages resulted in a higher rate of subsidence in two-level ACDF than the use of allografts. Two-level ACDF using either allografts or PEEK cages resulted in similar clinical outcomes, radiological improvements in alignment and fusion rates.
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Affiliation(s)
- Ing How Moo
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Carmen Jia Wen Kam
- Changi General Hospital, 2 Simei Street 3, Bukit Merah, 529889, Singapore
| | - Maksim Wen Sheng Lai
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - William Yeo
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Reuben Chee Cheong Soh
- Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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Teton ZE, Cheaney B, Obayashi JT, Than KD. PEEK interbody devices for multilevel anterior cervical discectomy and fusion: association with more than 6-fold higher rates of pseudarthrosis compared to structural allograft. J Neurosurg Spine 2020; 32:696-702. [PMID: 31978889 DOI: 10.3171/2019.11.spine19788] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/14/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Common interbody graft options for anterior cervical discectomy and fusion (ACDF) include allograft and polyetheretherketone (PEEK). PEEK has gained popularity due to its radiolucent properties and a modulus of elasticity similar to that of bone. PEEK devices also result in higher billing costs than allograft, which may drive selection. A previous study found a 5-fold higher rate of pseudarthrosis with the use of PEEK devices compared with structural allograft in single-level ACDF. Here the authors report on the occurrence of pseudarthrosis with PEEK devices versus structural allograft in patients who underwent multilevel ACDF. METHODS The authors retrospectively reviewed 81 consecutive patients who underwent a multilevel ACDF and had radiographic follow-up for at least 1 year. Data were collected on age, sex, BMI, tobacco use, pseudarthrosis, and rate of reoperation for pseudarthrosis. Logistic regression was used for data analysis. RESULTS Of 81 patients, 35 had PEEK implants and 46 had structural allograft. There were no significant differences between age, sex, smoking status, or BMI in the 2 groups. There were 26/35 (74%) patients with PEEK implants who demonstrated radiographic evidence of pseudarthrosis, compared with 5/46 (11%) patients with structural allograft (p < 0.001, OR 22.2). Five patients (14%) with PEEK implants required reoperation for pseudarthrosis, compared with 0 patients with allograft (p = 0.013). CONCLUSIONS This study reinforces previous findings on 1-level ACDF outcomes and suggests that the use of PEEK in multilevel ACDF results in statistically significantly higher rates of radiographic pseudarthrosis and need for revision surgery than allograft. Surgeons should consider these findings when determining graft options, and reimbursement policies should reflect these discrepancies.
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Affiliation(s)
- Zoe E Teton
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Barry Cheaney
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - James T Obayashi
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Khoi D Than
- 1Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
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Wang M, Chou D, Chang CC, Hirpara A, Liu Y, Chan AK, Pennicooke B, Mummaneni PV. Anterior cervical discectomy and fusion performed using structural allograft or polyetheretherketone: pseudarthrosis and revision surgery rates with minimum 2-year follow-up. J Neurosurg Spine 2020; 32:562-569. [PMID: 31835252 DOI: 10.3171/2019.9.spine19879] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/26/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Both structural allograft and PEEK have been used for anterior cervical discectomy and fusion (ACDF). There are reports that PEEK has a higher pseudarthrosis rate than structural allograft. The authors compared pseudarthrosis, revision, subsidence, and loss of lordosis rates in patients with PEEK and structural allograft. METHODS The authors performed a retrospective review of patients who were treated with ACDF at their hospital between 2005 and 2017. Inclusion criteria were adult patients with either PEEK or structural allograft, anterior plate fixation, and a minimum 2-year follow-up. Exclusion criteria were hybrid PEEK and allograft cases, additional posterior surgery, adjacent corpectomies, infection, tumor, stand-alone or integrated screw and cage devices, bone morphogenetic protein use, or lack of a minimum 2-year follow-up. Demographic variables, number of treated levels, interbody type (PEEK cage vs structural allograft), graft packing material, pseudarthrosis rates, revision surgery rates, subsidence, and cervical lordosis changes were collected. These data were analyzed by Pearson's chi-square test (or Fisher's exact test, according to the sample size and expected value) and Student t-test. RESULTS A total of 168 patients (264 levels total, mean follow-up time 39.5 ± 24.0 months) were analyzed. Sixty-one patients had PEEK, and 107 patients had structural allograft. Pseudarthrosis rates for 1-level fusions were 5.4% (PEEK) and 3.4% (allograft) (p > 0.05); 2-level fusions were 7.1% (PEEK) and 8.1% (allograft) (p > 0.05); and ≥ 3-level fusions were 10% (PEEK) and 11.1% (allograft) (p > 0.05). There was no statistical difference in the subsidence magnitude between PEEK and allograft in 1-, 2-, and ≥ 3-level ACDF (p > 0.05). Postoperative lordosis loss was not different between cohorts for 1- and 2-level surgeries. CONCLUSIONS In 1- and 2-level ACDF with plating involving the same number of fusion levels, there was no statistically significant difference in the pseudarthrosis rate, revision surgery rate, subsidence, and lordosis loss between PEEK cages and structural allograft.
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Affiliation(s)
- Minghao Wang
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
- 2Department of Neurosurgery, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Chih-Chang Chang
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Ankit Hirpara
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Yilin Liu
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Brenton Pennicooke
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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Structural Allograft versus Polyetheretherketone Implants in Patients Undergoing Spinal Fusion Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 136:101-109. [DOI: 10.1016/j.wneu.2020.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 12/30/2022]
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Sardana H, Sahu R, Kedia S. Letter to the Editor. PEEK interbody device and pseudarthrosis. J Neurosurg Spine 2019; 31:617-618. [PMID: 31200370 DOI: 10.3171/2019.3.spine19244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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