Hydroxyapatite Use in Spine Surgery—Molecular and Clinical Aspect

Personalized bioceramic grafts for craniomaxillofacial bone regeneration

The reconstruction of craniomaxillofacial bone defects remains clinically challenging. To date, autogenous grafts are considered the gold standard but present critical drawbacks. These shortcomings have driven recent research on craniomaxillofacial bone reconstruction to focus on synthetic grafts with distinct materials and fabrication techniques. Among the various fabrication methods, additive manufacturing (AM) has shown significant clinical potential. AM technologies build three-dimensional (3D) objects with personalized geometry customizable from a computer-aided design. These layer-by-layer 3D biomaterial structures can support bone formation by guiding cell migration/proliferation, osteogenesis, and angiogenesis. Additionally, these structures can be engineered to degrade concomitantly with the new bone tissue formation, making them ideal as synthetic grafts. This review delves into the key advances of bioceramic grafts/scaffolds obtained by 3D printing for personalized craniomaxillofacial bone reconstruction. In this regard, clinically relevant topics such as ceramic-based biomaterials, graft/scaffold characteristics (macro/micro-features), material extrusion-based 3D printing, and the step-by-step workflow to engineer personalized bioceramic grafts are discussed. Importantly, in vitro models are highlighted in conjunction with a thorough examination of the signaling pathways reported when investigating these bioceramics and their effect on cellular response/behavior. Lastly, we summarize the clinical potential and translation opportunities of personalized bioceramics for craniomaxillofacial bone regeneration.

Development and characterization of PLA nanocomposites reinforced with bio-ceramic particles for orthognathic implants: Enhanced mechanical and biological properties

The clinical application of osteofixation materials is crucial for maxillofacial reconstruction and orthognathic surgeries. To overcome the limitations of traditional metallic implants, bioabsorbable materials are gaining popularity due to their ability to avoid secondary removal surgeries and reduce stress shielding. This study investigates third-generation biomaterials, focusing on polylactic acid (PLA) for its biocompatibility and biodegradability, and hydroxyapatite (HAP) for its bioactive osteoconductive and bioresorbable properties. Eggshell nanoparticles (ES-NP), HAP, and bioinert alumina particles coated with titanium dioxide (TiO2@Al2O3) were prepared using ball milling, co-precipitation, and sol-gel methods, respectively. PLA-based nanocomposites PLA/ESNP/Al2O3 (PEA), PLA/HAP/Al2O3 (PHA), PLA/ESNP/TiO2@Al2O3 (PEAT), and PLA/HAP/TiO2@Al2O3 (PHAT) were fabricated via solvent casting. Characterization techniques including X-ray Diffraction (XRD), Fourier Transform Infrared Spectroscopy (FT-IR), and Field-Emission Scanning Electron Microscopy (FE-SEM) were used to analyze the developed nanoparticles and composites. Results indicated PEAT and PHAT composites exhibited tensile strengths of 33.59 ± 0.38 MPa and 32.46 ± 0.46 MPa, tensile moduli of 1756.17 ± 95.43 MPa and 2367.21 ± 158.84 MPa, and shore d hardness values of 84.10 ± 1.45 SHN and 78.00 ± 2.25 SHN, respectively. Both composites achieved a wettability angle of ∼65° and surface roughness below 2.19 μm, enhancing osteoblast adhesion. Additionally, MG63 cell viability was approximately 80 %, and hemolysis rates were below 2.17 %, demonstrating their potential for maxillofacial implant applications.

Synthetic or Natural (Bio-Based) Hydroxyapatite? A Systematic Comparison between Biomimetic Nanostructured Coatings Produced by Ionized Jet Deposition

Calcium phosphate (CaP)-based materials are largely explored in orthopedics, to increase osseointegration of the prostheses and specifically in spine surgery, to permit better fusion. To address these aims, nanostructured biogenic apatite coatings are emerging, since they better mimic the characteristics of the host tissue, thus potentially being better candidates compared to their synthetic counterpart. Here, we compare hydroxyapatite (HA) nanostructured coatings, obtained by ionized jet deposition, starting from synthetic and natural sources. The starting materials and the corresponding films are characterized and compared from a compositional and morphological point of view, then their stability is studied after post-treatment annealing. Although all the films are formed by globular aggregates and show morphological features at different scales (from nano to micro), significant differences are found in composition between the synthetic and naturally derived HA in terms of magnesium and sodium content, carbonate substitution and Ca/P ratio, while differences between the coatings obtained by the different natural HA sources are minor. In addition, the shape of the aggregates is also target-dependent. All coatings have a good stability after over 14 days of immersion in medium, with natural apatite coatings showing a better behavior, as no cracking and detachments are observed during immersion. Based on these results, both synthetic and naturally derived apatitic materials appear promising for applications in spine surgery, with coatings from natural sources possessing physiochemical properties more similar to the mineral phase of the human bone tissue.

Citric Acid: A Nexus Between Cellular Mechanisms and Biomaterial Innovations

Citrate-based biodegradable polymers have emerged as a distinctive biomaterial platform with tremendous potential for diverse medical applications. By harnessing their versatile chemistry, these polymers exhibit a wide range of material and bioactive properties, enabling them to regulate cell metabolism and stem cell differentiation through energy metabolism, metabonegenesis, angiogenesis, and immunomodulation. Moreover, the recent US Food and Drug Administration (FDA) clearance of the biodegradable poly(octamethylene citrate) (POC)/hydroxyapatite-based orthopedic fixation devices represents a translational research milestone for biomaterial science. POC joins a short list of biodegradable synthetic polymers that have ever been authorized by the FDA for use in humans. The clinical success of POC has sparked enthusiasm and accelerated the development of next-generation citrate-based biomaterials. This review presents a comprehensive, forward-thinking discussion on the pivotal role of citrate chemistry and metabolism in various tissue regeneration and on the development of functional citrate-based metabotissugenic biomaterials for regenerative engineering applications.

Interim 1-Year Radiographic and Clinical Outcomes Following Anterior Cervical Discectomy and Fusion Using Hydroxyapatite-Infused Polyetheretherketone Interbody Cages

BACKGROUND

This is a multicenter observational registry analysis of 1-year radiographic and clinical outcomes following anterior cervical discectomy and fusion (ACDF) using hydroxyapatite (HA)-infused polyetheretherketone (PEEK) intervertebral cages.

METHODS

Radiographic and clinical outcome data were collected preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. To assess fusion, dynamic flexion-extension radiographs were independently evaluated with a validated method. Clinical outcomes were assessed using the following disease-specific measures: Neck Disability Index (NDI) and visual analog scale (VAS) for neck, left arm, and right arm pain. Patient satisfaction was also evaluated.

RESULTS

A total of 789 ACDF patients (men: 51.5%/women: 48.5%; mean body mass index: 29.9 kg/m2) were included at the time of analysis, and 1565 segments have been operated. Successful fusion was confirmed in 91.3% of all operated levels after 6 months and 92.2% after 12 months. Mean NDI scores improved significantly (P < 0.01) preoperatively (46.3, n = 771) to postoperatively (12 months: 25.2, n = 281). Consistently, mean VAS neck (preoperative: 64.2, n = 770; 12 months: 28.6, n = 278), VAS right arm (preoperative: 42.6, n = 766; 12 months: 20.4, n = 277), and VAS left arm (preoperative: 41.1, n = 768; 12 months: 20.8, n = 277) decreased significantly (P < 0.01). Patients reported high satisfaction rates after surgery with no significant changes in postoperative patient satisfaction between 6 weeks and 12 months (95.1%, n = 273).

CONCLUSIONS

ACDF with HA-infused PEEK cages demonstrates promising radiographic and clinical outcomes, supporting the potential benefits of incorporating HA into PEEK cages to enhance fusion rates and improve patient outcomes.

CLINICAL RELEVANCE

This study demonstrates a >90% fusion rate by level with reliable improvements in patient reported outcomes, along with a high rate of patient satisfaction, in a large patient cohort undergoing ACDF with HA-infused PEEK cages.

LEVEL OF EVIDENCE

2 .

New technique and case report: Robot-assisted intralaminar screw fixation of spondylolysis in an adolescent

Introduction

Management of spondylolysis in adolescents is generally successful with conservative management. Uncommonly, surgical fixation is necessary for refractory cases. Direct repair with intralaminar screws is one commonly utilized technique. Recently, less invasive spinal procedures are becoming viable with the enabling of technologies, including robotics.

Case description

A 14-year-old baseball player and surfer presented with low back pain, diagnosed by MRI as bony edema and stress fractures of the posterior spinal elements. After 18 months, the pain was unresponsive to rest, physical therapy, and bracing. There was no radicular pain or neurologic symptoms. Computed tomography (CT) revealed bilateral, chronic nonhealing pars defects at L5. He underwent outpatient, robot-assisted percutaneous intralaminar fixation with hydroxyapatite-coated screws through a 2 cm skin incision.

Outcome

On postoperative day 1, the patient reported relief of his preoperative pain and he was ambulating without difficulty. At 2 weeks follow-up, the patient was completely pain free and surfing. At 2 months follow-up, low-dose CT demonstrated partial incorporation of the hydroxyapatite-coated screws, and the patient returned to sports. At 6 months follow-up, the patient had no pain and was swinging his baseball bat with full force. Low-dose CT revealed complete healing of the defects with full incorporation of the hydroxyapatite-coated screws.

Conclusions

A novel minimally invasive robotic percutaneous approach for direct spondylolysis repair using hydroxyapatite-coated screws is a potential surgical treatment option for non-healing pars defects in adolescent patients.

Morphology-Dependent Immunomodulatory Coating of Hydroxyapatite/PEO for Magnesium-Based Bone Implants

One of the most critical issues concerning orthopedic implants is the risk of chronic inflammation, which poses a threat to the bone healing process. Osteo-immunomodulation plays a pivotal role in implant technology by influencing proinflammatory and anti-inflammatory responses, ultimately promoting bone healing. This study aims to investigate the morphology-dependent osteo-immunomodulatory properties of a hydroxyapatite (HA)/plasma electrolytic oxidation (PEO)-coated WE43 alloy. In this context, following the PEO process with various operational parameters (duty cycles of 50-40, 50-20, 70-40%, and frequencies of 0.5, 0.8, and 1 kHz), a layer of HA was applied as the top coating using a straightforward hot-dip process. The results revealed the formation of the PEO layer with distinct morphologies and pore sizes, depending on the operational parameters. Specifically, a uniform PEO coating with small pore sizes (5.2-5.3 μm) led to the creation of plate-like HA particles, while a random-like HA structure formed on nonuniform surfaces with large pores (7.0-11.1 μm) of PEO. Moreover, it was observed that the plate-like HA coating exhibited higher adhesion strength than the random one (classified as class 2 vs class 3 based on cross-cut standards). Furthermore, electrochemical impedance spectroscopy (EIS) and polarization studies confirmed a substantial increase in the polarization resistance (680 kΩ) and total impedance (48 559.6 Ω) for the plate-like HA/PEO as compared to the substrate (an increase of 1511-fold and 311-fold, respectively) and the random HA/PEO samples (an increase of 85-fold and 18-fold, respectively). In addition, compared to random HA coatings, there was a significant enhancement in the viability (150% control vs 96% control), proliferation, and differentiation of MG63 cells when exposed to plate-like HA coatings. Moreover, surface morphology and chemistry pronouncedly impacted macrophages' viability, morphology, and phenotype. Notably, plate-like HA coatings resulted in a higher upregulation of BMP-2 and TGF-β than proinflammatory cytokines (IL-6 and M-CSF), indicating a polarization of macrophage type 1 (M1) toward type 2 (M2). In summary, the bilayer HA/PEO coating exhibited remarkable osteo-immunomodulatory activity, making it highly appealing for use in bone implant applications.

Development of Hydroxyapatite Coatings for Orthopaedic Implants from Colloidal Solutions: Part 1-Effect of Solution Concentration and Deposition Kinetics

This study introduces and explores the use of supersaturated solutions of calcium and phosphate ions to generate well-defined hydroxyapatite coatings for orthopaedic implants. The deposition of hydroxyapatite is conducted via several solutions of metastable precursors that precipitate insoluble hydroxyapatite minerals at a substrate-solution interface. Solutions of this nature are intrinsically unstable, but this paper outlines process windows in terms of time, temperature, concentration and pH in which coating deposition is controlled via the stop/go reaction. To understand the kinetics of the deposition process, comparisons based on ionic strength, particle size, electron imaging, elemental analyses and mass of the formed coating for various deposition solutions are carried out. This comprehensive dataset enables the measurement of deposition kinetics and identification of an optimum solution and its reaction mechanism. This study has established stable and reproducible process windows, which are precisely controlled, leading to the successful formation of desired hydroxyapatite films. The data demonstrate that this process is a promising and highly repeatable method for forming hydroxyapatites with desirable thickness, morphology and chemical composition at low temperatures and low capital cost compared to the existing techniques.

Overcoming barriers to patient adherence: the case for developing innovative drug delivery systems

Poor medication adherence is a pervasive issue with considerable health and socioeconomic consequences. Although the underlying reasons are generally understood, traditional intervention strategies rooted in patient-centric education and empowerment have proved to be prohibitively complex and/or ineffective. Formulating a pharmaceutical in a drug delivery system (DDS) is a promising alternative that can directly mitigate many common impediments to adherence, including frequent dosing, adverse effects and a delayed onset of action. Existing DDSs have already positively influenced patient acceptability and improved rates of adherence across various disease and intervention types. The next generation of systems have the potential to instate an even more radical paradigm shift by, for example, permitting oral delivery of biomacromolecules, allowing for autonomous dose regulation and enabling several doses to be mimicked with a single administration. Their success, however, is contingent on their ability to address the problems that have made DDSs unsuccessful in the past.

Application of 3D Printing in Bone Grafts

The application of 3D printing in bone grafts is gaining in importance and is becoming more and more popular. The choice of the method has a direct impact on the preparation of the patient for surgery, the probability of rejection of the transplant, and many other complications. The aim of the article is to discuss methods of bone grafting and to compare these methods. This review of literature is based on a selective literature search of the PubMed and Web of Science databases from 2001 to 2022 using the search terms “bone graft”, “bone transplant”, and “3D printing”. In addition, we also reviewed non-medical literature related to materials used for 3D printing. There are several methods of bone grafting, such as a demineralized bone matrix, cancellous allograft, nonvascular cortical allograft, osteoarticular allograft, osteochondral allograft, vascularized allograft, and an autogenic transplant using a bone substitute. Currently, autogenous grafting, which involves removing the patient’s bone from an area of low aesthetic importance, is referred to as the gold standard. 3D printing enables using a variety of materials. 3D technology is being applied to bone tissue engineering much more often. It allows for the treatment of bone defects thanks to the creation of a porous scaffold with adequate mechanical strength and favorable macro- and microstructures. Bone tissue engineering is an innovative approach that can be used to repair multiple bone defects in the process of transplantation. In this process, biomaterials are a very important factor in supporting regenerative cells and the regeneration of tissue. We have years of research ahead of us; however, it is certain that 3D printing is the future of transplant medicine.

Diagnosis and Management of Neuropathic Pain in Spine Diseases

Neuropathic pain is generally defined as a non-physiological pain experience caused by damage to the nervous system. It can occur spontaneously, as a reaction to a given stimulus, or independently of its action, leading to unusual pain sensations usually referred to as firing, burning or throbbing. In the course of spine disorders, pain symptoms commonly occur. According to available epidemiological studies, a neuropathic component of pain is often present in patients with spinal diseases, with a frequency ranging from 36% to 55% of patients. Distinguishing between chronic nociceptive pain and neuropathic pain very often remains a challenge. Consequently, neuropathic pain is often underdiagnosed in patients with spinal diseases. In reference to current guidelines for the treatment of neuropathic pain, gabapentin, serotonin and norepinephrine reuptake inhibitors and tricyclic antidepressants constitute first-line therapeutic agents. However, long-term pharmacologic treatment often leads to developing tolerance and resistance to used medications. Therefore, in recent years, a plethora of therapeutic methods for neuropathic pain have been developed and investigated to improve clinical outcomes. In this review, we briefly summarized current knowledge about the pathophysiology and diagnosis of neuropathic pain. Moreover, we described the most effective treatment approaches for neuropathic pain and discussed their relevance in the treatment of spinal pain.

Molecular Mechanisms and Clinical Application of Multipotent Stem Cells for Spinal Cord Injury

Spinal Cord Injury (SCI) is a common neurological disorder with devastating psychical and psychosocial sequelae. The majority of patients after SCI suffer from permanent disability caused by motor dysfunction, impaired sensation, neuropathic pain, spasticity as well as urinary complications, and a small number of patients experience a complete recovery. Current standard treatment modalities of the SCI aim to prevent secondary injury and provide limited recovery of lost neurological functions. Stem Cell Therapy (SCT) represents an emerging treatment approach using the differentiation, paracrine, and self-renewal capabilities of stem cells to regenerate the injured spinal cord. To date, multipotent stem cells including mesenchymal stem cells (MSCs), neural stem cells (NSCs), and hematopoietic stem cells (HSCs) represent the most investigated types of stem cells for the treatment of SCI in preclinical and clinical studies. The microenvironment of SCI has a significant impact on the survival, proliferation, and differentiation of transplanted stem cells. Therefore, a deep understanding of the pathophysiology of SCI and molecular mechanisms through which stem cells act may help improve the treatment efficacy of SCT and find new therapeutic approaches such as stem-cell-derived exosomes, gene-modified stem cells, scaffolds, and nanomaterials. In this literature review, the pathogenesis of SCI and molecular mechanisms of action of multipotent stem cells including MSCs, NSCs, and HSCs are comprehensively described. Moreover, the clinical efficacy of multipotent stem cells in SCI treatment, an optimal protocol of stem cell administration, and recent therapeutic approaches based on or combined with SCT are also discussed.

Hydroxyapatite Coating on Ti-6Al-7Nb Alloy by Plasma Electrolytic Oxidation in Salt-Based Electrolyte

Titanium alloys have good biocompatibility and good mechanical properties, making them particularly suitable for dental and orthopedic implants. Improving their osseointegration with human bones is one of the most essential tasks. This can be achieved by developing hydroxyapatite (HA) on the treating surface using the plasma electrolytic oxidation (PEO) method in molten salt. In this study, a coating of titanium oxide-containing HA nanoparticles was formed on Ti-6Al-7Nb alloy by PEO in molten salt. Then, samples were subjected to hydrothermal treatment (HTT) to form HA crystals sized 0.5 to 1 μm. The effect of the current and voltage frequency for the creation of the coating on the morphology, chemical, and phase composition was studied. The anti-corrosion properties of the samples were studied using the potentiodynamic polarization test (PPT) and electrochemical impedance spectroscopy (EIS). An assessment of the morphology of the sample formed at a frequency of 100 Hz shows that the structure of this coating has a uniform submicron porosity, and its surface shows high hydrophilicity and anti-corrosion properties (4.90 × 10⁶ Ohm·cm²). In this work, for the first time, the process of formation of a bioactive coating consisting of titanium oxides and HA was studied by the PEO method in molten salts.

Biological and Clinical Aspects of Metastatic Spinal Tumors

Simple Summary

Spine metastases are a common life-threatening complication of advanced-stage malignancies and often result in poor prognosis. Symptomatic spine metastases develop in the course of about 10% of malignant neoplasms. Therefore, it is essential for contemporary medicine to understand metastatic processes in order to find appropriate, targeted therapeutic options. Our literature review aimed to describe the up-to-date knowledge about the molecular pathways and biomarkers engaged in the spine’s metastatic processes. Moreover, we described current data regarding bone-targeted treatment, the emerging targeted therapies, radiotherapy, and immunotherapy used for the treatment of spine metastases. We hope that knowledge comprehensively presented in our review will contribute to the development of novel drugs targeting specific biomarkers and pathways. The more we learn about the molecular aspects of cancer metastasis, the easier it will be to look for treatment methods that will allow us to precisely kill tumor cells.

Abstract

Spine metastases are a common life-threatening complication of advanced-stage malignancies and often result in poor prognosis. Symptomatic spine metastases develop in the course of about 10% of malignant neoplasms. Therefore, it is essential for contemporary medicine to understand metastatic processes in order to find appropriate, targeted therapeutic options. Thanks to continuous research, there appears more and more detailed knowledge about cancer and metastasis, but these transformations are extremely complicated, e.g., due to the complexity of reactions, the variety of places where they occur, or the participation of both tumor cells and host cells in these transitions. The right target points in tumor metastasis mechanisms are still being researched; that will help us in the proper diagnosis as well as in finding the right treatment. In this literature review, we described the current knowledge about the molecular pathways and biomarkers engaged in metastatic processes involving the spine. We also presented a current bone-targeted treatment for spine metastases and the emerging therapies targeting the discussed molecular mechanisms.

Calcium Orthophosphate (CaPO4)-Based Bioceramics: Preparation, Properties, and Applications

Various types of materials have been traditionally used to restore damaged bones. In the late 1960s, a strong interest was raised in studying ceramics as potential bone grafts due to their biomechanical properties. A short time later, such synthetic biomaterials were called bioceramics. Bioceramics can be prepared from diverse inorganic substances, but this review is limited to calcium orthophosphate (CaPO4)-based formulations only, due to its chemical similarity to mammalian bones and teeth. During the past 50 years, there have been a number of important achievements in this field. Namely, after the initial development of bioceramics that was just tolerated in the physiological environment, an emphasis was shifted towards the formulations able to form direct chemical bonds with the adjacent bones. Afterwards, by the structural and compositional controls, it became possible to choose whether the CaPO4-based implants would remain biologically stable once incorporated into the skeletal structure or whether they would be resorbed over time. At the turn of the millennium, a new concept of regenerative bioceramics was developed, and such formulations became an integrated part of the tissue engineering approach. Now, CaPO4-based scaffolds are designed to induce bone formation and vascularization. These scaffolds are usually porous and harbor various biomolecules and/or cells. Therefore, current biomedical applications of CaPO4-based bioceramics include artificial bone grafts, bone augmentations, maxillofacial reconstruction, spinal fusion, and periodontal disease repairs, as well as bone fillers after tumor surgery. Prospective future applications comprise drug delivery and tissue engineering purposes because CaPO4 appear to be promising carriers of growth factors, bioactive peptides, and various types of cells.

Analysis of the Effect of Component Ratio Imbalances on Selected Mechanical Properties of Seasoned, Medium Viscosity Bone Cements

The paper presents the results of experimental strength tests of specimens made of two commercially available bone cements subjected to compression, that is a typical variant of load of this material during use in the human body, after it has been used for implantation of prostheses or supplementation of bone defects. One of the factors analysed in detail was the duration of cement seasoning in Ringer's solution that simulates the aggressive environment of the human body and material degradation caused by it. The study also focused on the parameters of quantitative deviation from the recommended proportions of liquid (MMA monomer, accelerator and stabiliser) and powder (PMMA prepolymer and initiator) components, i.e., unintentional inaccuracy of component proportioning at the stage of cement mass preparation. Statistical analysis has shown the influence of these factors on the decrease in compressive strength of the cements studied, which may be of significant importance in operational practice.

Low-Cost Cranioplasty-A Systematic Review of 3D Printing in Medicine

The high cost of biofabricated titanium mesh plates can make them out of reach for hospitals in low-income countries. To increase the availability of cranioplasty, the authors of this work investigated the production of polymer-based endoprostheses. Recently, cheap, popular desktop 3D printers have generated sufficient opportunities to provide patients with on-demand and on-site help. This study also examines the technologies of 3D printing, including SLM, SLS, FFF, DLP, and SLA. The authors focused their interest on the materials in fabrication, which include PLA, ABS, PET-G, PEEK, and PMMA. Three-dimensional printed prostheses are modeled using widely available CAD software with the help of patient-specific DICOM files. Even though the topic is insufficiently researched, it can be perceived as a relatively safe procedure with a minimal complication rate. There have also been some initial studies on the costs and legal regulations. Early case studies provide information on dozens of patients living with self-made prostheses and who are experiencing significant improvements in their quality of life. Budget 3D-printed endoprostheses are reliable and are reported to be significantly cheaper than the popular counterparts manufactured from polypropylene polyester.

Metallic Implants Used in Lumbar Interbody Fusion

Over the last decade, pedicle fixation systems have evolved and modifications in spinal fusion techniques have been developed to increase fusion rates and improve clinical outcomes after lumbar interbody fusion (LIF). Regarding materials used for screw and rod manufacturing, metals, especially titanium alloys, are the most popular resources. In the case of pedicle screws, that biomaterial can be also doped with hydroxyapatite, CaP, ECM, or tantalum. Other materials used for rod fabrication include cobalt-chromium alloys and nitinol (nickel-titanium alloy). In terms of mechanical properties, the ideal implant used in LIF should have high tensile and fatigue strength, Young's modulus similar to that of the bone, and should be 100% resistant to corrosion to avoid mechanical failures. On the other hand, a comprehensive understanding of cellular and molecular pathways is essential to identify preferable characteristics of implanted biomaterial to obtain fusion and avoid implant loosening. Implanted material elicits a biological response driven by immune cells at the site of insertion. These reactions are subdivided into innate (primary cellular response with no previous exposure) and adaptive (a specific type of reaction induced after earlier exposure to the antigen) and are responsible for wound healing, fusion, and also adverse reactions, i.e., hypersensitivity. The main purposes of this literature review are to summarize the physical and mechanical properties of metal alloys used for spinal instrumentation in LIF which include fatigue strength, Young's modulus, and corrosion resistance. Moreover, we also focused on describing biological response after their implantation into the human body. Our review paper is mainly focused on titanium, cobalt-chromium, nickel-titanium (nitinol), and stainless steel alloys.