Vertebral Endplate Cavities with Titanium Cages in Posterior Lumbar Interbody Fusion

Abstract

Background

Vertebral endplate cavities (VECs) have been reported with the use of titanium (Ti) cages. Only few articles have recently demonstrated unfavorable radiographic changes in the form of cysts or cavities, which may predispose to nonunion.

Methods

The aim was to assess the prevalence of VEC in posterior lumbar interbody fusion (PLIF) using Ti cages and to estimate their impact on fusion. The term “cavity” was used to describe the endplate changes. Computed tomography (CT) analysis of the VECs and fusion status following PLIFs with Ti cages was conducted by two observers. VECs were assessed according to the size, multiplicity, location, and presence of sclerosis.

Results

Forty-two consecutive patients with surgeries conducted on 52 levels were enrolled. There were 20 males and 22 females. The mean age was 43.6 ± 10.89 years. The mean follow-up was 20.85 ± 8.49 months. Definite union was seen in 48 levels (92.3%) by observer 1 and in 40 levels (76.9%) by observer 2. The strength of agreement was moderate. The presence of VEC was observed in 9 levels (17.3%) by observer 1 and in 12 levels (23.1%) by observer 2. The strength of agreement was moderate. The majority of VECs in the endplates were less than 5 mm. The strength of agreement was high. The strength of agreement for location and multiplicity were moderate. The VEC was significantly correlated with the fusion status.

Conclusion

Our study confirmed that VECs were observed following Ti cage placement after PLIF procedures. They tend to be small and might be associated with nonunion. Furthermore, it reflected the limited inter-rater reliability of the assessment of both the fusion status and VEC morphology after Ti PLIF cage placement.

Keywords

vertebral endplate - lumbar interbody fusion - cage - titanium

Ethical Approval

The approval code issued by the institutional review board (IRB) is 22–2017.

Informed Consent

Informed consent was obtained by all participants in this study.

^* The first two authors contributed equally to the study.

Publikationsverlauf

Eingereicht: 14. Januar 2024

Angenommen: 14. August 2024

Accepted Manuscript online:
16. August 2024

Artikel online veröffentlicht:
17. Dezember 2024

• References

• 1 Elgafy H, Olson D, Liu J, Lewis C, Semaan H. Effectiveness and safety of transforaminal lumbar interbody fusion in patients with previous laminectomy. Eur Spine J 2015; 24 (04) 810-816
• 2 Rousseau MA, Lazennec JY, Saillant G. Circumferential arthrodesis using PEEK cages at the lumbar spine. J Spinal Disord Tech 2007; 20 (04) 278-281
• 3 Rihn JA, Patel R, Makda J. et al. Complications associated with single-level transforaminal lumbar interbody fusion. Spine J 2009; 9 (08) 623-629
• 4 Canseco JA, Karamian BA, Patel PD. et al. PEEK versus titanium static interbody cages: a comparison of 1-year clinical and radiographic outcomes for 1-level TLIFs. Clin Spine Surg 2021; 34 (08) E483-E493
• 5 Vadapalli S, Sairyo K, Goel VK. et al. Biomechanical rationale for using polyetheretherketone (PEEK) spacers for lumbar interbody fusion: a finite element study. Spine 2006; 31 (26) E992-E998
• 6 Walsh WR, Pelletier MH, Christou C, He J, Vizesi F, Boden SD. The in vivo response to a novel Ti coating compared with polyether ether ketone: evaluation of the periphery and inner surfaces of an implant. Spine J 2018; 18 (07) 1231-1240
• 7 Phan K, Hogan JA, Assem Y, Mobbs RJ. PEEK-Halo effect in interbody fusion. J Clin Neurosci 2016; 24: 138-140
• 8 Pavlov PW, Meijers H, van Limbeek J. et al. Good outcome and restoration of lordosis after anterior lumbar interbody fusion with additional posterior fixation. Spine 2004; 29 (17) 1893-1899 , discussion 1900
• 9 van Dijk M, Smit TH, Sugihara S, Burger EH, Wuisman PI. The effect of cage stiffness on the rate of lumbar interbody fusion: an in vivo model using poly(l-lactic acid) and titanium cages. Spine 2002; 27 (07) 682-688
• 10 Spruit M, Falk RG, Beckmann L, Steffen T, Castelein RM. The in vitro stabilising effect of polyetheretherketone cages versus a titanium cage of similar design for anterior lumbar interbody fusion. Eur Spine J 2005; 14 (08) 752-758
• 11 McAfee PC, Boden SD, Brantigan JW. et al. Symposium: a critical discrepancy-a criteria of successful arthrodesis following interbody spinal fusions. Spine 2001; 26 (03) 320-334
• 12 Seaman S, Kerezoudis P, Bydon M, Torner JC, Hitchon PW. Titanium vs. polyetheretherketone (PEEK) interbody fusion: meta-analysis and review of the literature. J Clin Neurosci 2017; 44: 23-29
• 13 Fujibayashi S, Takemoto M, Izeki M, Takahashi Y, Nakayama T, Neo M. Does the formation of vertebral endplate cysts predict nonunion after lumbar interbody fusion?. Spine 2012; 37 (19) E1197-E1202
• 14 Tanida S, Fujibayashi S, Otsuki B. et al. Vertebral endplate cyst as a predictor of nonunion after lumbar interbody fusion: comparison of titanium and polyetheretherketone cages. Spine 2016; 41 (20) E1216-E1222
• 15 Sasaki M, Umegaki M, Fukunaga T. et al. Vertebral endplate cyst formation in relation to properties of interbody cages. Neurospine 2021; 18 (01) 170-176
• 16 Elfiky TA, Patil ND, Allam Y, Ragab R. Endplate changes with polyetheretherketone cages in posterior lumbar interbody fusion. Asian Spine J 2020; 14 (02) 229-237
• 17 Segi N, Nakashima H, Ito S. et al. Trabecular bone remodeling after posterior lumbar interbody fusion: comparison of the osseointegration in three-dimensional porous titanium cages and polyether-ether-ketone cages. Global Spine J 2024; (e-pub ahead of print)
• 18 Nemoto O, Asazuma T, Yato Y, Imabayashi H, Yasuoka H, Fujikawa A. Comparison of fusion rates following transforaminal lumbar interbody fusion using polyetheretherketone cages or titanium cages with transpedicular instrumentation. Eur Spine J 2014; 23 (10) 2150-2155
• 19 Formica M, Vallerga D, Zanirato A. et al. Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review. Musculoskelet Surg 2020; 104 (01) 1-15
• 20 Chun DS, Baker KC, Hsu WK. Lumbar pseudarthrosis: a review of current diagnosis and treatment. Neurosurg Focus 2015; 39 (04) E10
• 21 Hoppe S, Albers CE, Elfiky T. et al. First results of a new vacuum plasma sprayed (VPS) titanium-coated carbon/PEEK composite cage for lumbar interbody fusion. J Funct Biomater 2018; 9 (01) 23
• 22 Sakaura H, Ohnishi A, Yamagishi A, Ohwada T. Early fusion status after posterior lumbar interbody fusion with cortical bone trajectory screw fixation: a comparison of titanium-coated polyetheretherketone cages and carbon polyetheretherketone cages. Asian Spine J 2019; 13 (02) 248-253
• 23 Makino T, Takenaka S, Sakai Y, Yoshikawa H, Kaito T. Comparison of short-term radiographical and clinical outcomes after posterior lumbar interbody fusion with a 3D porous titanium alloy cage and a titanium-coated PEEK cage. Global Spine J 2022; 12 (05) 931-939
• 24 Joswig H, Stienen MN, Smoll NR. et al. Effects of smoking on subjective and objective measures of pain intensity, functional impairment, and health-related quality of life in lumbar degenerative disk disease. World Neurosurg 2017; 99: 6-13
• 25 Stienen MN, Ho AL, Staartjes VE. et al. Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature. Spine J 2019; 19 (07) 1276-1293