Effect of Cage Material and Size on Fusion Rate and Subsidence Following Biportal Endoscopic Transforaminal Lumbar Interbody Fusion

Overview

Journal Neurospine

Date 2024 Oct 4

PMID 39363473

Authors

Ki-Han You

Samuel K Cho

Jae-Yeun Hwang

Sun-Ho Cha

Min-Seok Kang

Sang-Min Park

Hyun-Jin Park

Affiliations

Soon will be listed here.

Abstract

Objective: Biportal endoscopic transforaminal lumbar interbody fusion (BE-TLIF) is an emerging, minimally invasive technique performed under biportal endoscopic guidance. However, concerns regarding cage subsidence and sufficient fusion during BE-TLIF necessitate careful selection of an appropriate interbody cage to improve surgical outcomes. This study compared the fusion rate, subsidence, and other radiographic parameters according to the material and size of the cages used in BE-TLIF.

Methods: In this retrospective cohort study, patients who underwent single-segment BE-TLIF between April 2019 and February 2023 were divided into 3 groups: group A, regular-sized three-dimensionally (3D)-printed titanium cages; group B, regular-sized polyetheretherketone cages; and group C, large-sized 3D-printed titanium cages. Radiographic parameters, including lumbar lordosis, segmental lordosis, anterior and posterior disc heights, disc angle, and foraminal height, were measured before and after surgery. The fusion rate and severity of cage subsidence were compared between the groups.

Results: No significant differences were noted in the demographic data or radiographic parameters between the groups. The fusion rate on 1-year postoperative computed tomography was comparable between the groups. The cage subsidence rate was significantly lower in group C than in group A (41.9% vs. 16.7%, p=0.044). The severity of cage subsidence was significantly lower in group C (0.93±0.83) than in groups A (2.20±1.84, p=0.004) and B (1.79±1.47, p=0.048).

Conclusion: Cage materials did not affect the 1-year postoperative outcomes of BE-TLIF; however, subsidence was markedly reduced in large cages. Larger cages may provide more stable postoperative segments.

Citing Articles

Anterior Lumbar Interbody Fusion (ALIF) Versus Full-Endoscopic/Percutaneous TLIF With a Large-Footprint Interbody Cage: A Comparative Observational Study.

Morgenstern C, Nogueras F, Delbos G, Morgenstern R Global Spine J. 2025; :21925682251316280.

PMID: 39864958 PMC: 11770686. DOI: 10.1177/21925682251316280.

References

Landham P, Don A, Robertson P . Do position and size matter? An analysis of cage and placement variables for optimum lordosis in PLIF reconstruction. Eur Spine J. 2017; 26(11):2843-2850. DOI: 10.1007/s00586-017-5170-z. View

Sultana T, Hossain M, Jeong J, Im S . Comparative Analysis of Radiologic Outcomes Between Polyetheretherketone and Three-Dimensional-Printed Titanium Cages After Transforaminal Lumbar Interbody Fusion. World Neurosurg. 2023; 179:e241-e255. DOI: 10.1016/j.wneu.2023.08.056. View

Li P, Jiang W, Yan J, Hu K, Han Z, Wang B . A novel 3D printed cage with microporous structure and in vivo fusion function. J Biomed Mater Res A. 2019; 107(7):1386-1392. DOI: 10.1002/jbm.a.36652. View

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):2150-5. DOI: 10.1007/s00586-014-3466-9. View

Pao J . Biportal Endoscopic Transforaminal Lumbar Interbody Fusion Using Double Cages: Surgical Techniques and Treatment Outcomes. Neurospine. 2023; 20(1):80-91. PMC: 10080423. DOI: 10.14245/ns.2346036.018. View

You K, Hwang J, Hong S, Kang M, Park S, Park H . Biportal endoscopic extraforaminal lumbar interbody fusion using a 3D-printed porous titanium cage with large footprints: technical note and preliminary results. Acta Neurochir (Wien). 2023; 165(6):1435-1443. DOI: 10.1007/s00701-023-05605-7. View

Jitpakdee K, Sommer F, Gouveia E, Mykolajtchuk C, Boadi B, Berger J . Expandable cages that expand both height and lordosis provide improved immediate effect on sagittal alignment and short-term clinical outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). J Spine Surg. 2024; 10(1):55-67. PMC: 10982918. DOI: 10.21037/jss-23-106. View

Park M, Park S, Son S, Park W, Choi S . Clinical and radiological outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) compared with conventional posterior lumbar interbody fusion (PLIF): 1-year follow-up. Neurosurg Rev. 2019; 42(3):753-761. DOI: 10.1007/s10143-019-01114-3. View

Heemskerk J, Oluwadara Akinduro O, Clifton W, Quinones-Hinojosa A, Abode-Iyamah K . Long-term clinical outcome of minimally invasive versus open single-level transforaminal lumbar interbody fusion for degenerative lumbar diseases: a meta-analysis. Spine J. 2021; 21(12):2049-2065. DOI: 10.1016/j.spinee.2021.07.006. View

10.

Yang J, Kim D, Park S . Comparison of Fusion, Subsidence, and Clinical Results Between 3D-Printed Porous Titanium Cage and Polyetheretherketone Cage in Posterior Lumbar Interbody Fusion: A Minimum of 2 Years Follow-Up. World Neurosurg. 2023; . DOI: 10.1016/j.wneu.2023.06.132. View

11.

Chu P, Wang T, Zheng J, Xu C, Yan Y, Ma Q . Global and Current Research Trends of Unilateral Biportal Endoscopy/Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Degenerative Diseases: A Bibliometric and Visualization Study. Orthop Surg. 2022; 14(4):635-643. PMC: 9002063. DOI: 10.1111/os.13216. View

12.

Bridwell K, Lenke L, McEnery K, Baldus C, Blanke K . Anterior fresh frozen structural allografts in the thoracic and lumbar spine. Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects?. Spine (Phila Pa 1976). 1995; 20(12):1410-8. View

13.

Zhao L, Xie T, Wang X, Yang Z, Pu X, Lu Y . Clinical and radiological evaluation of cage subsidence following oblique lumbar interbody fusion combined with anterolateral fixation. BMC Musculoskelet Disord. 2022; 23(1):214. PMC: 8898418. DOI: 10.1186/s12891-022-05165-4. View

14.

Oh K, Lee J, Lee J, Lee D, Shim H . The Correlation Between Cage Subsidence, Bone Mineral Density, and Clinical Results in Posterior Lumbar Interbody Fusion. Clin Spine Surg. 2017; 30(6):E683-E689. DOI: 10.1097/BSD.0000000000000315. View

15.

Zhang X, Wu H, Chen Y, Liu J, Chen J, Zhang T . Importance of the epiphyseal ring in OLIF stand-alone surgery: a biomechanical study on cadaveric spines. Eur Spine J. 2020; 30(1):79-87. DOI: 10.1007/s00586-020-06667-2. View

16.

Tohmeh A, Khorsand D, Watson B, Zielinski X . Radiographical and clinical evaluation of extreme lateral interbody fusion: effects of cage size and instrumentation type with a minimum of 1-year follow-up. Spine (Phila Pa 1976). 2014; 39(26):E1582-91. DOI: 10.1097/BRS.0000000000000645. View

17.

Lewandrowski K, Ransom N, Yeung A . Subsidence induced recurrent radiculopathy after staged two-level standalone endoscopic lumbar interbody fusion with a threaded cylindrical cage: a case report. J Spine Surg. 2020; 6(Suppl 1):S286-S293. PMC: 7063320. DOI: 10.21037/jss.2019.09.25. View

18.

Kim J, Choi D . Biportal Endoscopic Transforaminal Lumbar Interbody Fusion with Arthroscopy. Clin Orthop Surg. 2018; 10(2):248-252. PMC: 5964275. DOI: 10.4055/cios.2018.10.2.248. View

19.

Kim Y, Ha K, Kim Y, Kim K, Rhyu K, Park J . Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion. Asian Spine J. 2022; 16(6):1022-1033. PMC: 9827209. DOI: 10.31616/asj.2022.0435. View

20.

Kim D, Kwon O, Park J . Comparison Between 3-Dimensional-Printed Titanium and Polyetheretherketone Cages: 1-Year Outcome After Minimally Invasive Transforaminal Interbody Fusion. Neurospine. 2022; 19(3):524-532. PMC: 9537857. DOI: 10.14245/ns.2244140.070. View