Clinical and Radiographic Outcomes of Anterior Lumbar Interbody Fusions Using a Titanium Cage with a Biomimetic Surface

Patrick K. Jowdy; Mohamed A.R. Soliman; Esteban Quiceno; Shady Azmy; Daniel O. Popoola; Alexander O. Aguirre; Asham Khan; Paul J. Slosar; John Pollina; Jeffrey P. Mullin

doi:10.1055/a-2275-0528

Journal of Neurological Surgery Part A: Central European Neurosurgery, Table of Contents

J Neurol Surg A Cent Eur Neurosurg 2025; 86(03): 238-246
DOI: 10.1055/a-2275-0528

Original Article

Clinical and Radiographic Outcomes of Anterior Lumbar Interbody Fusions Using a Titanium Cage with a Biomimetic Surface

Patrick K. Jowdy

¹Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

²Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, United States

,

Mohamed A.R. Soliman

¹Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

²Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, United States

³Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt

,

Esteban Quiceno

¹Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

²Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, United States

,

Shady Azmy

⁴Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

,

Daniel O. Popoola

⁴Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

,

Alexander O. Aguirre

⁴Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

,

Asham Khan

¹Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

²Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, United States

,

Paul J. Slosar

⁵Peninsula Orthopedic Associates, Daly City, California, United States

,

John Pollina

¹Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

²Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, United States

,

Jeffrey P. Mullin

¹Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, United States

²Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, United States

› Author Affiliations

Abstract

Background We analyzed clinical and radiographic outcomes in patients undergoing anterior lumbar interbody fusions (ALIFs) using a new biomimetic titanium fusion cage (Titan nanoLOCK interbody, Medtronic, Minneapolis, Minnesota, United States). This specialized cage employs precise nanotechnology to stimulate inherent biochemical and cellular osteogenic reactions to the implant, aiming to amplify the rate of fusion. To our knowledge, this is the only study to assess early clinical and radiographic results in ALIFs.

Methods We conducted a retrospective review of data for patients who underwent single or multilevel ALIF using this implant between October 2016 and April 2021. Indications for treatment were spondylolisthesis, postlaminectomy syndrome, or spinal deformity. Clinical and radiographic outcome data for these patients were collected and assessed.

Results A total of 84 patients were included. The mean clinical follow-up was 36.6 ± 14 months. At 6 months, solid fusion was seen in 97.6% of patients. At 12 months, solid fusion was seen in 98.8% of patients. Significant improvements were seen in patient-reported outcome measures (PROMs; visual analog scale and Oswestry Disability Index) at 6 and 12 months compared with the preoperative scores (p < 0.001). One patient required reoperation for broken pedicle screws 2 days after the ALIF. None of the patients required readmission within 90 days of surgery. No patients experienced an infection.

Conclusions ALIF using a new titanium interbody fusion implant with a biomimetic surface technology demonstrated high fusion rates (97.6%) as early as 6 months. There was significant improvement in PROMs at 6 and 12 months.

Keywords

anterior lumbar interbody fusion - biomimetic surfaces - clinical outcomes - fusion - nanosurface technology - titanium

Full Text

References

References
1 Biondi J, Greenberg BJ. Redecompression and fusion in failed back syndrome patients. J Spinal Disord 1990; 3 (04) 362-369
2 Aota Y, Kumano K, Hirabayashi S. Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord 1995; 8 (06) 464-473
3 Turner JA, Loeser JD, Deyo RA, Sanders SB. Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications. Pain 2004; 108 (1–2): 137-147
4 Blumenthal S, McAfee PC, Guyer RD. et al. A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine 2005; 30 (14) 1565-1575 , discussion E387–E391
5 Djurasovic M, Glassman SD, Howard JM, Copay AG, Carreon LY. Health-related quality of life improvements in patients undergoing lumbar spinal fusion as a revision surgery. Spine 2011; 36 (04) 269-276
6 North RB, Kidd D, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery 2007; 61 (02) 361-368 , discussion 368–369
7 Ahmed SI, Bastrom TP, Yaszay B, Newton PO. Harms Study Group. 5-year reoperation risk and causes for revision after idiopathic scoliosis surgery. Spine 2017; 42 (13) 999-1005
8 Hofler RC, Swong K, Martin B, Wemhoff M, Jones GA. Risk of pseudoarthrosis after spinal fusion: analysis from the healthcare cost and utilization project. World Neurosurg 2018; 120: e194-e202
9 Adogwa O, Owens R, Karikari I. et al. Revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, adjacent-segment disease, or same-level recurrent stenosis. Part 2. A cost-effectiveness analysis: clinical article. J Neurosurg Spine 2013; 18 (02) 147-153
10 Adogwa O, Parker SL, Shau D. et al. Cost per quality-adjusted life year gained of revision fusion for lumbar pseudoarthrosis: defining the value of surgery. J Spinal Disord Tech 2015; 28 (03) 101-105
11 Banczerowski P, Czigléczki G, Papp Z, Veres R, Rappaport HZ, Vajda J. Minimally invasive spine surgery: systematic review. Neurosurg Rev 2015; 38 (01) 11-26 , discussion 26
12 Aunoble S, Hoste D, Donkersloot P, Liquois F, Basso Y, Le Huec JC. Video-assisted ALIF with cage and anterior plate fixation for L5-S1 spondylolisthesis. J Spinal Disord Tech 2006; 19 (07) 471-476
13 Mamuti M, Fan S, Liu J. et al. Mini-open anterior lumbar interbody fusion for recurrent lumbar disc herniation following posterior instrumentation. Spine 2016; 41 (18) E1104-E1114
14 Xiao R, Miller JA, Sabharwal NC. et al. Clinical outcomes following spinal fusion using an intraoperative computed tomographic 3D imaging system. J Neurosurg Spine 2017; 26 (05) 628-637
15 Mobbs RJ, Chung M, Rao PJ. Bone graft substitutes for anterior lumbar interbody fusion. Orthop Surg 2013; 5 (02) 77-85
16 Verma R, Virk S, Qureshi S. Interbody fusions in the lumbar spine: a review. HSS J 2020; 16 (02) 162-167
17 Najeeb S, Bds ZK, Bds SZ, Bds MS. Bioactivity and osseointegration of PEEK are inferior to those of titanium: a systematic review. J Oral Implantol 2016; 42 (06) 512-516
18 Willems K, Lauweryns P, Verleye G, VAN Goethem J. Randomized controlled trial of posterior lumbar interbody fusion with Ti- and CaP-nanocoated polyetheretherketone cages: comparative study of the 1-year radiological and clinical outcome. Int J Spine Surg 2019; 13 (06) 575-587
19 Olivares-Navarrete R, Gittens RA, Schneider JM. et al. Osteoblasts exhibit a more differentiated phenotype and increased bone morphogenetic protein production on titanium alloy substrates than on poly-ether-ether-ketone. Spine J 2012; 12 (03) 265-272
20 Matteson JL, Greenspan DC, Tighe TB, Gilfoy N, Stapleton JJ. Assessing the hierarchical structure of titanium implant surfaces. J Biomed Mater Res B Appl Biomater 2016; 104 (06) 1083-1090
21 Olivares-Navarrete R, Hyzy SL, Slosar PJ, Schneider JM, Schwartz Z, Boyan BD. Implant materials generate different peri-implant inflammatory factors: poly-ether-ether-ketone promotes fibrosis and microtextured titanium promotes osteogenic factors. Spine 2015; 40 (06) 399-404
22 Berger M, Cohen DJ, Bosh K. et al. 90. Nanoroughened microstructured orthopedic implant surfaces induce osteogenesis via soluble signaling factors produced by MSCs. Spine J 2020; 20 (09) S44
23 U.S. Food & Drug Administration, Office of the Commissioner, Office of Policy, Legislation, and International Affairs. Considering Whether an FDA-Regulated Product Involves the Application of Nanotechnology. 2014 . Accessed September 3, 2022 at: http://www.fda.gov/RegulatoryInformation/Guidances/ucm257698.htm
24 Agha RA, Fowler AJ, Rajmohan S, Barai I, Orgill DP. PROCESS Group. Preferred reporting of case series in surgery; the PROCESS guidelines. Int J Surg 2016; 36 (Pt A): 319-323
25 Strube P, Hoff E, Hartwig T, Perka CF, Gross C, Putzier M. Stand-alone anterior versus anteroposterior lumbar interbody single-level fusion after a mean follow-up of 41 months. J Spinal Disord Tech 2012; 25 (07) 362-369
26 Brantigan JW, Steffee AD, Lewis ML, Quinn LM, Persenaire JM. Lumbar interbody fusion using the Brantigan I/F cage for posterior lumbar interbody fusion and the variable pedicle screw placement system: two-year results from a Food and Drug Administration investigational device exemption clinical trial. Spine 2000; 25 (11) 1437-1446
27 Elsig JP, Laloux E, Commarmond J. Lumbar interbody fusion with PEKEKK composite cages. Spinal Restabilization Procedures. 2002; 1: 171-189
28 Chan AY, Lien BV, Choi EH. et al. Back pain outcomes after minimally invasive anterior lumbar interbody fusion: a systematic review. Neurosurg Focus 2020; 49 (03) E3
29 Garcia RM, Choy W, DiDomenico JD. et al. Thirty-day readmission rate and risk factors for patients undergoing single level elective anterior lumbar interbody fusion (ALIF). J Clin Neurosci 2016; 32: 104-108
30 Chan AK, Mummaneni PV, Shaffrey CI. Approach selection: multiple anterior lumbar interbody fusion to recreate lumbar lordosis versus pedicle subtraction osteotomy: when, why, how?. Neurosurg Clin N Am 2018; 29 (03) 341-354
31 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
32 Cutler AR, Siddiqui S, Mohan AL, Hillard VH, Cerabona F, Das K. Comparison of polyetheretherketone cages with femoral cortical bone allograft as a single-piece interbody spacer in transforaminal lumbar interbody fusion. J Neurosurg Spine 2006; 5 (06) 534-539
33 Niu CC, Liao JC, Chen WJ, Chen LH. Outcomes of interbody fusion cages used in 1 and 2-levels anterior cervical discectomy and fusion: titanium cages versus polyetheretherketone (PEEK) cages. J Spinal Disord Tech 2010; 23 (05) 310-316
34 Toth JM, Wang M, Estes BT, Scifert JL, Seim III HB, Turner AS. Polyetheretherketone as a biomaterial for spinal applications. Biomaterials 2006; 27 (03) 324-334
35 Campbell PG, Cavanaugh DA, Nunley P. et al. PEEK versus titanium cages in lateral lumbar interbody fusion: a comparative analysis of subsidence. Neurosurg Focus 2020; 49 (03) E10
36 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
37 Cuzzocrea F, Ivone A, Jannelli E. et al. PEEK versus metal cages in posterior lumbar interbody fusion: a clinical and radiological comparative study. Musculoskelet Surg 2019; 103 (03) 237-241
38 Virk S, Qureshi S, Sandhu H. History of spinal fusion: where we came from and where we are going. HSS J 2020; 16 (02) 137-142
39 Formica M, Quarto E, Zanirato A. et al. ALIF in the correction of spinal sagittal misalignment. A systematic review of literature. Eur Spine J 2021; 30 (01) 50-62
40 Shim JH, Kim WS, Kim JH, Kim DH, Hwang JH, Park CK. Comparison of instrumented posterolateral fusion versus percutaneous pedicle screw fixation combined with anterior lumbar interbody fusion in elderly patients with L5-S1 isthmic spondylolisthesis and foraminal stenosis. J Neurosurg Spine 2011; 15 (03) 311-319
41 Lee DG, Park CK, Lee DC. Clinical and radiological comparison of 2 level anterior lumbar interbody fusion with posterolateral fusion and percutaneous pedicle screw in elderly patients with osteoporosis. Medicine (Baltimore) 2020; 99 (10) e19205
42 Mannion RJ, Nowitzke AM, Wood MJ. Promoting fusion in minimally invasive lumbar interbody stabilization with low-dose bone morphogenic protein-2: but what is the cost?. Spine J 2011; 11 (06) 527-533
43 Pugely AJ, Petersen EB, DeVries-Watson N, Fredericks DC. Influence of 45S5 bioactive glass in a standard calcium phosphate collagen bone graft substitute on the posterolateral fusion of rabbit spine. Iowa Orthop J 2017; 37: 193-198
44 Roh JS, Yeung CA, Field JS, McClellan RT. Allogeneic morphogenetic protein vs. recombinant human bone morphogenetic protein-2 in lumbar interbody fusion procedures: a radiographic and economic analysis. J Orthop Surg Res 2013; 8: 49
45 Cohen JD, Kanim LE, Tronits AJ, Bae HW. Allografts and spinal fusion. Int J Spine Surg 2021; 15 (s1): 68-93
46 Noh T, Zakaria H, Massie L, Ogasawara CT, Lee GA, Chedid M. Bone marrow aspirate in spine surgery: case series and review of the literature. Cureus 2021; 13 (12) e20309
47 Hostin R, O'Brien M, McCarthy I, Bess S, Gupta M, Klineberg E. International Spine Study Group, Denver, CO. Retrospective study of anterior interbody fusion rates and patient outcomes of using mineralized collagen and bone marrow aspirate in multilevel adult spinal deformity surgery. Clin Spine Surg 2016; 29 (08) E384-E388
48 Mulconrey DS, Bridwell KH, Flynn J, Cronen GA, Rose PS. Bone morphogenetic protein (RhBMP-2) as a substitute for iliac crest bone graft in multilevel adult spinal deformity surgery: minimum two-year evaluation of fusion. Spine 2008; 33 (20) 2153-2159
49 Carreon LY, Djurasovic M, Glassman SD, Sailer P. Diagnostic accuracy and reliability of fine-cut CT scans with reconstructions to determine the status of an instrumented posterolateral fusion with surgical exploration as reference standard. Spine 2007; 32 (08) 892-895
50 Fogel GR, Toohey JS, Neidre A, Brantigan JW. Fusion assessment of posterior lumbar interbody fusion using radiolucent cages: X-ray films and helical computed tomography scans compared with surgical exploration of fusion. Spine J 2008; 8 (04) 570-577
51 Carreon LY, Glassman SD, Djurasovic M. Reliability and agreement between fine-cut CT scans and plain radiography in the evaluation of posterolateral fusions. Spine J 2007; 7 (01) 39-43
52 Carreon LY, Glassman SD, Schwender JD, Subach BR, Gornet MF, Ohno S. Reliability and accuracy of fine-cut computed tomography scans to determine the status of anterior interbody fusions with metallic cages. Spine J 2008; 8 (06) 998-1002
53 Choudhri TF, Mummaneni PV, Dhall SS. et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 4: radiographic assessment of fusion status. J Neurosurg Spine 2014; 21 (01) 23-30
54 Park DK, Rhee JM, Kim SS, Enyo Y, Yoshiok K. Do CT scans overestimate the fusion rate after anterior cervical discectomy and fusion?. J Spinal Disord Tech 2015; 28 (02) 41-46
55 Patil ND, El Ghait HA, Boehm C, Boehm H. Evaluation of spinal fusion in thoracic and thoracolumbar spine on standard X-rays: a new grading system for spinal interbody fusion. Global Spine J 2022; 12 (07) 1481-1494