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A minimum 2-year comparative study of autologous cancellous bone grafting versus beta-tricalcium phosphate in anterior cervical discectomy and fusion using a rectangular titanium stand-alone cage

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Abstract

Although titanium stand-alone cages are commonly used in anterior cervical discectomy and fusion (ACDF), there are several concerns such as cage subsidence after surgery. The efficacy of β-tricalcium phosphate (β-TCP) granules as a packing material in 1- or 2-level ACDF using a rectangular titanium stand-alone cage is not fully understood. The purpose of this study is to investigate the validity of rectangular titanium stand-alone cages in 1- and 2-level ACDF with β-TCP. This retrospective study included 55 consecutive patients who underwent ACDF with autologous iliac cancellous bone grafting and 45 consecutive patients with β-TCP grafting. All patients completed at least 2-year postoperative follow-up. Univariate and multivariate analyses were performed to examine the associations between study variables and nonunion after surgery. Significant neurological recovery after surgery was obtained in both groups. Cage subsidence was noted in 14 of 72 cages (19.4 %) in the autograft group and 12 of 64 cages (18.8 %) in the β-TCP group. A total of 66 cages (91.7 %) in the autograft group showed osseous or partial union, and 58 cages (90.6 %) in the β-TCP group showed osseous or partial union by 2 years after surgery. There were no significant differences in cage subsidence and the bony fusion rate between the two groups. Multivariate analysis using a logistic regression model showed that fusion level at C6/7, 2-level fusion, and cage subsidence of grades 2–3 were significantly associated with nonunion at 2 years after surgery. Although an acceptable surgical outcome with negligible complication appears to justify the use of rectangular titanium stand-alone cages in 1- and 2-level ACDF with β-TCP, cage subsidence after surgery needs to be avoided to achieve acceptable bony fusion at the fused segments. Fusion level at C6/7 or 2-level fusion may be another risk factor of nonunion.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan

    Toru Yamagata

  2. Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan

    Toru Yamagata, Kentaro Naito, Hironori Arima, Kenji Ohata & Toshihiro Takami

  3. Department of Neurosurgery, Yao Tokushukai General Hospital, Osaka, Japan

    Masaki Yoshimura

Authors
  1. Toru Yamagata
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  2. Kentaro Naito
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  3. Hironori Arima
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  4. Masaki Yoshimura
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  5. Kenji Ohata
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  6. Toshihiro Takami
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Corresponding author

Correspondence to Toshihiro Takami.

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Comments

Luciano Mastronardi, Roma, Italy

This is a retrospective case analysis on 90 subjects treated with ACDF with titanium stand-alone cages containing β-TCP (45) versus autologous cancellous bone (55). The study is correctly performed on the scientific point of view, even if a longer follow-up could be useful.

The results are in line with the international literature on titanium cages for ACDF: the authors obtained an acceptable surgical outcome with negligible complications in both groups, justifying the use of rectangular titanium stand-alone cages in 1- and 2-level ACDF with β-TCP. Anyway, they conclude that cage subsidence after surgery needs to be avoided to achieve acceptable bony fusion at the fused segments. In particular, fusion level at C6–7 or 2-level fusion seems to be another risk factor of nonunion

Nonunion and pseudoarthrosis (especially in two- or three-level cases and in smokers) as far as subsidence are very well known problems in these procedures, in particular by using titanium cages. New materials, as trabecular metal (porous tantalum), carbon fiber, and PEEK cages, reduce significatively these problems. In particular, I recommend to use the trabecular metal cages for the arthrodesis in all those cases in which a more aggressive drilling of endplates has to be performed for the treatment of spondylotic cervical spinal cord compression.

H. Selim Karabekir, Izmir, Turkey

In this retrospective study, the authors compared rectangular titanium stand-alone cage with autolog graft group with titanium stand-alone cage with β- tricalcium phosphate (β-TCP). As the authors mentioned, in the study, the aim of using cages are to restore the disc physiologic height, promote arthrodesis, and provide load-bearing support to anterior column at cervical spine, clearly. The most common complications of anterior cervical discectomy and fusion (ACDF) procedure are pseudoarthrosis, subsidence, dislocations and infections of the cages, and intervertebral space. The authors compared 55 cases who underwent ACDF using rectangular titanium stand-alone cages with autolog iliac graft and 45 cases using the same cages with β-TCP. The follow-up period is adequate to evaluate the process. Grading subsidence is also sufficient for evaluating lower end plate (accurately upper and plate of lower vertebrae) of the intervertebral space, but sometimes, subsidence occurs at upper endplate (accurately lower end plate of upper vertebrae) or both upper and lower end plates (5). So maybe grading scale can be developed to considerate these subsidence sides. The criteria of the obtaining union or nonunion are adequate for evaluation. The subsidence rates for autograft group were 16.7 % at the first year and 19.4 % at the second year follow-up. These rates were 17.2 % at the first year and 18.8 % at the second year at β-TCP granules group. At the literature the subsidence of the cervical cages are changing from 12 to 28.6 % related with the material of the cages (1–5). The union (union + partial union) rates at autograft group are 16.7 + 65.3 % = 82 % at the first year and 91.7 % at the second year follow-up. These rates are 21.9 + 60.9 % = 82.8 % at the first year and 90.6 % at the second year of the follow-up period. In the literature, the nonunion rates are 10–12 % for single-level ACDF and 13–47 % for two or more levels ACDF by using cages only or cages + plates (1,6). The authors had similar results with the literature at the study. So as a conclusion, for obtaining excellent results, the comparing of cage types (titanium, peek, mesh, carbon, bioabsorble, etc.) must be thought as multicentre and the number of the cases must be bigger and the follow-up period must be longer than the studies in the literature.

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Yamagata, T., Naito, K., Arima, H. et al. A minimum 2-year comparative study of autologous cancellous bone grafting versus beta-tricalcium phosphate in anterior cervical discectomy and fusion using a rectangular titanium stand-alone cage. Neurosurg Rev 39, 475–482 (2016). https://doi.org/10.1007/s10143-016-0714-y

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