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Evaluation of cage subsidence in standalone lateral lumbar interbody fusion: novel 3D-printed titanium versus polyetheretherketone (PEEK) cage



This study aims to compare the early subsidence rate (6–12 months) of standalone novel 3D-printed titanium (Ti) versus polyetheretherketone (PEEK) interbody cages after lateral lumbar interbody fusion (LLIF).


A retrospective study of 113 patients (186 levels) who underwent LLIF surgery with Ti or PEEK cages was conducted. Early subsidence was measured in each treated level using the Marchi et al. classification in radiographs or CT scans acquired at 6–12 months follow-up. Multivariate logistic regression analyses with generalized mixed models, setting subsidence as the outcome variable and including cage type (Ti vs PEEK) as well as significant and trending variables (p < 0.10) in univariate analyses, were conducted.


In total, 51 female and 62 male patients were analyzed. The median [IQR] age at surgery was 60.0 [51.0–70.0] years. Of the 186 levels, 119 levels were treated using PEEK and 67 levels with Ti cages. The overall subsidence rate for Grades I-III was significantly less in the Ti versus the PEEK group (p = 0.003). For high-grade subsidence (Grade II or III), Ti cages also demonstrated a subsidence rate (3.0%) that was significantly less compared to PEEK cages (18.5%) (p = 0.002). Multivariate analysis showed that patients treated with Ti cages were less likely to develop severe subsidence compared to those treated with PEEK (OR = 0.05, 95% CI = 0.01, 0.30) (p = 0.001).


Our study demonstrated that 3D-printed novel Ti cages had a significantly lower early subsidence rate compared to PEEK cages in standalone LLIF patients.

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Availability of data and material

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


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Author information




DAA performed all measurements and grading, collected all the data and wrote the manuscript. IO analyzed the data and reviewed and edited the manuscript. LO help validating the grade of subsidence and reviewed and edited the manuscript. EC reviewed and edited the manuscript. JZ analyzed the data. JS wrote the research plan for IRB approval and was in charge of the clinical research process and the project administration. AAS designed the study and reviewed and edited the manuscript. FPC designed the study and reviewed and edited the manuscript. FPG designed the study and reviewed and edited the manuscript. APH designed the study, reviewed and edited the manuscript and supervised all aspects of the study. All authors have read and approved the final submitted manuscript.

Corresponding author

Correspondence to Alexander P. Hughes.

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Conflict of interest

DAA, IO, LO, JZ, EC, JS have no relevant financial or non-financial interests to disclose. AAS declares financial interests: Royalties: Ortho Development Corp; Private investments: Vestia Ventures MiRUS Investment LLC, ISPH II LLC, ISPH 3 LLC, VBros Venture Partners X Centinel Spine; Consulting: Clariance Inc, Kuros Bioscience AG, Medical Device Business Services Inc.; Speaking and Teaching Arrangements: DePuy Synthes Products Inc.; Trips/Travel: Medical Device Business Services Inc; Research Support: Spinal Kinetcs Inc. FPC declares financial interests: Royalties: NuVasive Inc; Private investments: Bonovo Orthopedics Inc, Healthpoint Capital Partners LP, ISPH II LLC, Ivy Healthcare Capital Partners LLC, Medical Device Partners II LLC, Medical Device Partners III LLC, Orthobond Corporation, Spine Biopharma LLC, Tissue Differentiation Intelligence LLC, VBVP VI LLC, Woven Orthopedics Technologies; Consulting: 4Web Medical/4Web Inc, Spine Biopharma LLC, Research Support: 4Web Medical/4Web Inc, Beatrice & Samuel A. Seaver Foundation; Non-financial interests: Scientific Advisory Board: Healthpoint Capital Partners LP, Orthobond Corporation, Spine Biopharma LLC, Woven Orthopedic Technologies. FPG declares financial interests: Royalties: NuVasive Inc, Ortho Development Corp, Zimmer Biomet Holdings INC; Stock Ownership: Bonovo Orthopedics Inc, Liventa Bioscience (AF Cell Medical), Paradigm Spine LLC, Healthpoint Capital Partners LP, Alphatec Holdings LLC, LANX Inc, Centinel Spine Inc (fka Raymedica LLC), Tissue Differentiation Intelligence LLC, Spine Kinetics Inc; Consulting: DePuy Synthes Spine, NuVasive Inc, Non-financial interests: Consulting: EIT Emerging Implant Technologies, Spineart USA Inc, Ethicon Inc,. APH declares financial interests: Research Support: 4Web Medical; Fellowship Support: NuVasive Inc, Kuros Bioscience B.V. (Fig. 1)

Ethics approval, Consent to participate and Consent for publication

This study was approved by our hospital’s Institutional Review Board, and informed consent was waived due to the retrospective nature of this study. (IRB# 2014–097).

Fig. 1

Cage subsidence examples; a titanium cage multilevel SA-LLIF (L2/L3 Grade III, L3/L4 Grade 0, L4/L5 Grade 0); b PEEK cage multilevel SA-LLIF (L2/L3 Grade 0, L3/L4 Grade 0, L4/L5 Grade III)

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Adl Amini, D., Okano, I., Oezel, L. et al. Evaluation of cage subsidence in standalone lateral lumbar interbody fusion: novel 3D-printed titanium versus polyetheretherketone (PEEK) cage. Eur Spine J 30, 2377–2384 (2021).

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  • LLIF
  • Standalone
  • Cage subsidence
  • Titanium
  • PEEK
  • Lumbar fusion