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A systematic review of metal ion concentrations following instrumented spinal fusion

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Abstract

Purpose

Metallic spinal implants undergo wear and corrosion which liberates ionic or particulate metal debris. The purpose of this study was to identify and review studies that report the concentration of metal ions following multi-level spinal fusion and to evaluate the impact on clinical outcomes.

Methods

Databases (PubMed, EBSCO MEDLINE) were searched up to August 2019 for studies in English-language assessing metal ion levels [chromium (Cr), titanium (Ti), nickel (Ni)] in whole blood, serum, or plasma after spinal fusion using a specific search string. Study, patient, and implant characteristics, method of analysis, metal ion concentration, as well as clinical and radiographic results was extracted.

Results

The systematic search yielded 18 studies encompassing 653 patients. 9 studies reported Ti ions, eight reported Cr, and six reported Ni. Ti levels were elevated compared to controls/reference range/preoperative baseline in seven studies with the other two reporting no difference. Cr levels were elevated compared to controls/reference range in seven studies with one reporting no difference. Ni levels showed no difference from controls/reference range in four studies with one reporting above normal and another elevated compared to controls. Radiographic evidence of corrosion, implant failure, pseudarthrosis, revision surgery and adverse reaction reporting was highly variable.

Conclusion

Metal ions are elevated after instrumented spinal fusion; notably Cr levels from stainless steel implants and Ti from titanium implants. The association between clinical and radiographic outcomes remain uncertain but is concerning. Further research with standardized reporting over longer follow-up periods is indicated to evaluate the clinical impact and minimizing risk.

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Funding

No funding was received for this work.

Author information

Authors and Affiliations

  1. RCSI Bahrain, Busaiteen, Muharraq, Bahrain

    Omar Siddiqi

  2. Department of Surgery, London Health Sciences Center, E1-311, 800 Commissioners Road, East, London, ON, N6A 4G5, Canada

    Jennifer C. Urquhart & Parham Rasoulinejad

  3. Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

    Parham Rasoulinejad

  4. Lawson Health Research Institute, London, ON, Canada

    Jennifer C. Urquhart & Parham Rasoulinejad

Authors
  1. Omar Siddiqi
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  2. Jennifer C. Urquhart
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  3. Parham Rasoulinejad
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Contributions

OS: made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JCU: made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. PR: made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Parham Rasoulinejad.

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Conflict of interest

OS declares no conflict of interest; JCU declares no conflict of interest; PR declares no conflict of interest.

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This study did not require IRB approval since no patients were identified or directly involved in the analysis.

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Appendix

Appendix

See Tables 8, 9, 10, and 11.

Table 8 Strings of search terms
Full size table
Table 9 SIGN checklist cohort studies
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Table 10 SIGN checklist case–control studies
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Table 11 SIGN checklist RCT
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Siddiqi, O., Urquhart, J.C. & Rasoulinejad, P. A systematic review of metal ion concentrations following instrumented spinal fusion. Spine Deform 9, 13–40 (2021). https://doi.org/10.1007/s43390-020-00177-3

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  • DOI: https://doi.org/10.1007/s43390-020-00177-3

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