PEEK interbody devices for multilevel anterior cervical discectomy and fusion: association with more than 6-fold higher rates of pseudarthrosis compared to structural allograft

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Common interbody graft options for anterior cervical discectomy and fusion (ACDF) include allograft and polyetheretherketone (PEEK). PEEK has gained popularity due to its radiolucent properties and a modulus of elasticity similar to that of bone. PEEK devices also result in higher billing costs than allograft, which may drive selection. A previous study found a 5-fold higher rate of pseudarthrosis with the use of PEEK devices compared with structural allograft in single-level ACDF. Here the authors report on the occurrence of pseudarthrosis with PEEK devices versus structural allograft in patients who underwent multilevel ACDF.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors retrospectively reviewed 81 consecutive patients who underwent a multilevel ACDF and had radiographic follow-up for at least 1 year. Data were collected on age, sex, BMI, tobacco use, pseudarthrosis, and rate of reoperation for pseudarthrosis. Logistic regression was used for data analysis.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Of 81 patients, 35 had PEEK implants and 46 had structural allograft. There were no significant differences between age, sex, smoking status, or BMI in the 2 groups. There were 26/35 (74%) patients with PEEK implants who demonstrated radiographic evidence of pseudarthrosis, compared with 5/46 (11%) patients with structural allograft (p &lt; 0.001, OR 22.2). Five patients (14%) with PEEK implants required reoperation for pseudarthrosis, compared with 0 patients with allograft (p = 0.013).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This study reinforces previous findings on 1-level ACDF outcomes and suggests that the use of PEEK in multilevel ACDF results in statistically significantly higher rates of radiographic pseudarthrosis and need for revision surgery than allograft. Surgeons should consider these findings when determining graft options, and reimbursement policies should reflect these discrepancies.</jats:p></jats:sec>

Cellular allograft for multilevel stand-alone anterior cervical discectomy and fusion

“…The use of PEEK cages has been associated with higher rates of pseudarthrosis and, as such, represents a possible independent risk factor for fusion failure. 37,38…”

Anterior Cervical Discectomy and Fusion With “Kissing” Allograft Interbodies

“…With the rise of allograft and xenograft interbody options over structural iliac crest bone graft, there has been controversy regarding the incidence of pseudarthrosis and graft subsidence after ACDF [5][6][7]9]. In a systematic review of cervical pseudarthrosis by Leven and Cho, there was an overall fusion rate of 96% with one level ACDF with plate, 80%-95% fusion rate with 2-level ACDF with plate, and 70-80% fusion rate with > 2 level ACDF with plate with the use of structural allograft [5].…”

“…Patient charts, operative notes, radiographs, and post-operative clinic notes were reviewed to evaluate fusion rates, complications, and clinical outcomes. Bony fusion was evaluated on lateral cervical x-rays obtained at one-year post-op, as previously described by Teton and colleagues [ 6 ]. Exclusion criteria included any previous anterior or posterior cervical fusion surgery.…”

“…There remains controversy regarding the reported incidence of radiographic and clinical pseudarthrosis with the use of polyetheretherketone (PEEK) interbodies after ACDF [5][6][7][8]. Furthermore, there is evidence to suggest that the C5-6 and C6-7 levels have an intrinsically higher risk of pseudarthrosis than other cervical levels [9].…”

Recent Advances in PolyArylEtherKetones and Their In Vitro Evaluation for Hard Tissue Applications

“…The immunogenic effects of PEEK are still being explored and have not been widely confirmed in the peer-reviewed literature. Clinical evidence has emerged that rates of pseudarthrosis in medical procedures that utilized PEEK intervertebral bodies as spacers are greater than in cases that used metallic spacers (Sardana et al 2019;Teton et al 2020). While this recent evidence does not preclude the use of PEEK, the questions raised have led to a surge of innovations in PEEK design to overcome the emerging liabilities.…”