Graft subsidence and reoperation after lateral lumbar interbody fusion: a propensity score-matched and cost analysis of polyetheretherketone versus 3D-printed porous titanium interbodies

Objective: Lumbar interbody cage subsidence has a multifactorial etiology. Cage material, although well studied after transforaminal lumbar interbody fusion, has not been investigated as a contributing factor to subsidence after lateral lumbar interbody fusion (LLIF). In this study the authors compared rates of subsidence and reoperation after LLIF between polyetheretherketone (PEEK) and 3D-printed porous titanium (pTi) in an institutional propensity score-matched and cost analysis.

Methods: This is a retrospective observational cohort analysis of adult patients who underwent LLIF with pTi versus PEEK between 2016 and 2020. Demographic, clinical, and radiographic characteristics were collected. Propensity scores were calculated and 1:1 matching without replacement of surgically treated levels was performed. The primary outcome of interest was subsidence. The Marchi subsidence grade was determined at the time of last follow-up. Chi-square or Fisher's exact tests were used to compare subsidence and reoperation rates between lumbar levels treated with PEEK versus pTi. Modeling and cost analysis were performed using TreeAge Pro Healthcare.

Results: The authors identified a total of 192 patients; 137 underwent LLIF with PEEK (212 levels) and 55 had LLIF with pTi (97 levels). After propensity score matching, a total of 97 lumbar levels remained in each treatment group. After matching, there were no statistically significant differences between groups in baseline characteristics. Levels treated with pTi were significantly less likely to exhibit subsidence (any grade) compared to those treated with PEEK (8% vs 27%, p = 0.001). Five (5.2%) levels treated with PEEK required reoperation for subsidence, but only 1 (1.0%) level treated with pTi required reoperation for subsidence (p = 0.12). Given subsidence and revision rates experienced in the cohorts in this study, the pTi interbody device is economically superior to PEEK in a single-level LLIF as long as its cost is at least $1185.94 lower than that of PEEK.

Conclusions: The pTi interbody device was associated with less subsidence, but statistically similar revision rates after LLIF. pTi is potentially a superior economic choice at this study's reported revision rate.