Posterior Lumbar Interbody Fusion Using New Hydroxyapatite Block - Comparison with Metal and PEEK Cages -

Jae-Yoon Chung; Bong-Soon Chang; Choon-Ki Lee; Jae-Hyup Lee; Chang-Bae Kong; Jin-Sup Yeom; Kun-Woo Park; Hyuk-Ju Moon

doi:10.7469/JKSS.2009.16.4.243

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Chung, Chang, Lee, Lee, Kong, Yeom, Park, and Moon: Posterior Lumbar Interbody Fusion Using New Hydroxyapatite Block - Comparison with Metal and PEEK Cages -

Original Research

Journal of Korean Spine Surg 2009;16(4):243-250.

Published online: 18 January 2009

DOI: https://doi.org/10.7469/JKSS.2009.16.4.243

Posterior Lumbar Interbody Fusion Using New Hydroxyapatite Block - Comparison with Metal and PEEK Cages -

Jae-Yoon Chung, M.D., Bong-Soon Chang, M.D., Choon-Ki Lee, M.D., Jae-Hyup Lee, M.D., Chang-Bae Kong, M.D., Jin-Sup Yeom, M.D., Kun-Woo Park, M.D., Hyuk-Ju Moon, M.D.

Department of Orthopedic Surgery, College of Medicine, Seoul National University, Seoul, Korea

Address reprint requests to Bong-Soon Chang, M.D. Department of Jrthopedic Surgery, College of Medicine, Seoul National University, Seoul, Korea 101 Daehang-ro, Jongno-gu, Seoul, 110-744, Korea Tel: 82-2-2072-3864, Fax: 82-2-764-2718, E-mail: bschang@snu.ac.kr

Received 6 March 2009 Accepted 17 November 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

This is a retrospective study Objectives: This study compared the clinical outcomes of posterior lumbar interbody fusion (PLIF) using hydroxyapatite blocks with PLIF using a metal or poly-ether-ether-ketone (PEEK) cage. Summary of the Literature Review: There are few reports on the clinical outcomes of PLIF using a hydroxyapatite block for treating lumbar degenerative disease.

Materials and Methods

The 27 PLIF cases (62 units, HA block) that were followed up for 1-year were compared with 13 cases using a metal cage and 13 cases using a PEEK cage. Pedicle screw fixation was performed for all the cases. If the local bone is deficient, then an additional bone graft with autogeous iliac bone or bone substitute was used. The visual analog scale(VAS) for low back pain and radiating pain, the Oswestry disability index (ODI), the intervertebral height and the halo sign around the cages and pedicle screws were comparatively analyzed.

Results

The mean VAS score for low back pain before PLIF and using the HA block, the metal cage and the PEEK cage was 7.5, 8.3 and 6.2, respectively, and this was 3.3, 2.9 and 4.8 after PLIF (P<0.05 with using the HA block and the metal cage (Wilcoxon test). The mean VAS score for radiating pain before PLIF was 7.9, 8.3 and 8.5, respectively, and the VAS score was 3.5, 3.1 and 3.9, respectively, after PLIF (P<0.05 for all cases, Wilcoxon test). For the ODI, the means before PLIF were 60.3, 51.2 and 53.8, respectively, and they changed to 30.5, 24.9 and 29.7, respectively, after PLIF (P<0 .05 for all cases, Wilcoxon test). On the X-ray images, there was no halo sign greater than 2 mm near the pedicle screws or greater than 1 mm near the cages and no breakage of the HA block. No additional bone graft was needed for the PLIF using the HA block and local bone. There was no statistically significant differences among the groups (P< 0.05, One-way ANOVA).

Conclusion

PLIF using a HA block showed improvements, including the back pain, and the ODI was satisfactory and this didn't fall below those ODIs of using metal or PEEK cages. Although a HA block may have higher tendency to break, there was no breakage at the 1-year follow up.

Keywords: Posterior lumbar interbody fusion, Hydroxyapatite block, metal cage, PEEK cage

REFERENCES

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Fig. 1.

Close-up photograph and schematic design showing HA block(Bongros<-HA, Bioalpha<).

Fig. 2.

The sequential standing lateral radiographs of sixty-six-year-old female patient suffering from spinal stenosis with spondylolisthesis L4 on L5. She was treated with PLIF using local bone grafts and HA blocks. (A) The preoperative lateral radiograph showed a anterior transposition of L4 on L5 vertebral body. (B) The immediately postoperative lateral radiograph shows HA blocks with autogenous local bone graft and pedicle screw stabilization on L4-5. (C) The postoperative lateral radiograph (6 months later) shows bony bridging shadow between L4 and L5 vertebral body and the better visualization of grafted local bone surround HA blocks than initial image. (D) The postoperative lateral radiograph (12 months later) shows a better trabecular bony fusion between L4 and L5 vertebral body and well-maintained HA blocks.

Table 1.

Classification of fusion results (Brantigan and Steffee, 1991)^9,10)

Classification	Description
A	Obvious collapse of construct due to pseudoarthrosis, loss of disc height, vertebral slip, broken screws, displacement of the cage, resorption of bone graft.
B	Probable significant resorption of the bone graft due to pseudoarthrosis, major lucency, or gap visible in fusion area (2 mm around the entire periphery of graft).
C	Uncertain non-union, bone graft visible in the fusion area at approximately the density originally achieved at surgery.
	A small lucency or gap may be visible involving a portion of the fusion area with at least half of the graft area.
D	Probable fusion bone bridges entire fusion area with at least the density achieved at surgery.
	There should be no lucency between the donor and vertebral bone.
E	Fusion bone in the fusion area is radiographically more dense and mature than originally achieved by surgery.
	Optimally, there is no interface between the donor and vertebral bone, although a sclerotic line between the graft and vertebral bone indicates fusion. Other signs of the solid fusion include mature bony trabeculae bridging the fusion area, resorption of the anterior traction spur, anterior progression of the graft within disc space, and fusion of facet joints.

Table 2.

Data of three groups using HA blocks, metal cages, PEEK cages according to the fusion level

	HA block	Metal cage	PEEK cage
Number of cases	27	13	13
1 level PLIF (%)	23 (85.2%)	10 (76.9%)	10 (76.9%)
2 level PLIF (%)	4 (14.8%)	3 (23.1%)	3 (23.1%)
Mean (level)	1.15	1.23	1.23

Table 3.

Difference of Visual Analogue Scale(VAS) and Oswestry Disability Index(ODI) between preoperativestate and at 1-year follow-up after PLIF surgery

	HA block			Metal cage	PEEK cage		Difference between three groups (P-value)
	PreOP∗	PO 1Y∗∗	PreOP∗	PO 1Y∗∗	PreOP∗	PO 1Y∗∗	Difference between three groups (P-value)
VAS (lower back)	7.5±1.6	3.3±2.2	8.3±1.4	2.9±2.5	6.2±3.9	4.8±3.9	> 0.05
Improved Sx. (%)		56.4%		64.7%		32.9%
VAS (lower Ext.)	7.9±1.7	3.5±2.4	8.3±1.4	3.1±2.7	8.5±1.2	3.9±3.7	> 0.05
Improved Sx. (%)		56.4%		62.3%		54.1%
ODI	60.3±14.1	30.5±18.1	51.2±19.0	24.9±20.6	53.8±22.8	29.7±23.7	> 0.05
Improved ODI(%)		49.4%		51.5%		44.8%

PreOP∗, preoperative state; PO 1Y∗∗, follow-up at 1 years after PLIF surgery.

Table 4.

Anteroposterior (AP) disc height at immediate postoperative state and at 1-year follow-up after PILF

	HA block		Metal cage		PEEK cage		Difference between three groups (P-value)
	IMPO∗	PO 1Y∗∗	IMPO∗	PO 1Y∗∗	IMPO∗	PO 1Y∗∗	Difference between three groups (P-value)
MIH^†(mm)	13.44±1.69	13.16±1.71	14.90±1.57	14.60±1.48	12.21±1.48	11.89±0.97	> 0.05
Collapsed MIH^† (No. of cases)		0		0		0

IMPO∗, immediate postoperative state;

PO 1Y∗∗, follow-up at 1 years after PLIF surgery.

MIH†, middle intervertebral height (The middle intervertebral height was defined as the shortest distance between the center of a line bisecting the lower end plate and the line bisecting the upper end plate.)

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