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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 966-972

PEEK vs Titanium Cage for Anterior Column Reconstruction in Active Spinal Tuberculosis: A Comparative Study

Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission29-Jun-2020
Date of Decision14-Aug-2020
Date of Acceptance01-Feb-2021
Date of Web Publication2-Sep-2021

Correspondence Address:
Dr. Pankaj Kandwal
Department of Orthopaedics, AIIMS, Rishikesh - 249 203, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.325384

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 » Abstract 

Background: Posterolateral decompression and debridement in patients with TB spine led to defect in the anterior column which makes the spinal column unstable, thus making anterior column reconstruction an important step in surgical management.
Objective: Through the study, authors sought to answer the following questions: 1) What are the differences in clinical outcomes between patients with TB spine undergoing anterior column reconstruction using titanium mesh cage versus PEEK cage? 2) What are the differences in radiological outcomes between these two groups of patients?
Methods: This is a retrospective comparative study including patients with TB spine undergoing surgical management. The included subjects were divided into groups A and B depending on the implantation of PEEK or titanium mesh cage respectively for anterior column reconstruction. Outcome criteria analyzed included clinical criteria like VAS and ODI scores, radiological criteria like kyphosis correction, loss of kyphosis at follow-up, cage subsidence, and bony fusion on a 2D CT scan.
Results: The study population included 14 patients in Group A and 15 patients in Group B. Improvement in VAS and ODI scores was comparable between groups. There was no significant difference in radiological outcome measures between the two groups, however, two patients from group B showed implant-related complications needing revision. All patients showed good bony fusion at the final follow-up.
Conclusion: PEEK and titanium cages have comparable clinico-radiological outcomes for anterior column reconstruction in patients with active TB spine. Its advantages for being radiolucent and its ease of use may make it a choice of implant.

Keywords: Interbody fusion, PEEK cage, spine tuberculosis, thoracolumbar spine, titanium mesh cage
Key Message: PEEK cages are an attractive alternative to titanium cages for anterior column reconstruction in TB spine with comparable clinico.radiological outcomes.

How to cite this article:
Goyal N, Ahuja K, Yadav G, Gupta T, Ifthekar S, Kandwal P. PEEK vs Titanium Cage for Anterior Column Reconstruction in Active Spinal Tuberculosis: A Comparative Study. Neurol India 2021;69:966-72

How to cite this URL:
Goyal N, Ahuja K, Yadav G, Gupta T, Ifthekar S, Kandwal P. PEEK vs Titanium Cage for Anterior Column Reconstruction in Active Spinal Tuberculosis: A Comparative Study. Neurol India [serial online] 2021 [cited 2023 Jan 31];69:966-72. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/966/325384

The posterior approach for the surgical management of spinal tuberculosis (TB) achieves better deformity correction with less morbidity, early rehabilitation, and better functional outcomes.[1],[2],[3],[4] Posterolateral decompression and debridement lead to a defect in the anterior column which makes the spinal column unstable, thus making anterior column reconstruction an important step in the surgical management of these patients. The perfect material for anterior column reconstruction is debatable. An ideal interbody cage material should be biocompatible, have adequate compressive strength, non-mutagenic, non-cytotoxic, conducive to bone growth, and with a modulus of elasticity similar to bone. Additionally, it should be radiolucent and should not compromise the follow-up imaging. Over the last few decades, autogenous bone graft has been the most widely used interbody material to restore vertebral height following surgical debridement.[5] As shown by studies during the late part of the twentieth century, the titanium mesh cage became a good alternative to tricortical autologous bone graft as it offered several advantages over the latter.[5] But the disadvantages such as subsidence of the cage, difficulty in assessing the bony fusion due to radio-opacity, and high elastic modulus of the material led to the search for new materials for anterior column reconstruction. We explored the use of poly-ether-ether-ketone (PEEK) as a biocompatible alternative to metal implants in infective conditions owing to its radiolucent properties and ease of use.[6],[7] Although several studies have explored the use of tricortical graft and titanium mesh cage as an interbody spacer in the active tubercular spine, however, no study has analyzed the role of PEEK cage in TB of dorsal and lumbar spine to the best of our knowledge.[5],[8],[9],[10] The study aims to compare the clinico-radiological outcomes in patients with TB spine undergoing anterior column reconstruction with the titanium mesh cage and the PEEK cage.

 » Patients and Methods Top


This is a retrospective comparative study performed with the prospectively collected data at a single tertiary care institute. The records of all the patients surgically intervened for tubercular spine between July 2016 and Dec 2018 were reviewed after ethical clearance from the institutional review board. Patients aged 18–60 years with active dorsal or lumbar spine tuberculosis who underwent decompression, interbody fusion, and posterior instrumentation were included in the study. Patients, where interbody fusion was not done or done with the help of tricortical graft, were excluded from the study.

Surgery was indicated in patients due to progressive neurological deficit or neurological deficit not improving with a minimum of four weeks of ATT (Anti Tubercular Therapy) and instability: kyphosis more than 60°, the involvement of three or more consecutive vertebrae, pan-vertebral disease and presence of scoliosis.[11] Patients underwent a battery of investigations like X-rays, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans apart from blood investigations. Histopathology, culture and other molecular tests like CBNAAT (Cartridge Based Nucleic Acid Amplification Test) were either sent before or during surgery. Pre-operatively, patients were administered the standard Category I multidrug ATT regimen for tuberculosis consisted of Isoniazid, Rifampicin Ethambutol, and Pyrazinamide for 2 months in intensive phase followed by Isoniazid, Rifampicin, and Ethambutol in the continuation phase.[12] Patients underwent operative intervention with a mean of 8.8 ± 2.2 weeks of ATT cover.

All the patients underwent posterolateral decompression, posterior instrumentation with anterior column reconstruction through a posterior midline approach only. Response to therapy was monitored with a serial erythrocyte sedimentation rate (ESR) and C-reactive protein, high sensitivity (CRPH) levels at every follow-up.

Surgical technique

All of the surgeries were performed by a single senior spine surgeon (PK). Exposure through posterior midline approach and pedicle screws were inserted into proximal and distal healthy adjacent vertebrae [Figure 1]a and [Figure 1]b. Stabilization on the opposite side of the proposed decompression was done with the help of a temporary rod. Resection of at least 5-7 cm of the medial part of rib including transverse process, costotransverse joint, costovertebral joint, facet, and pedicle was done at thoracic level and the standard transforaminal approach was followed at lumbar level. Once satisfactory decompression of cord was done after removing all the necrotic material carefully, reconstruction of the anterior column was done with either titanium mesh or PEEK cage filled with locally available autograft mixed with streptomycin powder [Figure 1]c and [Figure 1]d.[13] The choice of cage was decided after explaining to the patient, keeping cost of cage and affordability in mind. Autograft was obtained from the unaffected posterior elements as they are typically spared in TB spine.
Figure 1: Steps of surgery showing, exposure through posterior midline approach (a), pedicle screw insertion (b), posterolateral decompression with exposed dura (c) and interbody fusion with PEEK cage (d)

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Patients were mobilized with a brace on 2nd postoperative day and were allowed to walk without brace at 12-16 weeks post-op. After surgery, the ATT regimen was given for minimum of 9 to 12 months and continued until the clinico-radiological resolution of the disease was observed on contrast MRI.[14]


On X-Rays, the segmental kyphosis angle was measured by Cobb's method. Kyphosis correction was noted in immediate post-op and at 1 year of follow-up. The fusion rate was evaluated at one-year follow-up on 2D CT by using a CT based classification system [Table 1].[15] The evidence of cage subsidence was noted according to the method described by K. Ha Sung et al.[16] Total intervertebral height (TIH) of two fused vertebral bodies was measured as the distance between the mid-point of the upper-end plate of the proximal vertebral body and the mid-point of the lower endplate of the distal vertebral body on a mid-sagittal section of CT scan. The degree of subsidence (ΔTIH) was reflected by the difference between immediate postoperative TIH and the latest follow-up TIH (on 2D CT) [Figure 2]. All the implant-related complications were documented. Patient-reported measures included a ten-point visual analog scale (VAS) for the pain and Oswestry Disability Index (ODI).
Table 1: CT based classification system to assess the bony fusion

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Figure 2: Degree of cage subsidence is measured by difference between the immediate postoperative TIH (a) and the latest follow-up TIH (b)

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Statistical analysis

Continuous data were compared using independent t-test. For nominal and ordinal data, Chi-Square test, and Mann-Whitney U test were used respectively. Values of P < 0.05 was considered significant. All the statistical analysis was performed using SPSS 25.

 » Results Top

Of the total patients, 29 patients met the inclusion criteria. 11 patients had instability as assessed on imaging, 10 patients had no improvement of neurology, 7 patients had worsening of neurology while on ATT and 1 patient had intractable pain. There were 14 patients in Group A with PEEK cage and 15 patients in Group B with mesh cage. Mean follow-up in Group A was 24.6 ± 6.9 months and 26.4 ± 6.2 months in Group B. The baseline demographic profile of patients in each group was similar [Table 2]. The pre-operative VAS score improved from 7.5 ± 1.1 and 7.6 ± 0.9 to 0.7 ± 0.9 and 1.1 ± 1.8 at last follow-up in Group A and B respectively. Similarly, in Group A, the ODI score improved from 76 ± 12.6 to 13.1 ± 4.8, and in Group B improved from 74.5 ± 13.4 to 14.9 ± 12.2 (P = 0.31). 17 patients had neurological deficits; 1 patient with Frankel Grade A paraplegia, 2 patients presented with Frankel Grade B paraplegia, 3 patients with Frankel C, 11 patients with Frankel D paraplegia. Post-surgery 13 out of 17 patients showed improvement and the remaining four patients remained Frankel grade D. All but one patient were independent ambulators at final follow-up with 21 patients with Frankel E, 7 patients with Frankel D, and 1 patient with Frankel C neurology [Table 3]. The neurological improvement in the two groups was comparable. The average kyphosis correction achieved in both the groups was similar i.e., 18 ± 9.4 degrees in Group A and 18.5 ± 9.8 degrees in Group B. The loss of correction at last follow-up was 5.3 ± 4.1 degrees and 6.5 ± 5.2 degrees in Group A and B respectively (P = 0.25). The average cage subsidence was 8.3 ± 4.4 mm in Group A patients and 10.6 ± 4.3 mm in Group B patients (p = 0.07). Grade 1 and Grade 2 on CT based classification for assessing bony fusion were considered good. Out of a total of 14 patients in Group A, 10 patients showed Grade 1 union showing complete fusion, 3 patients had Grade 2 union and 1 patient had Grade 3 union having unipolar pseudarthrosis [Figure 3]. In Group B, 8 patients showed Grade 1 union and 3 patients showed a Grade 2 union [Figure 4]. Two patients developed bipolar pseudarthrosis (Grade 4) in Group B which leading to proximal screw loosening and failure of fixation was managed by extension of the instrumentation [Table 4] and [Figure 5]. At the last follow-up, both patients had improvement in VAS and ODI scores with no loss of kyphosis. One patient in each group developed post-op superficial surgical site infection which was managed by debridement and lavage followed by cultured organism-specific antibiotics.
Figure 3: 34 year old female with D12-L1 TB spine, Pre-op radiograph (a), MRI image showing enhanced vertebrae with involvement (b), Post-op radiograph (c), Post-op CT Scan (d), 12 months follow-up radiograph (e) and Follow-up CT scan to assess bony fusion and cage subsidence (f)

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Figure 4: 18 year old female with D12-L2 tuberculosis, Pre-op radiograph in AP (a) and lateral view (b), Post-op radiograph (c), 12 months follow-up radiograph in AP (d) and lateral view (e) and Follow-up CT scan to assess bony fusion and cage subsidence (f)

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Table 2: Demographic profile of patients taken in each group (Group A=PEEK cage, Group B=Titanium mesh cage)

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Table 3: Preop and Post-op neurological status of patients in both the groups

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Table 4: Results of outcome measures assessed and the comparison between the groups

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Figure 5: 40 year old male with tubercular spine of D12-L1 with Frankel Grade A paraplegia, Preop radiograph (a), STIR image showing cord compression with involved vertebrae (b), Post-op radiograph (c), 12 months follow-up radiograph showing failure of fixation (d), Follow-up CT scan to assess the deformity (e), Post-op radiograph of second procedure with extension of instrumentation (f) and Post-op CT scan (g)

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 » Discussion Top

Treatment of TB spine has seen a paradigm shift from predominantly to surgical management.[17],[18] As shown by Oga et al., unlike pyogenic infections, there is no biofilm formation by tubercle bacilli on the metal surface making spinal instrumentation safe.[19] With improved spinal instrumentation and single-stage surgeries leading to early mobilization and rehabilitation, there is a reduction of morbidity in these patients.[9] Posterior stabilization with anterior column reconstruction and thorough debridement are the main pillars of surgical management. Surgery through the midline posterior approach is now the most widely accepted strategy among most surgeons.[20],[21],[22] Along with it, there is a need for anterior column reconstruction due to the substantial destruction of anterior structures by the disease. However, the perfect material for anterior column reconstruction has been a constant topic of debate. The earliest material used by the surgeons was autogenous iliac crest bone graft which remained the gold standard for generations and is still widely used at several centers but had several limitations including graft slippage, graft fracture, or subsidence leading to loss of kyphosis correction and intervertebral height and a high incidence of donor site morbidity.[8] As shown by various studies, the infection rate of donor sites can range from 35-40% leading to increased donor site morbidity.[23],[24] The primary argument regarding the use of iliac crest autograft was the age-old principle of avoidance of metal in an environment of infection. But in the last decade, there has been an abundance of literature where researchers have used titanium mesh cages in active TB spine with excellent clinico-radiological outcomes. [5, 8, 10, 25, 26] The primary basis of the use of titanium was due to the paucibacillary nature of infection and the formation of an antibacterial coating of titanium oxide reducing the formation of biofilm as compared to steel.[27] Additionally, these cages offer better deformity correction than bony allografts, less graft slippage and there was immediate stability to the construct which led to early rehabilitation. Gao et al. compared the results between titanium mesh cages and autogenous bone graft to restore the vertebral heights and showed kyphosis correction loss and decrease in intervertebral height was significantly less in the group with titanium cages.[8] Although titanium mesh cages are widely used in combination with locally derived autograft and allograft, it is not without limitations. Titanium mesh cages have significant cage subsidence due to pointed edges which sink in the adjacent vertebrae leading to loss of kyphosis correction and decreased intervertebral height. Another practical limitation of using titanium is significant metal artifacts seen in follow-up imaging (CT and MRI) which may compromise accurate identification of bony fusion and disease activity.[28] This has led to a renewed interest in the search for the perfect implant for interbody fusion.

PEEK is a high-temperature polymer that has attracted a lot of attention as a potential material for interbody fusion for its various advantages. Apart from being radiolucent, PEEK has a modulus of elasticity similar to bone, thus theoretically reducing subsidence by the virtue of its load-sharing properties.[29] Similar to titanium, PEEK is also biocompatible, non-mutagenic, non-cytotoxic, and not adherent to glycocalyx forming bacteria.[30] PEEK cage is available in several predesigned shapes and sizes and is easier to implant in the interbody region through the posterior approach. Some authors have published successful outcomes in patients with spondylodiscitis undergoing interbody fusion using PEEK cages in the cervical, dorsal, lumbar, and lumbosacral spine.[6],[31],[32],[33],[34] Zhechen et al. have reported their outcomes of PEEK cages in cervical spine TB only.[35] However, no study has reported the outcome of the PEEK cage in active TB of the dorsal or lumbar spine to the best of our understanding.

We at our institution have been using PEEK cages routinely in patients with trauma and degenerative conditions for interbody fusion. In this article, we have compared the clinico-radiological outcomes of patients with TB spine undergoing anterior column reconstruction with PEEK cage and titanium mesh cage.

There was a significant improvement in clinical outcomes as measured by VAS and ODI scores in both groups as expected. However, the scores between the two groups were comparable. Both groups were found to have significant segmental kyphosis correction at their final follow-up when compared to the pre-operative kyphosis angle. As opposed to the theoretical hypothesis there was no significant difference found in the segmental kyphosis correction or loss of correction at the final follow-up. Both the groups showed comparable subsidence of the cage at the time of the final follow-up. Some amount of cage subsidence is expected in all patients with spondylodiscitis undergoing interbody cage implantation due to partially destroyed endplates. This may manifest as persistent pain in patients with significant cage subsidence. However, all our patients were pain-free at the final follow-up. Our radiological results are similar to the outcomes reported by Schomacher et al. who have compared clinic-radiological results of PEEK and titanium cages in patients with bacterial spondylodiscitis undergoing surgery.[36] Both the groups in our series had a loss of kyphosis correction of 5 degrees and a loss of intervertebral height of 0.8-1 cm which is comparable to previously published data. All our patients showed solid bony fusion at 12 months follow-up with no difference between the two groups. Two patients in group B developed significant graft subsidence and proximal screw loosening leading to kyphosis and instability. Both needed revision surgery and extension of instrumentation. These failures have not been reflected in our results probably due to the small sample size. Large scale multicentric studies are warranted to compare outcomes of titanium and PEEK cages in TB spine for further validation.

The limitations of the study are the small sample size and retrospective study design. Additionally, longer follow-up may be desirable to analyze the long term clinico-radiological differences between PEEK and Titanium cage. Nevertheless, it is the first study that studied the role of PEEK cages for anterior column reconstruction in the dorsal or lumbar TB spine. All the surgeries were performed by a single fellowship-trained senior spine surgeon, thus eliminating any potential operator related bias.

 » Conclusion Top

PEEK cages are an attractive alternative to titanium cages for anterior column reconstruction in TB spine with comparable clinico-radiological outcomes. Its advantages for being radiolucent and ease of use may make it a choice of implant for some surgeons. However, this needs to be objectively established through further research with a larger sample size.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]

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