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Meta-analysis
ACE Report #9307

Similar fusion rate and clinical outcome in ACDF completed with PEEK vs titanium cage


Study Type:Meta-analysis/Systematic Review
OE Level Evidence:2
Journal Level of Evidence:N/A

Is PEEK cage better than titanium cage in anterior cervical discectomy and fusion surgery? A meta-analysis

BMC Musculoskelet Disord. 2016 Sep 1;17:379

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Synopsis

Four studies (two randomized controlled trials [RCTs] and two non-RCT comparative trials) were included in this systematic review and meta-analysis to compare outcomes following anterior cervical discectomy and fusion with either a polyetheretherketon (PEEK) cage or a titanium cage. Pooled results demonstrated no significant differences in the rate of successful fusion, clinical outcome on the Odom's criteria measure, final segmental angle, or loss in segmental correction over follow-up between groups. A significantly higher incidence of cage migration was noted with titanium cages. The results from this meta-analysis were based on data from only four studies, only two of which were RCTs. This highlights the need for additional RCTs to verify the results of this meta-analysis and strengthen the current body of literature comparing PEEK and titanium cages in ACDF procedures.

Publication Funding Details +
Funding:
Non-Industry funded
Sponsor:
National Natural Science Foundation of China; Project of Natural Science Foundation of Tianjin
Conflicts:
None disclosed

Risk of Bias

5/10

Reporting Criteria

14/20

Fragility Index

N/A

Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

3/4

Introduction

2/4

Accessing Data

3/4

Analysing Data

3/4

Results

3/4

Discussion

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Degenerative disease and radiculopathy of the cervical spine have traditionally been treated via anterior cervical discectomy and fusion (ACDF). Two common materials for fusion cages are polyetheretherketone (PEEK) and titanium. Despite their common use in ACDF procedures, only a few randomized controlled trials have been performed comparing the two types of cages, and a meta-analysis pooling the results of the high-quality literature had yet to be performed.

What was the principal research question?

In anterior cervical discectomy and fusion, are there any significant differences in the rate of successful fusion, clinical outcome, or radiographic measures between procedures completed with polyetheretherketone (PEEK) cages and titanium cages?

Study Characteristics -
Data Source:
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for relevant articles published up to October 2015. Reference lists of identified articles were manually searched for additional studies possibly missed by the electronic search.
Index Terms:
Keyword terms included: "cervical", "titanium", "polyetheretherketone", and "PEEK".
Study Selection:
Eligibility criteria included: randomized and non-randomized comparative studies; enrollment of participants undergoing anterior cervical discectomy and fusion; compared between groups who received a PEEK fusion cage and who received a titanium fusion cage; and reported sufficient data for pooling in the full-text. Search and selection was performed independently by two reviewers, with disagreements resolved through discussion and consensus. A total of four studies, two randomized controlled trials and two non-randomized clinical trials, were selected for final inclusion.
Data Extraction:
Data extraction was performed independently by two reviewers, with disagreements resolved by discussion and consensus.
Data Synthesis:
Statistical analysis was performed using Review Manager software (RevMan 5.1). Mean differences were calculated for continuous outcomes, and odds ratios for dichotomous outcomes, both with associated 95% confidence intervals. Heterogeneity was assessed using the Chi-square test and I-squared (I^2) statistic and considered significant at values of p<0.1 and >50% for the tests, respectively. A random-effects model was used in the presence of significant statistical heterogeneity, and a fixed-effects model when heterogeneity was not significant.

What were the important findings?

  • Dichotomized results for Odom's criteria of clinical outcome demonstrated no significant difference between PEEK cages and titanium cages (3 studies; OR 0.89 [95%CI 0.49-1.63]; p=0.71).
  • Qualitative assessment of the Neck Disability Index demonstrated significantly lower NDI scores for the PEEK group compared to the titanium group at 12-month follow-up in one study, while no significant differences were noted between groups at over 2-year follow-up in another study.
  • No significant difference in overall fusion rate was observed between PEEK groups and titanium groups (3 studies; OR 0.20 [95%CI 0.01-3.93]; p=0.29).
  • The incidence of cage subsidence was significantly higher for titanium cages (33/211) compared to PEEK cages (11/184) (4 studies; OR 3.14 [95%CI 1.56-6.30]; p=0.001).
  • Analyses demonstrated no significant differences in either final segmental angle (3 studies; MD -1.19 [95%CI -2.60, 0.23]; p=0.10) or loss of segmental correction at follow-up (3 studies; MD 2.03 [95%CI -1.10, 5.17]; p=0.20).

What should I remember most?

In anterior cervical discectomy and fusion (ACDF), no significant differences were observed between PEEK cages and titanium cages in pooled results of fusion success, the clinical outcome on Odom's criteria, or angle of segmental correction. Cage migration was significantly more frequent with titanium cages compared to PEEK cages.

How will this affect the care of my patients?

The results of this study suggest that the use of either a PEEK cage or a titanium cage offers similar results following anterior cervical discectomy and fusion. However, the current results are based on data from only four studies and ever fewer randomized controlled trials. As such, additional RCTs are needed to verify the suggestions of the current body of literature comparing PEEK and titanium cages in ACDF procedures.

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