title: The Effect of Cervical Interbody Cage Morphology, Material Composition, and Substrate Density on Cage Subsidence.
abstract: BACKGROUND
  Interbody cages used in spinal fusion surgery can subside into the adjacent vertebral bodies after implantation, leading to loss of spinal height, malalignment, and possible radicular symptoms. Several factors may contribute to cage subsidence.
  
  
  METHODS
  This in vitro investigation examined the possible contribution of substrate density, cage contact area (ie, cage footprint), cage filling, cage end plate surface texture, and cage material composition on the magnitude of subsidence. Commercially available cervical interbody cages of two sizes (16 × 12 mm and 17 × 14 mm) were implanted between foam blocks of two different densities and were cyclically loaded. Cages were made of titanium alloy (Ti4Al6V), silicon nitride ceramic (Si3N4), or polyether ether ketone (n = 8 cages of each material type). Additional testing was performed on Si3N4 cages of the smaller size with nontextured surfaces and with filled cores.
  
  
  RESULTS
  Subsidence measurements showed that lower foam density had the greatest influence on subsidence, followed by smaller cage footprint. Cage material had no effect on subsidence. In the additional testing of small-footprint Si3N4 cages, the cages in which the core was filled with a load-bearing porous material had less subsidence in lower-density foam than the cages with an empty core had, whereas cage end plate surface texture had no effect on subsidence.
  
  
  CONCLUSIONS
  Ranking of the relative impact of these factors indicated that substrate density had the greatest contribution to the measured subsidence (approximately 1.7 times and approximately 67 times greater than the contributions of cage footprint area and material, respectively). The contribution of cage footprint area to subsidence was found to be 40 times greater than the contribution of cage material to subsidence.
authors.affiliation: From the Orthopaedic Specialists of North Carolina, Raleigh, NC (Dr. Suh); the Orthopaedic Bioengineering Research Laboratory, Department of Mechanical Engineering, and School of Biomedical Engineering, Colorado State University, Fort Collins, CO (Dr. Puttlitz and Dr. McGilvray); Amedica, Salt Lake City, UT (Dr. Lewis and Dr. Bal); and the Department of Orthopaedic Surgery, University of Missouri, Columbia, MO (Dr. Bal).
authors.forename: Paul B
authors.initials: PB
authors.lastname: Suh
authors.forename: Christian
authors.initials: C
authors.lastname: Puttlitz
authors.forename: Chad
authors.initials: C
authors.lastname: Lewis
authors.forename: B Sonny
authors.initials: BS
authors.lastname: Bal
authors.forename: Kirk
authors.initials: K
authors.lastname: McGilvray
mesh_terms: D001696:Biomechanical Phenomena; D002574:Cervical Vertebrae / Q000502:physiology / Q000601:surgery*; D006801:Humans; D066298:In Vitro Techniques; D016268:Internal Fixators; D008422:Materials Testing; D011475:Prosthesis Failure; D013123:Spinal Fusion / Q000295:instrumentation*; D016474:Weight-Bearing