Carbon fiber–reinforced PEEK spinal implants for primary and metastatic spine tumors: a systematic review on implant complications and radiotherapy benefits
Presented at the 2023 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves
Hammad A. Khan
Hammad A. KhanDepartment of Neurosurgery, NYU Grossman School of Medicine, New York; and
By minimizing imaging artifact and particle scatter, carbon fiber–reinforced polyetheretherketone (CF-PEEK) spinal implants are hypothesized to enhance radiotherapy (RT) planning/dosing and improve oncological outcomes. However, robust clinical studies comparing tumor surgery outcomes between CF-PEEK and traditional metallic implants are lacking. In this paper, the authors performed a systematic review of the literature with the aim to describe clinical outcomes in patients with spine tumors who received CF-PEEK implants, focusing on implant-related complications and oncological outcomes.
开云体育世界杯赔率
A systematic review of the literature published between database inception and May 2022 was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The PubMed database was queried using the terms "carbon fiber" and "spine" or "spinal." The inclusion criteria were articles that described patients with CF-PEEK pedicle screw fixation and had a minimum of 5 patients. Case reports and phantom studies were excluded.
RESULTS
This review included 11 articles with 326 patients (237 with CF-PEEK–based implants and 89 with titanium-based implants). The mean follow-up period was 13.5 months, and most tumors were metastatic (67.1%). The rates of implant-related complications in the CF-PEEK and titanium groups were 7.8% and 4.7%, respectively. The rate of pedicle screw fracture was 1.7% in the CF-PEEK group and 2.4% in the titanium group. The rates of reoperation were 5.7% (with 60.0% because of implant failure or junctional kyphosis) and 4.8% (all because of implant failure or junctional kyphosis) in the CF-PEEK and titanium groups, respectively. When reported, 72.5% of patients received postoperative RT (41.0% stereotactic body RT, 30.8% fractionated RT, 25.6% proton, 2.6% carbon ion). Four articles suggested that implant artifact was reduced in the CF-PEEK group. Local recurrence occurred in 14.4% of CF-PEEK and 10.7% of titanium-implanted patients.
CONCLUSIONS
While CF-PEEK harbors similar implant failure rates to traditional metallic implants with reduced imaging artifact, it remains unclear whether CF-PEEK implants improve oncological outcomes. This study highlights the need for prospective, direct comparative clinical studies.
INCLUDE WHEN CITINGPublished online June 23, 2023; DOI: 10.3171/2023.5.SPINE23106.
DisclosuresDr. Laufer reported personal fees from Spine Wave and Globus during the conduct of the study. Dr. Chhabra reported personal fees from Icotec for medical consulting outside the submitted work.
Schneider
U
,
Pedroni
E
,
Lomax
A
.
The calibration of CT Hounsfield units for radiotherapy treatment planning
.Phys Med Biol
.
1996
;
41
(
1
):
111
–
124
.
8685250)| false
GiantsoudiD,De ManB,VerburgJ,et al.Metal artifacts in computed tomography for radiation therapy planning: dosimetric effects and impact of metal artifact reduction.Phys Med Biol.2017;62(8):R49–R80.
Giantsoudi
D
,
De Man
B
,
Verburg
J
,
Metal artifacts in computed tomography for radiation therapy planning: dosimetric effects and impact of metal artifact reduction
.Phys Med Biol
.
2017
;
62
(
8
):
R49
–
R80
.
28323641)| false
RutzHP,WeberDC,SugaharaS,et al.Extracranial chordoma: outcome in patients treated with function-preserving surgery followed by spot-scanning proton beam irradiation.Int J Radiat Oncol Biol Phys.2007;67(2):512–520.
NevelskyA,BorzovE,DanielS,Bar-DeromaR.Perturbation effects of the carbon fiber-PEEK screws on radiotherapy dose distribution.J Appl Clin Med Phys.2017;18(2):62–68.
Nevelsky
A
,
Borzov
E
,
Daniel
S
,
Bar-Deroma
R
.
Perturbation effects of the carbon fiber-PEEK screws on radiotherapy dose distribution
.J Appl Clin Med Phys
.
2017
;
18
(
2
):
62
–
68
.
28300369)| false
ShiC,LinH,HuangS,et al.Comprehensive evaluation of carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) spinal hardware for proton and photon planning.Technol Cancer Res Treat.2022;21:15330338221091700.
Shi
C
,
Lin
H
,
Huang
S
,
Comprehensive evaluation of carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) spinal hardware for proton and photon planning
.Technol Cancer Res Treat
.
2022
;
21
:
15330338221091700
.
35410544)| false
KrätzigT,MendeKC,MohmeM,et al.Carbon fiber-reinforced PEEK versus titanium implants: an in vitro comparison of susceptibility artifacts in CT and MR imaging.Neurosurg Rev.2021;44(4):2163–2170.
Krätzig
T
,
Mende
KC
,
Mohme
M
,
Carbon fiber-reinforced PEEK versus titanium implants: an in vitro comparison of susceptibility artifacts in CT and MR imaging
.Neurosurg Rev
.
2021
;
44
(
4
):
2163
–
2170
.)| false
PoelR,BelosiF,AlbertiniF,et al.Assessing the advantages of CFR-PEEK over titanium spinal stabilization implants in proton therapy—a phantom study.Phys Med Biol.2020;65(24):245031.
Poel
R
,
Belosi
F
,
Albertini
F
,
Assessing the advantages of CFR-PEEK over titanium spinal stabilization implants in proton therapy—a phantom study
.Phys Med Biol
.
2020
;
65
(
24
):
245031
.
32315991)| false
HuberFA,SprengelK,MüllerL,GrafLC,OsterhoffG,GuggenbergerR.Comparison of different CT metal artifact reduction strategies for standard titanium and carbon-fiber reinforced polymer implants in sheep cadavers.BMC Med Imaging.2021;21(1):29.
Huber
FA
,
Sprengel
K
,
Müller
L
,
Graf
LC
,
Osterhoff
G
,
Guggenberger
R
.
Comparison of different CT metal artifact reduction strategies for standard titanium and carbon-fiber reinforced polymer implants in sheep cadavers
.BMC Med Imaging
.
2021
;
21
(
1
):
29
.
33588781)| false
UriO,FolmanY,LauferG,BehrbalkE.A novel spine fixation system made entirely of carbon-fiber-reinforced PEEK composite: an in vitro mechanical evaluation.Adv Orthop.2020;2020:4796136.
Uri
O
,
Folman
Y
,
Laufer
G
,
Behrbalk
E
.
A novel spine fixation system made entirely of carbon-fiber-reinforced PEEK composite: an in vitro mechanical evaluation
.Adv Orthop
.
2020
;
2020
:
4796136
.)| false
OikonomidisS,GrevenJ,BredowJ,et al.Biomechanical effects of posterior pedicle screw-based instrumentation using titanium versus carbon fiber reinforced PEEK in an osteoporotic spine human cadaver model.Clin Biomech (Bristol, Avon).2020;80:105153.
Oikonomidis
S
,
Greven
J
,
Bredow
J
,
Biomechanical effects of posterior pedicle screw-based instrumentation using titanium versus carbon fiber reinforced PEEK in an osteoporotic spine human cadaver model
.Clin Biomech (Bristol, Avon)
.
2020
;
80
:
105153
.)| false
NealMT,RichardsAE,CurleyKL,et al.Carbon fiber-reinforced PEEK instrumentation in the spinal oncology population: a retrospective series demonstrating technique, feasibility, and clinical outcomes.Neurosurg Focus.2021;50(5):E13.
CofanoF,Di PernaG,MonticelliM,et al.Carbon fiber reinforced vs titanium implants for fixation in spinal metastases: a comparative clinical study about safety and effectiveness of the new "carbon-strategy."J Clin Neurosci.2020;75:106–111.
Cofano
F
,
Di Perna
G
,
Monticelli
M
,
Carbon fiber reinforced vs titanium implants for fixation in spinal metastases: a comparative clinical study about safety and effectiveness of the new "carbon-strategy."J Clin Neurosci
.
2020
;
75
:
106
–
111
.
32173153)| false
BorianiS,PipolaV,CecchinatoR,et al.Composite PEEK/carbon fiber rods in the treatment for bone tumors of the cervical spine: a case series.Eur Spine J.2020;29(12):3229–3236.
Boriani
S
,
Pipola
V
,
Cecchinato
R
,
Composite PEEK/carbon fiber rods in the treatment for bone tumors of the cervical spine: a case series
.Eur Spine J
.
2020
;
29
(
12
):
3229
–
3236
.
32691220)| false
TedescoG,GasbarriniA,BandieraS,GhermandiR,BorianiS.Composite PEEK/carbon fiber implants can increase the effectiveness of radiotherapy in the management of spine tumors.J Spine Surg.2017;3(3):323–329.
Tedesco
G
,
Gasbarrini
A
,
Bandiera
S
,
Ghermandi
R
,
Boriani
S
.
Composite PEEK/carbon fiber implants can increase the effectiveness of radiotherapy in the management of spine tumors
.J Spine Surg
.
2017
;
3
(
3
):
323
–
329
.
29057339)| false
BorianiS,TedescoG,MingL,et al.Carbon-fiber-reinforced PEEK fixation system in the treatment of spine tumors: a preliminary report.Eur Spine J.2018;27(4):874–881.
Boriani
S
,
Tedesco
G
,
Ming
L
,
Carbon-fiber-reinforced PEEK fixation system in the treatment of spine tumors: a preliminary report
.Eur Spine J
.
2018
;
27
(
4
):
874
–
881
.
28815357)| false
RingelF,RyangYM,KirschkeJS,et al.Radiolucent carbon fiber-reinforced pedicle screws for treatment of spinal tumors: advantages for radiation planning and follow-up imaging.World Neurosurg.2017;105:294–30.1.
BorianiS,BandieraS,BiaginiR,De IureF,GiuntiA.The use of the carbon-fiber reinforced modular implant for the reconstruction of the anterior column of the spine. A clinical and experimental study conducted on 42 cases.Chir Organi Mov.2000;85(4):30.9–335.
Boriani
S
,
Bandiera
S
,
Biagini
R
,
De Iure
F
,
Giunti
A
.
The use of the carbon-fiber reinforced modular implant for the reconstruction of the anterior column of the spine. A clinical and experimental study conducted on 42 cases
.Chir Organi Mov
.
2000
;
85
(
4
):
30.9
–
335
.
11569357)| false
MütherM,LüthgeS,GerwingM,StummerW,SchwakeM.Management of spinal dumbbell tumors via a minimally invasive posterolateral approach and carbon fiber-reinforced polyether ether ketone instrumentation: technical note and surgical case series.World Neurosurg.2021;151:277–283.e1.
Müther
M
,
Lüthge
S
,
Gerwing
M
,
Stummer
W
,
Schwake
M
.
Management of spinal dumbbell tumors via a minimally invasive posterolateral approach and carbon fiber-reinforced polyether ether ketone instrumentation: technical note and surgical case series
.World Neurosurg
.
2021
;
151
:
277
–
283.e1
.)| false
MüllerBS,RyangYM,OechsnerM,et al.The dosimetric impact of stabilizing spinal implants in radiotherapy treatment planning with protons and photons: standard titanium alloy vs. radiolucent carbon-fiber-reinforced PEEK systems.J Appl Clin Med Phys.2020;21(8):6–14.
Müller
BS
,
Ryang
YM
,
Oechsner
M
,
The dosimetric impact of stabilizing spinal implants in radiotherapy treatment planning with protons and photons: standard titanium alloy vs. radiolucent carbon-fiber-reinforced PEEK systems
.J Appl Clin Med Phys
.
2020
;
21
(
8
):
6
–
14
.
32476247)| false
PatchellRA,TibbsPA,RegineWF,et al.Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial.Lancet.2005;366(9486):643–648.
MoussazadehN,LauferI,YamadaY,BilskyMH.Separation surgery for spinal metastases: effect of spinal radiosurgery on surgical treatment goals.Cancer Contr.2014;21(2):168–174.
Moussazadeh
N
,
Laufer
I
,
Yamada
Y
,
Bilsky
MH
.
Separation surgery for spinal metastases: effect of spinal radiosurgery on surgical treatment goals
.Cancer Contr
.
2014
;
21
(
2
):
168
–
174
.)| false
AmankulorNM,XuR,IorgulescuJB,et al.The incidence and patterns of hardware failure after separation surgery in patients with spinal metastatic tumors.Spine J.2014;14(9):1850–1859.
Amankulor
NM
,
Xu
R
,
Iorgulescu
JB
,
The incidence and patterns of hardware failure after separation surgery in patients with spinal metastatic tumors
.Spine J
.
2014
;
14
(
9
):
1850
–
1859
.
24216397)| false
PedreiraR,Abu-BonsrahN,Karim AhmedA,et al.Hardware failure in patients with metastatic cancer to the spine.J Clin Neurosci.2017;45:166–171.
Pedreira
R
,
Abu-Bonsrah
N
,
Karim Ahmed
A
,
Hardware failure in patients with metastatic cancer to the spine
.J Clin Neurosci
.
2017
;
45
:
166
–
171
.)| false
DeLaneyTF,LiebschNJ,PedlowFX,et al.Long-term results of Phase II study of high dose photon/proton radiotherapy in the management of spine chordomas, chondrosarcomas, and other sarcomas.J Surg Oncol.2014;110(2):115–122.
DeLaney
TF
,
Liebsch
NJ
,
Pedlow
FX
,
Long-term results of Phase II study of high dose photon/proton radiotherapy in the management of spine chordomas, chondrosarcomas, and other sarcomas
.J Surg Oncol
.
2014
;
110
(
2
):
115
–
122
.
24752878)| false
RotondoRL,FolkertW,LiebschNJ,et al.High-dose proton-based radiation therapy in the management of spine chordomas: outcomes and clinicopathological prognostic factors.J Neurosurg Spine.2015;23(6):788–797.
IndelicatoDJ,RotondoRL,Begosh-MayneD,et al.A prospective outcomes study of proton therapy for chordomas and chondrosarcomas of the spine.Int J Radiat Oncol Biol Phys.2016;95(1):297–30.3.
Indelicato
DJ
,
Rotondo
RL
,
Begosh-Mayne
D
,
A prospective outcomes study of proton therapy for chordomas and chondrosarcomas of the spine
.Int J Radiat Oncol Biol Phys
.
2016
;
95
(
1
):
297
–
30.3
.
27084648)| false
Al-OmairA,MasucciL,Masson-CoteL,et al.Surgical resection of epidural disease improves local control following postoperative spine stereotactic body radiotherapy.Neuro Oncol.2013;15(10):1413–1419.
Al-Omair
A
,
Masucci
L
,
Masson-Cote
L
,
Surgical resection of epidural disease improves local control following postoperative spine stereotactic body radiotherapy
.Neuro Oncol
.
2013
;
15
(
10
):
1413
–
1419
.
24057886)| false
ShenFH,GasbarriniA,LuiDF,ReynoldsJ,CapuaJ,BorianiS.Integrated custom composite polyetheretherketone/carbon fiber (PEEK/CF) vertebral body replacement (VBR) in the treatment of bone tumors of the spine: a preliminary report from a multicenter study.Spine (Phila Pa 1976).2022;47(3):252–260.
Shen
FH
,
Gasbarrini
A
,
Lui
DF
,
Reynolds
J
,
Capua
J
,
Boriani
S
.
Integrated custom composite polyetheretherketone/carbon fiber (PEEK/CF) vertebral body replacement (VBR) in the treatment of bone tumors of the spine: a preliminary report from a multicenter study
.Spine (Phila Pa 1976)
.
2022
;
47
(
3
):
252
–
260
.
34310537)| false
