Nonmetallic Carbon Fiber-Reinforced Polyetheretherketone Implants Vs Titanium Implants: Analysis of Clinical Outcomes and Influence on Postoperative Radiotherapy Planning in Metastatic Spine Tumor Surgery

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Figure 1
Overall survival results.
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Figure 2
Sample computed tomography imaging. (a) Axial CT section at the T7 vertebra with bilateral titanium pedicle screw instrumentation. Note the increased artifact generated. (b) Axial CT section at L1 vertebra with carbon fiber–reinforced polyetheretherketone pedicle screws. Note minimal artifact generated.

Table 1

Demographic and clinical characteristics by study group.

Characteristic	Titanium	CFR-PEEK	P
Number of patients, n (%)	42 (67.7%)	20 (32.3%)	-
Age at surgery, y, mean ± SD	63.0 ± 10.3	63.8 ± 15.2	0.813
Sex, n (%)			-
Man	26 (61.9%)	9 (45.0%)
Woman	16 (30.10%)	11 (55.0%)
Primary tumor,^{^a} n (%)			0.089^{^c}
Lung, osteosarcoma, stomach, and bladder	13 (31.0)	5 (25.0)
Esophagus and pancreas	1 (2.38)	0 (0)
Liver, gallbladder, and unidentified	1 (2.38)	2 (10.0)
Kidney and uterus	1 (2.38)	4 (20.0)
Rectum	15 (35.7)	3 (15.0)
Thyroid, breast, prostate, and carcinoid tumor	11 (26.2)	6 (30.0)
SINS, n (%)			0.509^{^c}
0–6	2 (4.80)	0 (0)
7–12	27 (64.2)	15 (75.0)
13–18	13 (31.0)	5 (25.0)
SINS, mean ± SD	11.45 ± 2.36	11.50 ± 1.24	0.933
CCI score, median (range)	9.00 (3.00–11.00)	9.00 (2.00–13.00)	0.106^{^d}
Modified Tokuhashi score, mean ± SD	8.62 ± 2.45	8.40 ± 2.70	0.376
Predicted survivability,^{^a} n (%)			0.259^{^c}
0–6 mo	14 (54.5)	8 (40.0)
9–11 mo	19 (27.3)	11 (50.0)
>11 mo	9 (18.2)	1 (10.0)
ECOG score, n (%)
0	23 (54.8)	10 (50.0)	0.230^{^c}
1	13 (31.0)	3 (15.0)
2	3 (7.14)	4 (20.0)
3	3 (7.14)	2 (10.0)
4	0 (0)	1 (5.0)
Independence,^{^b} n (%)			0.328^{^c}
Independent	39 (92.9)	17 (85.0)
Dependent	3 (7.14)	3 (15.0)

Abbreviations: CCI, Charlson Comorbidity Index; CFR-PEEK, carbon fiber-reinforced polyetheretherketone; ECOG, Eastern Cooperative Oncology Group; SINS, spinal instability neoplastic score.
↵a Based on modified Tokuhashi scoring system.
↵b Based on ECOG score.
↵c χ ² test was performed.
↵d Mann-Whitney U test was performed.

Table 2

Surgical and operative results.

Outcome Measure	Titanium	CFR-PEEK	P
Duration of operation, min, median (range)	286 (94–726)	270 (154–468)	0.243^{^b}
Total length of stay, d, median (range)	17 (5–62)	10 (3–33)	0.093^{^b}
Estimated blood loss, mL, median (range)	500 (50–3500)	275 (40–600)	0.050^{^b}
No. of levels instrumented, median (range)	5.00 (1.00–15.00)	4.00 (2.00–7.00)	0.007^{^b}
Cases where decompression was performed, n (%)	32 (76.2)	10 (50.0)	-
Number of levels decompressed, n (%)			0.108^{^a}
0	10 (23.8)	10 (50.0)
1	9 (21.4)	6 (30.0)
2	13 (31.0)	2 (10.0)
3	7 (16.7)	2 (10.0)
4	3 (7.1)	0 (0)
Number of levels decompressed, n (%)			0.009
<2	19 (45.2)	16 (80.0)
≥2	23 (54.8)	4 (20.0)
Area of decompression, n (%)			-
Thoracic	14 (33.3)	6 (30.0)
Thoracolumbar	8 (19.0)	1 (5.0)
Lumbar	6 (14.3)	1 (5.0)
Lumbosacral	1 (2.4)	1 (5.0)
Sacral	0 (0)	0 (0)
None	13 (31.0)	11 (55.0)
Surgical complications, n (%)	5 (22.7)	3 (15)	-
Intraoperative incidental durotomy	2	1
Delayed wound healing	2	0
Superficial skin infection	1	0
Deep surgical infection	0	1
Hardware breakage (screw/rod)	0	0
Screw loosening	0	1
Medical complications, n (%)	14 (33.3)	2 (10.5)	0.029^{^a}
Change in ASIA score, n (%)			0.846^{^a}
Worsened	0 (0)	0 (0)
No change	8 (19.0)	3 (15.0)
Improved	34 (81.0)	17 (85.0)

Abbreviations: ASIA, American Spinal Injury Association; CFR-PEEK, carbon fiber-reinforced polyetheretherketone.
↵a χ ² test was performed.
↵b Mann-Whitney U test was performed.

Table 3

Radiotherapy data by study group.

Parameter	Titanium	CFR-PEEK	P
Artifact volume, mm³	73.4 ± 50.3	20.0 ± 20.7	<0.001 ^{^a}
Artifact volume per level, mm³	13.2 ± 8.81	3.35 ± 3.24	<0.001 ^{^a}
Time taken to contour artifacts, min	17.3 ± 5.84	9.60 ± 7.17	0.049 ^{^a}
No. of spinal levels covered for radiotherapy	5.97 ± 2.40	5.50 ± 2.42	0.559^{^a}