Endplate Trauma During Implant Insertion Affects the Expulsion Risk of Anterior Lumbar Interbody Fusion Devices

Background Anterior cage migration in anterior lumbar interbody fusion is a serious complication. To address this risk, cage designs are now available with integrated screw or blade fixation or specially designed surface geometries with large teeth or ridges. However, the implantation technique itself has not yet been addressed as a potential risk factor for cage migration. This study aimed to investigate whether a cage that is implantable without gouging the vertebral endplates has improved resistance to anterior migration. Methodology A novel three-piece modular cage was inserted between two vertebral body replacements (polyurethane (PU) foam grade 15 pcf) in two ways. In group 1 (modular), the cage was inserted in a wedge within a wedge fashion according to the manufacturer's instructions such that damage to the PU foam was minimized. In group 2 (mono-bloc), the modular cage was inserted pre-assembled as a one-piece, mono-bloc device. This insertion method required impaction and increased the potential of gouging the PU surfaces. Then, an axial preload was applied to the PU test blocks to simulate the preload on the spine in vivo and an anteriorly direct expulsion force was applied to the cages. Results The mean expulsion yield load in the test group with modular implantation was 392 ± 19 N compared to 287 ± 16 N in the test group where the mono-bloc implants were inserted and endplate gouging occurred. This difference was statistically significant (p < 0.05). Thus, the onset of cage migration occurred at significantly higher loads in the test group with modular insertion without endplate gouging compared to one-piece impaction with gouging taking place. In contrast, the stiffness and the ultimate load were similar in both test groups (p > 0.05). Conclusions This study showed that the cage insertion technique may have a significant effect on the cage migration risk. Prevention of endplate gouging during cage implantation has the potential to improve the primary stability of the cage.