Abstract
To the Editor,
We read with interest the article by Toop et al 1 titled “Subsidence Rates Associated with Porous 3D-Printed vs Solid Titanium Cages in Transforaminal Lumbar Interbody Fusion.”
The meticulous comparison of subsidence rates and clinical outcomes between 3D-printed porous titanium (3DPT) cages and solid titanium (ST) cages in transforaminal lumbar interbody fusion (TLIF) underscores the critical role of implant materials in surgical outcomes.
However, there are few important points that need attention and further discussion: 1. While the reduced subsidence rates with 3DPT cages are impressive, the clinical significance remains unclear. The similar patient-reported outcomes and revision rates between the groups suggest that minor subsidence may not significantly impact functional recovery or patient satisfaction. Future studies should explore whether these findings persist over longer follow-up periods and in larger cohorts.
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2. The study does not address the cost implications of using 3DPT cages. Although the authors note no cost difference between the two cage types in their setting, broader adoption of 3DPT technology could potentially increase healthcare costs. A detailed cost-benefit analysis incorporating surgical outcomes, revision rates, and long-term durability would provide a more comprehensive perspective for low and middle income countries. 3. As a retrospective analysis, the study is inherently subject to selection bias and confounding factors. Confounder like alcohol use and smoking which promote non-union are not evenly distributed between both cohorts. Significant use of BMP and allograft in solid titanium cage group and not in 3DPT cage group affects the result of final outcome of study regarding union. While the authors attempt to mitigate these issues through rigorous statistical methods, a prospective randomized controlled trial would provide higher-quality evidence.3,4
We express our gratitude to the authors for publishing this important work.
