Cervical Cage Subsidence

Cervical Cage Subsidence

Cage subsidence was defined as the sum subsidence of the superior and inferior part of the cage into the vertebral body. Mild and major cage subsidence was defined as ≤2 mm and >2 mm, respectively. The extent of cage subsidence was greater after ACDF with cage alone. Cage subsidence occurred more often when the end plate was removed. Additional anterior plate fixation is recommended when the end plate is removed 1).


Subsidence in ACDF with cages occurs in 21% of patients. The risk for subsidence seems lower using PEEK or titanium cages or adding screws 2).


Zero profile anchored spacer (ROI-C) use resulted in a higher subsidence rate than conventional cage and plate construct (CPC) use in multi-segment ACDF procedures. The male sex, the use of ROI-C, operation in multiple segments, and over-distraction were the most significant factors associated with an increase in the risk of cage subsidence 3).


The greater the cage height, the greater the risk of cage subsidence in ACDF. Polyetheretherketone cages are superior to titanium cages for the maintenance of intervertebral height in cases where cage height is >5.5 mm 4)


Subsidence irrespective of the measurement technique or definition does not appear to have an impact on successful fusion and/or clinical outcomes. A validated definition and standard measurement technique for subsidence is needed to determine the actual incidence of subsidence and its impact on radiographic and clinical outcomes 5).

PEEK cages showed a high rate of secondary subsidence (32%) 6).

Titanium Wing cage-augmented ACDF was associated with comparatively good long-term results. Subsidence was present but did not cause clinical complications. Furthermore, radiological studies demonstrated that the physiological alignment of the cervical spine was preserved and a solid bone arthrodesis was present at 2 years after surgery 7).


There is evidence documenting relatively frequent complications in stand-alone cage assisted ACDF, such as cage subsidence and cervical kyphosis 8).

Subsidence irrespective of the measurement technique or definition does not appear to have an impact on successful fusion and/or clinical outcomes. A validated definition and standard measurement technique for subsidence is needed to determine the actual incidence of subsidence and its impact on radiographic and clinical outcomes 9).


Findings suggest that the value of ratio of anterior endplate more than 1.18, alignment of titanium mesh cage (TMC) and poor bone mineral density are the risk factors for subsidence. TMC subsidence does not negatively affect the clinical outcomes after operation. Avoiding over expansion of intervertebral height, optimizing placing of TMC and initiation of anti-osteoporosis treatments 6 months prior to surgery might help surgeons to reduce subsidence after ACCF 10).

Lee et al. from Yangsan retrospectively reviewed the medical records of 40 patients who underwent stand-alone single-level ACDF using a polyetheretherketone (PEEKcage between January 2012 and December 2018. The study population comprised 19 male and 21 female patients aged 24-70 years. The minimum follow-up period was 1 year. Twenty-seven patients had preoperative bone mineral density (BMD) data on dual-energy X-ray absorptiometry. Clinical parameters included sex, age, body mass indexsmoking history, and prior medical history. Radiologic parameters included the C2-7 cobb angle, segmental angle, sagittal vertical axis, disc height, and total intervertebral height (TIH) at the preoperative and postoperative periods. Cage decrement was defined as the reduction in TIH at the 6-month follow-up compared to preoperative TIH. To evaluate the bone quality, Hounsfield unit (HU) value was calculated in the axial and sagittal images of conventional computed tomography.

Lumbar BMD values and cervical HU values were significantly correlated (r=0.733, p<0.001). They divided the patients into two groups based on cage decrement, and 47.5% of the total patients were regarded as cage decrement. There were statistically significant differences in the parameters of measuring the HU value of the vertebra and intraoperative distraction between the two groups. Using these identified factors, we performed a receiver operating characteristic (ROC) curve analysis. Based on the ROC curve, the cut-off point was 530 at the HU value of the upper cortical and cancellous vertebrae (p=0.014; area under the curve [AUC], 0.727; sensitivity, 94.7%; specificity, 42.9%) and 22.41 at intraoperative distraction (p=0.017; AUC, 0.722; sensitivity, 85.7%; specificity, 57.9%). Using this value, they converted these parameters into a bifurcated variable and assessed the multinomial regression analysis to evaluate the risk factors for cage decrement in ACDF. Intraoperative distraction and HU value of the upper vertebral body were independent factors of postoperative subsidence.

Insufficient intraoperative distraction and low Hounsfield unit (HU) value showed a strong relationship with postoperative intervertebral height reduction following single stand-alone PEEK cage ACDF 11).

Mende et al. performed a retrospective analysis of ACDF patients from 2004 to 2010. Numeric analog scale (NAS) score pre-op and post-op, Oswestry Disability Index (ODI) on x-rays, endplate (EP) and cage dimensions, implant position, lordotic/kyphotic subsidence patterns (>5°), and cervical alignment were recorded. Subsidence was defined as height loss >40%. Patients were grouped into single segment (SS), double segment (DS), and plated procedures. We included 214 patients. Prevalence of subsidence was 44.9% overall, 40.9% for SS, and 54.8% for DS. Subsidence presented mostly for dorsal (40.7%) and mid-endplate position (46.3%, p < 0.01); dorsal placement resulted in kyphotic (73.7%) and central placement in balanced implant migration (53.3%, p < 0.01). Larger cages (>65% EP) showed less subsidence (64.6 vs. 35.4%, p < 0.01). There was no impact of subsidence on ODI or alignment. NAS was better for subsided implants in SS (p = 0.06). Cages should be placed at the anterior endplate rim in order to reduce the risk of subsidence. Spacers should be adequately sized for the respective segment measuring at least 65% of the segment dimensions. The cage frame should not rest on the vulnerable central endplate. For multilevel surgery, ventral plating may be beneficial regarding construct stability. The reduction of micro-instability or over-distraction may explain lower NAS for subsided implants 12).

a retrospective observational cohort study to test the hypothesis that radiographic subsidence of cervical cages is not associated with adverse clinical outcomes. 33 cervical segments were treated surgically by ACDF with stand-alone cage in 17 patients (11 female, 6 male), mean age 56 years (33-82 years), and re-examined after eight and twenty-six months (mean) by means of radiology and score assessment (Medical Outcomes Study Short Form (MOS-SF 36), Oswestry Neck Disability Index (ONDI), painDETECT questionnaire and the visual analogue scale (VAS)).

Results: Subsidence was observed in 50.5% of segments (18/33) and 70.6% of patients (12/17). 36.3% of cases of subsidence (12/33) were observed after eight months during mean time of follow-up 1. After 26 months during mean time of follow-up 2, full radiographic fusion was seen in 100%. MOS-SF 36, ONDI and VAS did not show any significant difference between cases with and without subsidence in the two-sample t-test. Only in one type of scoring (painDETECT questionnaire) did a statistically significant difference in t-Test emerge between the two groups (p = 0.03; α = 0.05). However, preoperative painDETECT score differ significantly between patients with subsidence (13.3 falling to 12.6) and patients without subsidence (7.8 dropped to 6.3).

Conclusions: The radiological findings indicated 100% healing after stand-alone treatment with ACDF. Subsidence occurred in 50% of the segments treated. No impact on the clinical results was detected in the medium-term study period 13).


1)

Pinder EM, Sharp DJ. Cage subsidence after anterior cervical discectomy and fusion using a cage alone or combined with anterior plate fixation. J Orthop Surg (Hong Kong). 2016 Apr;24(1):97-100. doi: 10.1177/230949901602400122. PMID: 27122522.
2)

Noordhoek I, Koning MT, Jacobs WCH, Vleggeert-Lankamp CLA. Incidence and clinical relevance of cage subsidence in anterior cervical discectomy and fusion: a systematic review. Acta Neurochir (Wien). 2018 Apr;160(4):873-880. doi: 10.1007/s00701-018-3490-3. Epub 2018 Feb 21. PMID: 29468440; PMCID: PMC5859059.
3)

Jin ZY, Teng Y, Wang HZ, Yang HL, Lu YJ, Gan MF. Comparative Analysis of Cage Subsidence in Anterior Cervical Decompression and Fusion: Zero Profile Anchored Spacer (ROI-C) vs. Conventional Cage and Plate Construct. Front Surg. 2021 Oct 27;8:736680. doi: 10.3389/fsurg.2021.736680. PMID: 34778358; PMCID: PMC8579909.
4)

Igarashi H, Hoshino M, Omori K, Matsuzaki H, Nemoto Y, Tsuruta T, Yamasaki K. Factors Influencing Interbody Cage Subsidence Following Anterior Cervical Discectomy and Fusion. Clin Spine Surg. 2019 Aug;32(7):297-302. doi: 10.1097/BSD.0000000000000843. PMID: 31169615.
5) , 9)

Karikari IO, Jain D, Owens TR, Gottfried O, Hodges TR, Nimjee SM, Bagley CA. Impact of Subsidence on Clinical Outcomes and Radiographic Fusion Rates in Anterior Cervical Discectomy and Fusion: A Systematic Review. J Spinal Disord Tech. 2014 Feb;27(1):1-10. PubMed PMID: 24441059.
6)

König SA, Spetzger U. Distractable titanium cages versus PEEK cages versus iliac crest bone grafts for the replacement of cervical vertebrae. Minim Invasive Ther Allied Technol. 2013 Nov 29. [Epub ahead of print] PubMed PMID: 24289173.
7)

Schmieder K, Wolzik-Grossmann M, Pechlivanis I, Engelhardt M, Scholz M, Harders A. Subsidence of the wing titanium cage after anterior cervical interbody fusion: 2-year follow-up study. J Neurosurg Spine. 2006 Jun;4(6):447-53. PubMed PMID: 16776355.
8)

Cloward RB: The anterior approach for removal of ruptured cervical disks. 1958. J Neurosurg Spine 6:496-511, 2007
10)

Ji C, Yu S, Yan N, Wang J, Hou F, Hou T, Cai W. Risk factors for subsidence of titanium mesh cage following single-level anterior cervical corpectomy and fusion. BMC Musculoskelet Disord. 2020 Jan 14;21(1):32. doi: 10.1186/s12891-019-3036-8. PMID: 31937288; PMCID: PMC6961320.
11)

Lee JS, Son DW, Lee SH, Ki SS, Lee SW, Song GS, Woo JB, Kim YH. The Effect of Hounsfield Unit Value with Conventional Computed Tomography and Intraoperative Distraction on Postoperative Intervertebral Height Reduction in Patients Following Stand-Alone Anterior Cervical Discectomy and Fusion. J Korean Neurosurg Soc. 2021 Dec 29. doi: 10.3340/jkns.2021.0131. Epub ahead of print. PMID: 34963207.
12)

Mende KC, Eicker SO, Weber F. Cage deviation in the subaxial cervical spine in relation to implant position in the sagittal plane. Neurosurg Rev. 2017 Apr 4. doi: 10.1007/s10143-017-0850-z. [Epub ahead of print] PubMed PMID: 28374128.
13)

Zajonz D, Franke AC, von der Höh N, Voelker A, Moche M, Gulow J, Heyde CE. Is the radiographic subsidence of stand-alone cages associated with adverse clinical outcomes after cervical spine fusion? An observational cohort study with 2-year follow-up outcome scoring. Patient Saf Surg. 2014 Nov 7;8(1):43. doi: 10.1186/s13037-014-0043-4. PMID: 25408710; PMCID: PMC4234826.

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