Denisov A. Polyetheretherketone vs titanium cages in oncological spine surgery: Beyond mechanics toward oncological precision. World J Orthop 2026; 17(7): 120589 [DOI: 10.5312/wjo.120589]
Corresponding Author of This Article
Anton Denisov, MD, Consultant, Researcher, Department of Orthopedic, University Hospital Mollet, Ronda dels Pinetons, 6-8, Barcelona 08403, Spain. denisov1993@gmail.com
Research Domain of This Article
Orthopedics
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review-article
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World J Orthop. Jul 18, 2026; 17(7): 120589 Published online Jul 18, 2026. doi: 10.5312/wjo.120589
Polyetheretherketone vs titanium cages in oncological spine surgery: Beyond mechanics toward oncological precision
Anton Denisov
Anton Denisov, Department of Orthopedic, University Hospital Mollet, Barcelona 08403, Spain
Anton Denisov, Senior Biostatistics Division, The Taylor Collaboration, San Francisco 94111, CA, United States
Author contributions: Denisov A contributed to conceptualization, methodology, formal analysis, data curation, writing - original draft preparation, writing - review and editing, supervision, and project administration.
AI contribution statement: AI tools (ChatGPT, Grammarly) have been used during preparation of the manuscript, mainly for language correction. AI was used only to help with grammar, wording, and improving readability. It was not used to create scientific content, arguments, or conclusions. One figure was created with the help of an AI tool to summarize the main concepts of the article. This figure is illustrative and does not present original data.
Conflict-of-interest statement: The author reports no relevant conflicts of interest for this article.
Corresponding author: Anton Denisov, MD, Consultant, Researcher, Department of Orthopedic, University Hospital Mollet, Ronda dels Pinetons, 6-8, Barcelona 08403, Spain. denisov1993@gmail.com
Received: March 3, 2026 Revised: April 10, 2026 Accepted: June 4, 2026 Published online: July 18, 2026 Processing time: 130 Days and 13 Hours
Abstract
Spinal reconstruction in oncological patients presents unique challenges that extend beyond mechanical stability to include impaired bone biology, radiotherapy considerations, and the need for accurate postoperative imaging. Implant material selection - primarily between titanium and polyetheretherketone (PEEK), including carbon fiber-reinforced PEEK - has therefore evolved into a critical component of oncological treatment strategy. To critically evaluate current evidence comparing titanium and PEEK-based cages in oncological spine surgery, with emphasis on biomechanical performance, imaging characteristics, radiotherapy implications, and clinical outcomes. Narrative review of contemporary literature focusing on implant material properties, biomechanical studies, imaging and radiotherapy data, and clinical outcomes in oncological and relevant non-oncological populations. Titanium cages provide superior mechanical strength and osteointegration, making them favorable in cases requiring immediate structural stability, such as multilevel corpectomy or extensive vertebral destruction. However, their high elastic modulus may contribute to stress shielding and increased subsidence risk, particularly in compromised bone. Additionally, titanium implants generate significant imaging artifacts and may affect radiotherapy dose distribution. PEEK and carbon fiber-reinforced PEEK implants offer radiolucency, enabling improved postoperative imaging and more accurate radiotherapy planning, with minimal radiation perturbation. Despite these advantages, PEEK-based implants demonstrate limited intrinsic osteointegration and have not shown clear superiority in fusion rates or clinical outcomes. Current evidence indicates comparable complication rates, hardware durability, and patient-reported outcomes between materials. Importantly, no high-level data demonstrate that improved imaging or dosimetric accuracy with PEEK translates into better oncological outcomes. Hybrid implants, such as titanium-coated PEEK, and patient-specific 3D-printed constructs represent promising developments but lack robust oncological validation. Implant selection in oncological spine surgery should extend beyond biomechanics to incorporate imaging requirements, radiotherapy planning, and tumor-specific factors. Titanium remains the standard for structural reliability, whereas PEEK-based implants offer advantages in imaging and radiotherapy compatibility. However, no material has demonstrated clear oncological superiority. A multidisciplinary, patient-specific approach is essential, and future prospective studies should focus on oncological endpoints, including local tumor control, recurrence, and survival.
Core Tip: In oncological spine surgery, cage selection must balance mechanical stability, fusion biology, and postoperative tumor surveillance. Titanium cages provide superior strength and osteointegration, particularly valuable in multilevel or structurally compromised reconstructions, but may impair imaging due to artifact formation. Polyetheretherketone cages allow clearer radiographic follow-up and reduced stress shielding, though their bioinert nature may limit fusion in irradiated or bone-compromised patients. Individualized implant selection - potentially incorporating hybrid technologies - remains essential to optimize both mechanical and oncological outcomes.
