The Posterior Superior Iliac Rim Screw as an Adjunct to Pelvic Fixation in Complex Spinopelvic Stabilization

Abstract As the popularity of minimally invasive surgery (MIS) continues to grow, novel techniques are needed to meet the demands of multisegment fixation for advanced spinal diseases. In one such example, iliac bolts are often required to anchor large fusion constructs, but MIS technical notes are missing from the literature. A 67-yr-old female presented with a symptomatic coronal deformity: preoperative pelvic incidence = 47°, pelvic tilt = 19°, and lumbar lordosis = 29°, sagittal vertical axis = +5.4 cm with 30° of scoliosis. The operative plan included T10-ilium fusion with transforaminal interbody grafts at L2-3, L3-4, L4-5, and L5-S1. The intraoperative video is of minimally invasive placement of iliac bolts using the O-Arm Surgical Imaging System (Medtronic®). The patient consented to the procedure. A mini-open exposure that remains above the fascial planes allows for multilevel instrumentation with appropriate decompression at the interbody segments. After the placement of the pedicle screws under image-guidance, the direction is turned to the minimally invasive iliac bolts. Following the trajectory described in the standard open approach,1 the posterior superior iliac spine (PSIS) is identified with the navigation probe, which will guide the Bovie cautery through the fascia. This opening assists in the trajectory of the navigated-awl tap toward the anterior superior iliac spine (ASIS). Next, 8.5 mm x 90 mm iliac screws were placed in the cannulated bone under navigation. After intraoperative image confirmation of screw placement, the contoured rods are threaded under the fascia. The setscrews lock the rod in position. MIS approaches obviate cross-linking the rods, rendering pelvic fixation more facile. This technique allows for minimal dissection of the posterior pelvic soft tissue while maintaining adequate fixation.

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Failure Types and Related Factors of Spinopelvic Fixation After Long Construct Fusion for Adult Spinal Deformity

Neurosurgery ◽

10.1093/neuros/nyaa469 ◽

2020 ◽

Author(s):

Se-Jun Park ◽

Jin-Sung Park ◽

Yunjin Nam ◽

Tae-Hoon Yum ◽

Youn-Taek Choi ◽

...

Keyword(s):

Risk Factors ◽

Ct Scan ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Study Cohort ◽

Related Factors ◽

Fixation Failure ◽

Failure Group ◽

Pelvic Fixation ◽

Spinopelvic Fixation

Abstract BACKGROUND Rigid internal fixation of the spine is an essential part of adult spinal deformity (ASD) surgery. Despite the use of pelvic fixation and anterior column support, spinopelvic fixation failure (SPFF) still remains an issue. Few studies have evaluated the types of such failure or its related factors. OBJECTIVE To classify the types of SPFF and investigate its risk factors, including the fusion status at L5-S1 on CT scan. METHODS The study cohort consisted of ninety-eight ASD patients who underwent more than 4-level fusions to the sacrum with interbody fusion at L5-S1. Patients with SPFF were divided into the two groups: above-S1 and below-S1 failure groups. The patient, surgical, and radiographic variables in each group were compared to those of the no-failure group. The L5-S1 fusion status was assessed using 2-yr computed tomography (CT) scan. Univariate and multivariate analyses were performed to determine the risk factors for each failure group. RESULTS The mean age was 68.5 yr. Follow-up duration was 55.7 mo. The SPFF developed in 46 (46.9%) patients at 32.7 mo postoperatively. There were 15 patients in the above-S1 failure group and 31 patients in the below-S1 failure group. Multivariate analysis revealed that nonunion at L5-S1 was a single risk factor for above-S1 failure. In contrast, the risk factors for below-S1 failure included a greater number of fused segments and postoperative less thoracic kyphosis. CONCLUSION SPFF develops in different patterns with different risk factors. Above-S1 SPFF was associated with nonunion at L5-S1, while below-S1 SPFF was associated with mechanical stress.

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Instrumentation Techniques Including Sacral and Pelvic Fixation

Spine Surgery ◽

10.1007/978-3-319-98875-7_56 ◽

2019 ◽

pp. 465-472

Author(s):

Yann Philippe Charles

Keyword(s):

Pelvic Fixation

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Is L5/S1 interbody fusion necessary in long-segment surgery for adult degenerative scoliosis? A systematic review and meta-analysis

Journal of Neurosurgery Spine ◽

10.3171/2021.9.spine21883 ◽

2021 ◽

pp. 1-8

Keyword(s):

Systematic Review ◽

Interbody Fusion ◽

Case Reports ◽

Adult Spinal Deformity ◽

Meta Analysis ◽

Lumbar Interbody Fusion ◽

Lumbosacral Junction ◽

Pelvic Fixation ◽

Group 2 ◽

Group 1

OBJECTIVE There is no consensus regarding the best surgical strategy at the lumbosacral junction (LSJ) in long constructs for adult spinal deformity (ASD). The use of interbody fusion (IF) has been advocated to increase fusion rates, with additional pelvic fixation (PF) typically recommended. The actual benefit of IF even when extending to the pelvis, however, has not been vigorously analyzed. The goal of this work was to better understand the role of IF, specifically with respect to arthrodesis, when extending long constructs to the ilium. METHODS A systematic review of the PubMed and Cochrane databases was performed to identify the relevant studies in English, addressing the management of LSJ in long constructs (defined as ≥ 5 levels) in ASD. The search terms used were as follows: “Lumbosacral Junction,” “Long Constructs,” “Long Fusion to the Sacrum,” “Sacropelvic Fixation,” “Interbody Fusion,” and “Iliac Screw.” The authors excluded technical notes, case reports, literature reviews, and cadaveric studies; pediatric populations; pathologies different from ASD; studies not using conventional techniques; and studies focused only on alignment of different levels. RESULTS The PRISMA protocol was used. The authors found 12 retrospective clinical studies with a total of 1216 patients who were sorted into 3 different categories: group 1, using PF or not (n = 6); group 2, using PF with or without IF (n = 5); and group 3, from 1 study comparing anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion. Five studies in group 1 and 4 in group 2 had pseudarthrosis rate as primary outcome and were selected for a quantitative analysis. Forest plots were used to display the risk ratio, and funnel plots were used to look at the risk of publication bias. The summary risk ratios were 0.36 (0.23–0.57, p < 0.001) and 1.03 (0.54–1.96, p = 0.94) for the PF and IF, respectively; there is a protective effect of overall pseudarthrosis for using PF in long constructs for ASD surgeries, but not for using IF. CONCLUSIONS The long-held contention that L5/S1 IF is always advantageous in long-construct deformity surgery is not supported by the current literature. Based on the findings from this systematic review and meta-analysis, PF with or without additional L5/S1 interbody grafting demonstrates similar overall construct pseudarthrosis rates. The added risk and costs associated with IF, therefore, should be more closely considered on a case-by-case basis.

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Use of the S-hook for Pelvic Fixation in Rib-Based Treatment of Early-Onset Scoliosis

Spine ◽

10.1097/brs.0000000000000443 ◽

2015 ◽

Vol 40 (11) ◽

pp. 816-822 ◽

Cited By ~ 6

Author(s):

Norman Ramirez ◽

John M. Flynn ◽

John T. Smith ◽

Michael Vitale ◽

Peter F. Sturm ◽

...

Keyword(s):

Early Onset ◽

Early Onset Scoliosis ◽

Pelvic Fixation

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Pelvic Fixation using S2AI and Triangular Titanium Implants (Bedrock Technique)

World Neurosurgery ◽

10.1016/j.wneu.2021.07.027 ◽

2021 ◽

Author(s):

Bryan Ladd ◽

David Polly

Keyword(s):

Titanium Implants ◽

Pelvic Fixation

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PELVIC FIXATION IN SPINE SURGERY

The Journal of Bone and Joint Surgery (American) ◽

10.2106/00004623-200511002-00011 ◽

2005 ◽

Vol 87 ◽

pp. 89-106 ◽

Cited By ~ 1

Author(s):

ALI MOSHIRFAR ◽

FRANK F. RAND ◽

PAUL D. SPONSELLER ◽

STEPHEN J. PARAZIN ◽

A. JAY KHANNA ◽

...

Keyword(s):

Spine Surgery ◽

Pelvic Fixation

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A biomechanical investigation of the sacroiliac joint in the setting of lumbosacral fusion: impact of pelvic fixation versus sacroiliac joint fixation

Journal of Neurosurgery Spine ◽

10.3171/2019.3.spine181127 ◽

2019 ◽

Vol 31 (4) ◽

pp. 562-567 ◽

Cited By ~ 2

Author(s):

Harry Mushlin ◽

Daina M. Brooks ◽

Joshua Olexa ◽

Bryan J. Ferrick ◽

Stephen Carbine ◽

...

Keyword(s):

Sacroiliac Joint ◽

Screw Fixation ◽

Intact Specimen ◽

Lumbosacral Fusion ◽

Pelvic Fixation ◽

Biomechanical Investigation ◽

Flexion Extension ◽

Iliac Screw ◽

Sacroiliac Fusion ◽

Bending Modes

OBJECTIVEThe sacroiliac joint (SIJ) is a known source of low-back pain. Randomized clinical trials support sacroiliac fusion over conservative management for SIJ dysfunction. Clinical studies suggest that SIJ degeneration occurs in the setting of lumbosacral fusions. However, there are few biomechanical studies to provide a good understanding of the effect of lumbosacral fusion on the SIJ. In the present study, researchers performed a biomechanical investigation to discern the effect of pelvic versus SIJ fixation on the SIJ in lumbosacral fusion.METHODSSeven fresh-frozen human cadaveric specimens were used. There was one intact specimen and six operative constructs: 1) posterior pedicle screws and rods from T10 to S1 (PS); 2) PS + bilateral iliac screw fixation (BIS); 3) PS + unilateral iliac screw fixation (UIS); 4) PS + UIS + 3 contralateral unilateral SIJ screws (UIS + 3SIJ); 5) PS + 3 unilateral SIJ screws (3SIJ); and 6) PS + 6 bilateral SIJ screws (6SIJ). A custom-built 6 degrees-of-freedom apparatus was used to simulate three bending modes: flexion-extension (FE), lateral bending (LB), and axial rotation (AR). Range of motion (ROM) was recorded at L5–S1 and the SIJ.RESULTSAll six operative constructs had significantly reduced ROM at L5–S1 in all three bending modes compared to that of the intact specimen (p < 0.05). In the FE mode, the BIS construct had a significant reduction in L5–S1 ROM as compared to the other five constructs (p < 0.05). SIJ ROM was greatest in the FE mode compared to LB and AR. Although the FE mode did not show any statistically significant differences in SIJ ROM across the constructs, there were appreciable differences. The PS construct had the highest SIJ ROM. The BIS construct reduced bilateral SIJ ROM by 44% in comparison to the PS construct. The BIS and 6SIJ constructs showed reductions in SIJ ROM nearly equal to those of the PS construct. UIS and 3SIJ showed an appreciable reduction in unfused SIJ ROM compared to PS.CONCLUSIONSThis investigation demonstrated the effects of various fusion constructs using pelvic and sacroiliac fixation in lumbosacral fusion. This study adds biomechanical evidence of adjacent segment stress in the SIJ in fusion constructs extending to S1. Unilateral pelvic fixation, or SIJ fusion, led to an appreciable but nonsignificant reduction in the ROM of the unfused contralateral SIJ. Bilateral pelvic fixation showed the greatest significant reduction of movement at L5–S1 and was equivalent to bilateral sacroiliac fusion in reducing SIJ motion.

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