An S-2 Alar Iliac Pelvic Fixation

Neurosurg Focus 28 (3):E13, 2010

An S-2 alar iliac pelvic fixation

Technical note

La u r e n E. Ma t t e i n i , M.D.,1 Kh a l e d M. Ke b a i s h , M.D.,2 W. Ro b e r t Vo lk , M.D.,1 Pa t r i c k F. Be r g i n , M.D.,1 Wa r r e n D. Yu, M.D.,1 a n d Jo s e p h R. O’Br i e n , M.D., M.P.H.1 1Orthopaedic Surgery, George Washington University, Washington, DC; and 2Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland

Multiple techniques of pelvic fixation exist. Distal fixation to the pelvis is crucial for spinal deformity surgery. Fixation techniques such as transiliac bars, iliac bolts, and iliosacral screws are commonly used, but these techniques may require separate incisions for placement, leading to potential wound complications and increased dissection. Ad- ditionally, the use of transverse connector bars is almost always necessary with these techniques, as their placement is not in line with the S-1 pedicle screw and cephalad instrumentation. The S-2 alar iliac pelvic fixation is a newer technique that has been developed to address some of these issues. It is an in-line technique that can be placed during an open procedure or percutaneously. (DOI: 10.3171/2010.1.FOCUS09268)

Ke y Wo r d s • sacropelvic fixation • iliac fixation • percutaneous approach

i s t a l fixation in thoracolumbar spinal deformity erative management, including 8 epidural injections and surgery is crucial when arthrodesis to the sacrum 2 courses of physical therapy, had failed to resolve her is indicated.10 Multiple studies have shown that pain. At the time of presentation, she was taking high- Dlong instrumentation and fusion to the sacrum without dose oral narcotics on a daily basis without durable pain supplemental pelvic fixation predisposes to fixation fail- relief. The patient was neurologically intact with respect ure and reoperation.3,4,12 Kim and colleagues6 have shown to leg sensation and motor function. that the L5–S1 junction is the single level with the high- Imaging studies showed a postlaminectomy degen- est incidence of pseudarthrosis in adult scoliosis surgery, erative scoliosis with severe hypertrophy of facet joints. with a rate of 24%. Pseudarthrosis in adult thoracolumbar The worst areas were L2–3 and L4–5, with moderate spinal deformity surgery is associated with adverse clini- degeneration of L3–4. Radiographs demonstrated a 35° cal outcomes.4 Multiple techniques exist for spinal fixa- dextroscoliotic degenerative lumbar curve from T-11 to tion distal to S-1 pedicle screws. Techniques for pelvic L-5. Lateral listhesis of 5 mm was noted at L3–4. After a fixation include transiliac bars, iliac bolts, and iliosacral discussion of the risks and benefits of surgery, the patient screws. These techniques frequently require separate in- agreed to undergo corrective spinal surgery to address cisions for placement or the use of offset connectors, add- her postlaminectomy spinal deformity. ing to surgical time and morbidity.1,5,7,11 The S2–AI technique is an alternative, low-profile, in-line technique that Operative Technique can provide distal fixation in spinal deformity surgery. The patient underwent a 2-stage posterior–anterior lumbar fusion and stabilization with instrumentation. Case Report The first operation was a revision posterior decompression and fusion with instrumentation placed from T-10 to We describe the case of a 73-year-old woman who the pelvis, including S2–AI screws. underwent laminectomy 10 years prior to presentation. The patient was given general anesthesia and placed At presentation she complained of significant low-back prone on a Jackson frame to enhance lumbar lordosis. pain, which had worsened over the last few years, and, Prophylactic antibiotics were administered and the pa- at present time, she had pain at rest as well. Her activity tient’s back was prepared and draped in a sterile fashion. level had declined significantly due to her pain. Nonop- The previous incision was used and extended proximally to the T-9 level. Dissection was carried out through the Abbreviation used in this paper: S2–AI = S-2 alar iliac. subcutaneous tissue to the fascial layer. Using a Cobb

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Fig. 2. Percutaneous placement in a cadaveric specimen: the screws have been placed in full on the left side and the rod advanced. This image illustrates the S2–AI screw in line with the cephalad instrumentation.

Fig. 1. Standing 3-ft radiographs of S2–AI pelvic fixation in a patient treated for thoracolumbar spinal deformity. Final steps during this operation included the place- elevator and electrocautery for dissection, the spinous ment of posterior interbody cages at L2–3 and L3–4, as processes of L-1 and L-2, remnant laminae of L-2, L-3, well as prophylactic vertebroplasty at T-9 to prevent prox- L-4, L-5, S-1, along with S-2, were exposed. A localizing imal junctional kyphosis due to fracture. Appropriate- radiograph was acquired to confirm the levels. Dissec- length rods were contoured and the spine was reduced to tion was carried out over the facet joints to the transverse the coronally straight rods. Segmental compression was processes. The sacrum was exposed to the level of the applied to the construct and the end caps were torqued S-1 foramen. Next, revision decompression of the neural down. Copious irrigation of the wound and arthrodesis elements was undertaken from L-1 to S-1 by mobilizing followed. Local bone, cancellous chips, demineralized the scar-bone interface and performing complete bilateral bone matrix, and iliac crest were placed onto the decor facetectomy. Then, pedicle screws were placed using in- ticated surfaces. The wound was closed in layers. The ternal and external landmarks from T-10 to S-1, with the patient tolerated this procedure well and recovered in the exception of the right pedicle of T-12, which was skipped hospital until transfer to a rehabilitation center on postop- due to medial wall perforation. erative Day 10. Following this step, using fluoroscopic guidance, S2– The second-stage anterior discectomy and fusion of AI screws were placed bilaterally. The starting point is 1 L5–S1 was performed 1 month after the first operation. A mm inferior and 1 mm lateral to the S-1 dorsal foramen, right retroperitoneal exposure was done by a fellowship- which was directly visualized. Angulation was directed trained vascular surgeon. The L5–S1 disc space was ex- toward the greater trochanter and approximately 30° ante- posed and the great vessels protected. A discectomy was rior from the floor. A 3.5-mm pelvic drill (extended length) performed, the endplates prepared, and a femoral ring al- was used to “tap” drill through the sacroiliac articulation. lograft filled with demineralized bone matrix was placed On average, it will be at 35–40 mm before the ilium is at L5–S1. An anterior plate was used with 2 locking reached. The anteroposterior radiograph is used to ensure screws in both L-5 and S-1. The surgical wound was ir- placement cephalad to the sciatic notch. The pelvic inlet rigated and closed by the approach surgeon without com- radiograph is then used to ensure extrapelvic placement, plication. The patient again recovered in the hospital and as judged by viewing the anterior sacroiliac joint (see Fig. was discharged to home on postoperative Day 3. Standing 4). Once the drill was in the ilium, a ball-tipped probe was radiographs showed adequate alignment and hardware placed into the ilium and manually advanced through the placement at 1 year postoperatively (Fig. 1). cancellous bed until a cortex is reached. The length was At 1-year follow-up, the patient was off all narcotic measured and the tract was then tapped past the sacroiliac medications and had returned to independent activities. articulation. A 7 × 80–mm screw was inserted. Again, ra- Her Oswestry Disability Index score improved from 50 diography was used to evaluate placement. preoperatively to 20 at 1 year postoperatively.

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Fig. 3. A: Axial CT scan cut through the ilia demonstrating the trajectory of the S2–AI screws. The black line on the patient’s right illustrates the trajectory of a traditional iliac screw. B: Open cadaveric specimen with a probe illustrating the trajectory of the S2–AI screw. The line demarcates the articular and nonarticular portion of the sacroiliac joint. The medial ilium has been excised for better visualization. C: Removed left ilium of a cadaveric specimen after S2–AI screw placement. Asterisk marks the greater sciatic notch. The line demarcates the articular and nonarticular portion of the sacroiliac joint. V = ventral.

Discussion to link long constructs to the S2–AI screws, even with the presence of dual-bilateral S2–AI screw placement. An S2–AI sacropelvic fixation is a new technique Concerns have been raised regarding the penetra- described contemporaneously by Dr. Sponseller10 and Dr. tion of the sacroiliac articulation by the S2–AI screw. It Kebaish for use in the pediatric and adult population, re- spectively. O’Brien et al.9 adapted it for use in minimally is important to review the sacroiliac joint articulation to invasive applications (Fig. 2). The S2–AI technique for address these concerns. Anatomical studies have demon- pelvic fixation is a modification of an S-2 alar screw driv- strated that the projection of the lateral sacral mass on the en through the sacroiliac articulation into the iliac wing. ilium is larger than the projection of the sacroiliac articular cartilage.13 The posterior aspect of the sacroiliac joint This technique is preferable because the screws have a 13 2,10 corresponds to a nonarticular area. In a cadaveric study, lower profile and are in line with cephalad instrumen- 9 tation. On average, the S2–AI screw was 2 cm deeper than O’Brien et al. found that approximately 60% of S2–AI the starting point for a traditional iliac screw.10 The rela- screws did violate the articular cartilage of the sacroiliac tively deeper location and smaller dissection to place the joint (Fig. 3). Though a concern, the clinical significance S2–AI screw is crucial in cases where wound breakdown of this penetration is unknown. It is important to note that can be an issue—such as in neuromuscular scoliosis.10 traditional iliac screws do bridge the sacroiliac joint with Furthermore, with 4 years of clinical experience, the au- fixation on either side of it. At 5–10 years postoperatively, thors have found no need for the use of offset connectors Tsuchiya et al.11 found no increase in sacroiliac degeneration with traditional iliac fixation. Two-year prospective clinical data have been presented on the S2–AI technique at the 2009 Annual Meetings of the Scoliosis Research Society and North American Spine Society (Sponseller PD et al., presented at the Scoliosis Research Society Annual Meeting, 2009; and Kebaish K et al., presented at the North American Spine Society Annual Meeting, 2009). The authors have found no increase in sacroiliac degeneration or pain at 2-year follow-up in either adult or pediatric populations. More long-term data are needed, but the S2–AI technique exhibits promise as a good alternative to iliac fixation at this time. The S2–AI screw can be placed by either open or percutaneous approaches, a detail that currently limits the application of traditional iliac fixation. Wang et al.12 used minimally invasive technique to place iliac screws; however, these constructs did not include S1 pedicle screws. No reports currently exist that have placed minimally invasive iliac screws with S1 pedicle screws. Re- cently, O’Brien and colleagues8 found that percutaneous S2–AI placement was feasible, reproducible, and safe in a cadaveric feasibility study. As centers move toward expanding the application of minimally invasive spine Fig. 4. The pelvic inlet view is used to ensure that placement is ex- surgery, it is crucial to have a minimally invasive pelvic trapelvic. The anterior sacroiliac joint is a key reference. fixation option.

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Conclusions sacral screws, and sacral fixation. Spine (Phila Pa 1976) 27: 776–786, 2002 The S2–AI fixation is a potential option in open and 6. Kim YJ, Bridwell KH, Lenke LG, Cho KJ, Edwards CC II, minimally invasive spinal surgery. The screws are in-line Rinella AS: Pseudarthrosis in adult spinal deformity follow- with cephalad instrumentation, are approximately 2 cm ing multisegmental instrumentation and arthrodesis. J Bone deeper compared with iliac screws, cross-connectors are Joint Surg Am 88:721–728, 2006 not needed, and lengths of 80–100 mm are attainable. 7. Lebwohl NH, Cunningham BW, Dmitriev A, Shimamoto Limitations of the technique include direct penetration of N, Gooch L, Devlin V, et al: Biomechanical comparison of lumbosacral fixation techniques in a calf spine model. Spine the sacroiliac joint, and pending biomechanical evalua- (Phila Pa 1976) 27:2312–2320, 2002 tion. 8. O’Brien JR, Matteini LM, Kebaish KM, Yu WD: Feasibility of minimally invasive sacropelvic fixation: percutaneous S2 Disclosure iliac fixation. Spine 35 [in press], 2010 9. O’Brien JR, Yu WD, Bhatnagar R, Sponseller P, Kebaish KM: The authors report no conflict of interest concerning the mate- An anatomic study of the S2 iliac technique for lumbopel- rials or methods used in this study or the findings specified in this vic screw placement. Spine (Phila Pa 1976) 34:E439–E442, paper. 2009 10. Sponseller P: The S2 portal to the ilium. Semin Spine Surg 2: References 83–87, 2007 1. Bridwell KH, Edwards CC II, Lenke LG: The pros and cons 11. Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C: to saving the L5-S1 motion segment in a long scoliosis fusion Minimum 5-year analysis of L5-S1 fusion using sacropelvic construct. Spine (Phila Pa 1976) 28:S234–S242, 2003 fixation (bilateral S1 and iliac screws) for spinal deformity. 2. Chang TL, Sponseller PD, Kebaish KM, Fishman EK: Low Spine (Phila Pa 1976) 31:303–308, 2006 profile pelvic fixation: anatomic parameters for sacral alar- 12. Wang MY, Ludwig SC, Anderson DG, Mummaneni PV: Per- iliac fixation versus traditional iliac fixation. Spine (Phila Pa cutaneous iliac screw placement: description of a new mini- 1976) 34:436–440, 2009 mally invasive technique. Neurosurg Focus 25(2):E17, 2008 3. Edwards CC II, Bridwell KH, Patel A, Rinella AS, Berra A, 13. Xu R, Ebraheim NA, Douglas K, Yeasting RA: The projection Lenke LG: Long adult deformity fusions to L5 and the sa- of the lateral sacral mass on the outer table of the posterior crum. A matched cohort analysis. Spine:1996–2005, 2004 ilium. Spine (Phila Pa 1976) 21:790–795, 1996 4. Edwards CC II, Bridwell KH, Patel A, Rinella AS, Jung Kim Y, Berra AB, et al: Thoracolumbar deformity arthrodesis to Manuscript submitted November 13, 2009. L5 in adults: the fate of the L5-S1 disc. Spine (Phila Pa 1976) Accepted January 5, 2010. 28:2122–2131, 2003 Address correspondence to: Joseph R. O’Brien, M.D., M.P.H., 5. Emami A, Deviren V, Berven S, Smith JA, Hu SS, Bradford 2150 Pennsylvania Avenue, NW, Department of Orthopaedic DS: Outcome and complications of long fusions to the sacrum Surgery, George Washington University MFA, Washington, DC in adult spine deformity: luque-galveston, combined iliac and 20037. email: [email protected].

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