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Operative Orthopädie und Traumatologie

, Volume 25, Issue 3, pp 294–314 | Cite as

Reinforcement of lumbosacral instrumentation using S1–pedicle screws combined with S2–alar screws

  • H. KollerEmail author
  • J. Zenner
  • A. Hempfing
  • L. Ferraris
  • O. Meier
Tipps und Tricks

Abstract

Objective

Increasing construct stability of lumbosacral instrumentations using S2–ala screws as an alternate to iliac screws.

Indications

Revision surgery after failed lumbosacral fusion; long instrumentations to the sacrum; L5–S1 fusion without anterior support.

Contraindications

Lack of sacral bone stock.

Surgical technique

Midline approach. The entry point for S2–ala screws is caudal to the posterior S1 foramen and close to the lateral sacral crest. Screw tract preparation for S2–ala screws necessitates 30–45° angulation in the axial plane. Biplanar fluoroscopy with inlet and outlet views ensure screw accuracy. With S2–ala screws, bicortical fixation is the goal.

Postoperative management

Patients are mobilized under the surveillance of physiotherapists on day 1 and released from the hospital after 10 days. Clinical and radiographic controls are performed at 6, 12 and 24 months.

Results

Retrospective review of 80 patients undergoing S2–ala screw fixation. Main diagnosis was degenerative lumbar instability, adult scoliosis, high-grade listhesis, and nonidiopathic scoliosis. In 66% of patients, the instrumentation using S2–ala screws was part of a major lumbosacral revision surgery. Follow-up averaged 26 months. There were no deaths or major neurovascular complications. First time fusion rate at L5–S1 was greater than 90%. Eight patients (10%) experienced a complication which could be related to the S2–ala screws. Out of 160 S2-ala screws, 16 screws were judged to cause focal irritation and were removed, indicating a survival rate of 90% for the S2–ala screw.

Keywords

Lumbosacral fixation Spinal deformity surgery Lumbopelvic fixation S2–ala screw S2–ala–ilium screws 

Augmentation lumbosakraler Instrumentationen mittels S1–Pedikelschrauben und S2–Ala-Schrauben

Zusammenfassung

Operationsziel

Steigerung der Konstruktstabilität bei lumbosakralen Fusionen mit S2–Ala-Schrauben als Alternative zu Iliumschrauben.

Indikationen

Revisionschirurgie, lange Fusionen bis zum Sakrum; Kontraindikation zur ventralen Fusion.

Kontraindikationen

Fehlender sakraler Knochenstock.

Operationstechnik

Mittellinienzugang. Der Eintrittspunkt für die S2–Ala-Schrauben liegt kaudal des dorsalen S1-Foramens und nahe der lateralen Crista sacralis. Die Pfadbereitung einer S2-Ala-Schraube erfordert eine laterale Angulation von 30–45° in der Axialen. „Inlet“- und „Outlet“-Aufnahmen mit dem Bildwandler sichern die Genauigkeit der Schraubenplazierung. Mit S2–Ala-Schrauben wird eine bikortikale Fixation angestrebt.

Weiterbehandlung

Die Mobilisierung der Patienten erfolgt am 1. Tag unter physiotherapeutischer Anleitung. Die stationäre Entlassung erfolgt nach ca. 10 Tagen, orthesenfrei bei sicherer Mobilisation. Klinische und radiologische Verlaufskontrolle werden nach 6, 12 und 24 Monaten durchgeführt.

Ergebnisse

Insgesamt wurden 80 Fälle mit einer Kombination S1-Pedikel- und S2–Ala-Schrauben nachuntersucht. Bei 66% der Patienten wurde die Implantation der S2–Ala-Schrauben im Rahmen eines Revisionseingriffs durchgeführt. Der Nachuntersuchungszeitraum betrug durchschnittlich 26 Monate. Todesfälle oder schwere neurovaskuläre Komplikationen traten nicht ein. Die primäre Fusionsrate L5–S1 beziffert sich auf mehr als 90%. Zuletzt konnte in allen Fällen eine lumbosakrale Fusion erzielt werden. Bei 8 Patienten (10%) kam es zu einer Komplikation, welche auf die S2–Ala-Schrauben zurückgeführt werden konnte. Von insgesamt 160 implantierten S2–Ala-Schrauben waren 16 die Ursache fokaler Beschwerden und wurden daher elektiv entfernt. Die Überlebensrate der S2–Ala-Schrauben betrug 90%.

Schlüsselwörter

Lumbosakrale Fixation Wirbelsäulendeformitäten Lumboplevine Fixation S2–Ala-Schrauben S2–Ala–Iliumschrauben 

Notes

Conflict of interest

On behalf of all authors, the corresponding author states that there are no conflicts of interest.

References

  1. 1.
    Birknes JK, White AP, Albert TJ et al (2008) Adult degenerative scoliosis: a review. Neursurgery 63:94–103CrossRefGoogle Scholar
  2. 2.
    Daubs MD, Lenke LG, Cheh G et al (2007) Adult spinal deformity surgery. Spine 32:2238–2244PubMedCrossRefGoogle Scholar
  3. 3.
    Tsuchiya K, Bridwell KH, Kuklo TR et al (2006) Minimum 5-years analysis of L5-S1 fusion using sacropelvic fixation (bilateral and iliac screws) for spinal deformity. Spine 31:303–308PubMedCrossRefGoogle Scholar
  4. 4.
    Mok JM, Cloyd JM, Bradford DS et al (2009) Reoperation after primary fusion for adult spinal deformity. Rate, reason and timing. Spine 34:832–839PubMedCrossRefGoogle Scholar
  5. 5.
    Pichelmann MA, Lenke L, Bridwell KH et al (2010) Revision rates following primary adult spinal deformity surgery. Spine 35:219–226PubMedCrossRefGoogle Scholar
  6. 6.
    Kim YJ, Bridwell KH, Lenke LG et al (2006) Pseudoarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: Prevalence and risk factor analysis of 144 cases. Spine 31:2329–2336PubMedCrossRefGoogle Scholar
  7. 7.
    Weistroffer JK, Perra JH, Lonstein JE et al (2008) Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients. Spine 33:1478–1483PubMedCrossRefGoogle Scholar
  8. 8.
    Cunningham BW, Stephen JL, Long J et al (2002) Biomechanical evaluation of lumbosacral reconstruction techniques for spondylolisthesis. Spine 27:2321–2327PubMedCrossRefGoogle Scholar
  9. 9.
    Emami A, Deviren V, Berven S et al (2002) Outcome and complications of long fusion to the sacrum in adult spinal deformity. Luque-Galveston, combined iliac and sacral screws, and sacral fixation. Spine 27:776–786PubMedCrossRefGoogle Scholar
  10. 10.
    Orita S, Ohtori S, Eguchi Y et al (2010) Radiographic evaluation of monocortical versus tricortical purchase approaches in lumbosacral fixation with sacral pedicle screws. A prospective study of ninety consecutive patients. Spine 35:E1230–E1237PubMedCrossRefGoogle Scholar
  11. 11.
    Carlson GD, Abitbol JJ, Anderson DR (1992) An in vitro study of the biomechanics of fixation. Spine 17:196–203CrossRefGoogle Scholar
  12. 12.
    Kim J-H, Horton W, Hamasaki T et al (2010) Spinal instrumentation for sacral-pelvic fixation. A biomechanical comparison between constructs ending with either S2-bicortical, bitriangulated screws or iliac screws. J Spinal Disord Tech 23:506–512PubMedCrossRefGoogle Scholar
  13. 13.
    McCord DH, Cunnningham BW, Shono Y (1992) Biomechanical analysis of lumbosacral fixation. Spine 17:235–243CrossRefGoogle Scholar
  14. 14.
    Nottmeier EW, Pirris SM, Balseiro S, Fenton D (2010) Three-dimensional image-guided placement of S2 alar screws to adjunct or salvage lumbosacral fixation. Spine J 10:595–601PubMedCrossRefGoogle Scholar
  15. 15.
    Chang TL, Sponseller PD, Kebaish KM, Fishman EK (2009) Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation versus traditional iliac fixation. Spine 34:436–440PubMedCrossRefGoogle Scholar
  16. 16.
    Kuklo TR, Bridwell KH, Lewis SJ et al (2001) Minimum 2-year analysis of sacropelvic fixation and L5–S1 fusion using S1 and iliac screws. Spine 26:1976–1983PubMedCrossRefGoogle Scholar
  17. 17.
    Lebwohl NH, Cuningham BW, Dmitirev et al (2002) Biomechanical comprison of lumbosacral fixation techniques in a calf spine model. Spine 27:2312–2320PubMedCrossRefGoogle Scholar
  18. 18.
    Zindrick MR, Wiltse LL, Widell EH et al (1986) A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res 203:99–112PubMedGoogle Scholar
  19. 19.
    Leong JCY, Lu W, Zheng Y et al (1998) Comparison of the strengths of lumbosacral fixation achieved with techniques using one and two triangulated sacral screws. Spine 23:2289–2294PubMedCrossRefGoogle Scholar
  20. 20.
    Tis JE, Helgeson M, Lehman RA, Dmitriev AE (2009) A biomechanical comparison of different types of lumbopelvic fixation. Spine 34:E866–E872PubMedCrossRefGoogle Scholar
  21. 21.
    O’Brien JR, Yu WD, Bhatnagar R et al (2009) An anatomic study of the S2 iliac technique for lumbopelvic screw placement. Spine 34:E439–E442CrossRefGoogle Scholar
  22. 22.
    Lee S-H, Jin W, Kim K-T et al (2010) Trajectory of transsacral iliac screw for lumbopelvic fixation. J Spinal Disord Tech 24:151–156CrossRefGoogle Scholar
  23. 23.
    Zhuang XM, Yu BS, Zhen ZM et al (2010) Effect of the degree of osteoporosis on the biomechanical anchoring strength of the sacral pedicle screws. Spine 35:E925–E931PubMedCrossRefGoogle Scholar
  24. 24.
    Arman C, Naderi S, Kiray A et al (2009) The human sacrum and safe approaches for screw placement. J Clin Neurosci 16:1046–1049PubMedCrossRefGoogle Scholar
  25. 25.
    Esses SI, Botsford DJ, Huler RJ, Rauschning W (1991) Surgical anatomy of the sacrum. A guide for rational screw fixation. Spine 16:283–288CrossRefGoogle Scholar
  26. 26.
    Mirkovic S, Abitol J, Steinmann J et al (1991) Anatomic consideration for sacral screw placement. Spine 16:289–294CrossRefGoogle Scholar
  27. 27.
    Djurasovic M, Glassman SD, Dimar II JR et al (2011) Does fusion status correlate with patient outcomes in lumbar spinal fusion. Spine 36:404–409PubMedGoogle Scholar
  28. 28.
    Merritt AL, Spinnicke A, Pettigrew K, Alamin TF (2010) Gluteal-sparing approach of posterior iliac crest bone graft. Spine 35:1396–1400PubMedCrossRefGoogle Scholar
  29. 29.
    Arman C, Naderi S, Kiray A et al (2009) The human sacrum and safe approaches for screw placement. J Clin Neurosci 16:1046–1049PubMedCrossRefGoogle Scholar
  30. 30.
    Chang T-L, Sponseller PD, Kebaish KM, Fishman EK (2009) Low profile pelvic fixation. Spine 34:436–440PubMedCrossRefGoogle Scholar
  31. 31.
    Ebraheim NA, Lu J, Biyani A et al (1997) The relationship of lumbosacral plexus to the sacrum and the sacroiliac joint. Am J Orthop 26:105–110PubMedGoogle Scholar
  32. 32.
    Ebraheim NA, Xu R, Biyani A, Nadaud MC (1997) Morphologic considerations of the first sacral pedicle for iliosacral screw placement. Spine 22:841–846PubMedCrossRefGoogle Scholar
  33. 33.
    Mirkovic S, Abitbol JJ, Steinman J et al (1991) Anatomic consideration for sacral screw placement. Spine 16:289–294CrossRefGoogle Scholar
  34. 34.
    Okutan O, Kaptanoglu E, Solaroglu I et al (2004) Determination of the length of anteromedial screw trajectory by measuring interforaminal distance in the first sacral vertebra. Spine 29:1608–1611PubMedCrossRefGoogle Scholar
  35. 35.
    Xu R, Ebraheim NA, Yeasting RA et al (1995) Morphometric evaluation of the first sacral vertebra and the projection of its pedicle on the posterior aspect of the sacrum. Spine 20:936–940PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • H. Koller
    • 1
    Email author
  • J. Zenner
    • 1
  • A. Hempfing
    • 1
  • L. Ferraris
    • 1
  • O. Meier
    • 1
  1. 1.Werner-Wicker-ClinikGerman Scoliosis CenterBad WildungenGermany

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