Advertisement

Surgical options for lumbosacral fusion: biomechanical stability, advantage, disadvantage and affecting factors in selecting options

  • Hiroyuki YoshiharaEmail author
General Review

Abstract

Purpose

Numerous surgical procedures and instrumentation techniques for lumbosacral fusion (LSF) have been developed. This is probably because of its high mechanical demand and unique anatomy. Surgical options include anterior column support (ACS) and posterior stabilization procedures. Biomechanical studies have been performed to verify the stability of those options. The options have their own advantage but also disadvantage aspects. This review article reports the surgical options for lumbosacral fusion, their biomechanical stability, advantages/disadvantages, and affecting factors in option selection.

Methods

Review of literature.

Conclusion

LSF has lots of options both for ACS and posterior stabilization procedures. Combination of posterior stabilization procedures is an option. Furthermore, combinations of ACS and posterior stabilization procedures are other options. It is difficult to make a recommendation or treatment algorithm of LSF from the current literature. However, it is important to know all aspects of the options and decision-making of surgical options for LSF needs to be tailored for each patient, considering factors such as biomechanical stress and osteoporosis.

Keywords

Lumbosacral fusion Lumbosacral junction Spine Surgery Biomechanics Option 

Notes

Conflict of interest

None.

References

  1. 1.
    Pateder DB, Park YS, Kebaish KM et al (2006) Spinal fusion after revision surgery for pseudarthrosis in adult scoliosis. Spine 31:E314–E319CrossRefPubMedGoogle Scholar
  2. 2.
    Tsuchiya K, Bridwell KH, Kuklo TR et al (2006) Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine 31:303–308CrossRefPubMedGoogle Scholar
  3. 3.
    Harimaya K, Mishiro T, Lenke LG, Bridwell KH, Koester LA, Sides BA (2011) Etiology and revision surgical strategies in failed lumbosacral fixation of adult spinal deformity constructs. Spine 36(20):1701–1710CrossRefPubMedGoogle Scholar
  4. 4.
    Leong JC, Lu WW, Zheng Y et al (1998) Comparison of the strengths of lumbosacral fixation achieved with techniques using one and two triangulated sacral screws. Spine 23:2289–2294CrossRefPubMedGoogle Scholar
  5. 5.
    Alegre GM, Gupta MC, Bay BK et al (2001) S1 screw bending moment with posterior spinal instrumentation across the lumbosacral junction after unilateral iliac crest harvest. Spine 26:1950–1955CrossRefPubMedGoogle Scholar
  6. 6.
    Stovall DO Jr, Goodrich JA, Lundy D et al (1997) Sacral fixation technique in lumbosacral fusion. Spine 22:32–37CrossRefPubMedGoogle Scholar
  7. 7.
    Allen BL Jr, Ferguson RL (1984) The Galveston technique of pelvic fixation with L-rod instrumentation of the spine. Spine 9:388–394CrossRefPubMedGoogle Scholar
  8. 8.
    Aryan HE, Newman CB, Gold JJ, Acosta FL Jr, Coover C, Ames CP (2008) Percutaneous axial lumbar interbody fusion (AxiaLIF) of the L5-S1 segment: initial clinical and radiographic experience. Minim Invasive Neurosurg 51(4):225–230CrossRefPubMedGoogle Scholar
  9. 9.
    Beaubien BP, Derincek A, Lew WD, Wood KB (2005) In vitro, biomechanical comparison of an anterior lumbar interbody fusion with an anteriorly placed, low-profile lumbar plate and posteriorly placed pedicle screws or translaminar screws. Spine 30:1846–1851CrossRefPubMedGoogle Scholar
  10. 10.
    Alegre GM, Gupta MC, Bay BK et al (2001) S1 screw bending moment with posterior spinal instrumentation across the lumbosacral junction after unilateral iliac crest harvest. Spine 26:1950–1955CrossRefPubMedGoogle Scholar
  11. 11.
    Glazer PA, Colliou O, Lotz JC et al (1996) Biomechanical analysis of lumbosacral fixation. Spine 21:1211–1222CrossRefPubMedGoogle Scholar
  12. 12.
    Kostuik JP, Valdevit A, Chang HG et al (1998) Biomechanical testing of the lumbosacral spine. Spine 23:1721–1728CrossRefPubMedGoogle Scholar
  13. 13.
    Cunningham BW, Sefter JC, Hu N, Kim SW, Bridwell KH, McAfee PC (2010) Biomechanical comparison of iliac screws versus interbody femoral ring allograft on lumbosacral kinematics and sacral screw strain. Spine 35(6):E198–E205CrossRefPubMedGoogle Scholar
  14. 14.
    Fleischer GD, Kim YJ, Ferrara LA, Freeman AL, Boachie-Adjei O (2012) Biomechanical analysis of sacral screw strain and range of motion in long posterior spinal fixation constructs: effects of lumbosacral fixation strategies in reducing sacral screw strains. Spine 37(3):E163–E169CrossRefPubMedGoogle Scholar
  15. 15.
    Ploumis A, Wu C, Fischer G, Mehbod AA, Wu W, Faundez A, Transfeldt EE (2008) Biomechanical comparison of anterior lumbar interbody fusion and transforaminal lumbar interbody fusion. J Spinal Disord Tech 21:120–125CrossRefPubMedGoogle Scholar
  16. 16.
    Tzermiadianos MN, Mekhail A, Voronov LI, Zook J, Havey RM, Renner SM, Carandang G, Abjornson C, Patwardhan AG (2008) Enhancing the stability of anterior lumbar interbody fusion: a biomechanical comparison of anterior plate versus posterior transpedicular instrumentation. Spine 33:E38–E43CrossRefPubMedGoogle Scholar
  17. 17.
    Gerber M, Crawford NR, Chamberlain RH, Fifield MS, LeHuec JC, Dickman CA (2006) Biomechanical assessment of anterior lumbar interbody fusion with an anterior lumbosacral fixation screw-plate: comparison to stand-alone anterior lumbar interbody fusion and anterior lumbar interbody fusion with pedicle screws in an unstable human cadaver model. Spine 31:762–768CrossRefPubMedGoogle Scholar
  18. 18.
    Phillips FM, Cunningham B, Carandang G, Ghanayem AJ, Voronov L, Havey RM, Patwardhan AG (2004) Effect of supplemental translaminar facet screw fixation on the stability of stand-alone anterior lumbar interbody fusion cages under physiologic compressive preloads. Spine 29(16):1731–1736CrossRefPubMedGoogle Scholar
  19. 19.
    Schultz A (1987) Loads on the lumbar spine. In: Jayson MIV (ed) The Lumbar Spine and Back Pain. Churchill Livingstone, Edinburgh, pp 204–214Google Scholar
  20. 20.
    Nachemson A (1987) Lumbar intradiscal pressure. In: Jayson MIV (ed) The Lumbar Spine and Back Pain. Edinburgh, Churchill Livingstonel, pp 191–203Google Scholar
  21. 21.
    Han JS, Goel VK, Ahn JY et al (1995) Loads in the spinal structures during lifting: development of a three-dimensional comprehensive biomechanical model. Eur Spine J 4:153–168CrossRefPubMedGoogle Scholar
  22. 22.
    Luk KD, Chen L, Lu WW (2005) A stronger bicortical sacral pedicle screw fixation through the s1 endplate: an in vitro cyclic loading and pull-out force evaluation. Spine 30(5):525–529CrossRefPubMedGoogle Scholar
  23. 23.
    Minamide A, Akamaru T, Yoon ST, Tamaki T, Rhee JM, Hutton WC (2003) Transdiscal L5-S1 screws for the fixation of isthmic spondylolisthesis: a biomechanical evaluation. J Spinal Disord Tech 16(2):144–149CrossRefPubMedGoogle Scholar
  24. 24.
    Zindrick MR, Wiltse LL, Widell EH, Thomas JC, Holland WR, Field BT, Spencer CW (1986) A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res 203:99–112PubMedGoogle Scholar
  25. 25.
    Smith SA, Abitbol JJ, Carlson GD, Anderson DR, Taggart KW, Garfin SR (1993) The effects of depth of penetration, screw orientation, and bone density on sacral screw fixation. Spine 18(8):1006–1010CrossRefPubMedGoogle Scholar
  26. 26.
    Zhu Q, Lu WW, Holmes AD, Zheng Y, Zhong S, Leong JC (2000) The effects of cyclic loading on pull-out strength of sacral screw fixation: an in vitro biomechanical study. Spine 25(9):1065–1069CrossRefPubMedGoogle Scholar
  27. 27.
    Lehman RA Jr, Kuklo TR, Belmont PJ Jr, Andersen RC, Polly DW Jr (2002) Advantage of pedicle screw fixation directed into the apex of the sacral promontory over bicortical fixation: a biomechanical analysis. Spine 27(8):806–811CrossRefPubMedGoogle Scholar
  28. 28.
    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(7):595–601CrossRefPubMedGoogle Scholar
  29. 29.
    McCord DH, Cunningham BW, Shono Y, Myers JJ, McAfee PC (1992) Biomechanical analysis of lumbosacral fixation. Spine 17(8 Suppl):S235–S243CrossRefPubMedGoogle Scholar
  30. 30.
    Leong JC, Lu WW, Zheng Y, Zhu Q, Zhong S (1998) Comparison of the strengths of lumbosacral fixation achieved with techniques using one and two triangulated sacral screws. Spine 23(21):2289–2294CrossRefPubMedGoogle Scholar
  31. 31.
    Kim JH, Horton W, Hamasaki T, Freedman B, Whitesides TE Jr, Hutton WC (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(8):506–512CrossRefPubMedGoogle Scholar
  32. 32.
    Ould-Slimane M, Miladi L, Rousseau MA, Bonaccorsi R, Catonne Y, Lazennec JY, Pascal-Moussellard H (2013) Sacropelvic fixation with iliosacral screws: applications and results in adult spinal deformities. J Spinal Disord Tec 26(4):212–217CrossRefGoogle Scholar
  33. 33.
    Ebraheim NA, Xu R, Biyani A, Nadaud MC (1997) Morphologic considerations of the first sacral pedicle for iliosacral screw placement. Spine 22(8):841–846CrossRefPubMedGoogle Scholar
  34. 34.
    Camp JF, Caudle R, Ashmun RD, Roach J (1990) Immediate complications of Cotrel-Dubousset instrumentation to the sacro-pelvis. A clinical and biomechanical study. Spine 15(9):932–941CrossRefPubMedGoogle Scholar
  35. 35.
    Kebaish KM (2010) Sacropelvic fixation: techniques and complications. Spine 35(25):2245–2251CrossRefPubMedGoogle Scholar
  36. 36.
    Cunningham BW, Lewis SJ, Long J, Dmitriev AE, Linville DA, Bridwell KH (2002) Biomechanical evaluation of lumbosacral reconstruction techniques for spondylolisthesis: an in vitro porcine model. Spine 27(21):2321–2327CrossRefPubMedGoogle Scholar
  37. 37.
    Lebwohl NH, Cunningham BW, Dmitriev A, Shimamoto N, Gooch L, Devlin V, Boachie-Adjei O, Wagner TA (2002) Biomechanical comparison of lumbosacral fixation techniques in a calf spine model. Spine 27(21):2312–2320CrossRefPubMedGoogle Scholar
  38. 38.
    Yu BS, Li ZM, Zhou ZY, Zeng LW, Wang LB, Zheng ZM, Lu WW (2011) Biomechanical effects of insertion location and bone cement augmentation on the anchoring strength of iliac screw. Clin Biomech 26(6):556–561CrossRefGoogle Scholar
  39. 39.
    Santos ER, Sembrano JN, Mueller B, Polly DW (2011) Optimizing iliac screw fixation: a biomechanical study on screw length, trajectory, and diameter. J Neurosurg Spine 14(2):219–225CrossRefPubMedGoogle Scholar
  40. 40.
    Tomlinson T, Chen J, Upasani V, Mahar A (2008) Unilateral and bilateral sacropelvic fixation result in similar construct biomechanics. Spine 33(20):2127–2133CrossRefPubMedGoogle Scholar
  41. 41.
    Ngu BB, Belkoff SM, Gelb DE, Ludwig SC (2006) A biomechanical comparison of sacral pedicle screw salvage techniques. Spine 31(6):E166–E168CrossRefPubMedGoogle Scholar
  42. 42.
    McLachlin SD, Al Saleh K, Gurr KR, Bailey SI, Bailey CS, Dunning CE (2011) Comparative assessment of sacral screw loosening augmented with PMMA versus a calcium triglyceride bone cement. Spine 36(11):E699–E704CrossRefPubMedGoogle Scholar
  43. 43.
    Zheng ZM, Zhang KB, Zhang JF, Yu BS, Liu H, Zhuang XM (2009) The effect of screw length and bone cement augmentation on the fixation strength of iliac screws: a biomechanical study. J Spinal Disord Tech 22(8):545–550CrossRefPubMedGoogle Scholar
  44. 44.
    Yu BS, Yang ZK, Li ZM, Zeng LW, Wang LB, Lu WW (2011) Which is the preferred revision technique for loosened iliac screw? A novel technique of boring cement injection from the outer cortical shell. J Spinal Disord Tech 24(6):E49–E56CrossRefPubMedGoogle Scholar
  45. 45.
    Botolin S, Agudelo J, Dwyer A, Patel V, Burger E (2010) High rectal injury during trans-1 axial lumbar interbody fusion L5-S1 fixation: a case report. Spine 35(4):E144–E148CrossRefPubMedGoogle Scholar
  46. 46.
    Moshirfar A, Rand FF, Sponseller PD, Parazin SJ, Khanna AJ, Kebaish KM, Stinson JT, Riley LH (2005) Pelvic fixation in spine surgery. Historical overview, indications, biomechanical relevance, and current techniques. J Bone Joint Surg Am 87(Suppl 2):89–106CrossRefPubMedGoogle Scholar
  47. 47.
    Kuklo TR, Bridwell KH, Lewis SJ, Baldus C, Blanke K, Iffrig TM, Lenke LG (2001) Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine 26(18):1976–1983CrossRefPubMedGoogle Scholar
  48. 48.
    Shen FH, Mason JR, Shimer AL, Arlet VM (2012) Pelvic fixation for adult scoliosis. Eur Spine J October 23 Epub ahead of printGoogle Scholar
  49. 49.
    Linville D II, Cunningham BW, Dmitriev A (2004) Does iliac crest bone graft harvest affect iliac screw fixation—an in vitro biomechanical study? Paper presented at: the Scoliosis Research Society 39th Annual Meeting: September 6–9, Buenos Aires, ArgentinaGoogle Scholar
  50. 50.
    Kebaish KM, Mohammed A, Zimmerman R, et al (2009) A new low profile sacro-pelvic fixation technique using S2 alar iliac (S2AI) screws in adult deformity fusion to the sacrum: a prospective study with minimum 2-year follow-up. In: Proceedings of the NASS 24th Annual Meeting. Spine J 9:56S–57S AbstractGoogle Scholar
  51. 51.
    Stevens DB, Beard C (1989) Segmental spinal instrumentation for neuromuscular spinal deformity. Clin Orthop Relat Res 242:164–168PubMedGoogle Scholar
  52. 52.
    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(5):436–440CrossRefPubMedGoogle Scholar
  53. 53.
    Kostuik JP, Errico TJ, Gleason TF (1986) Techniques of internal fixation for degenerative conditions of the lumbar spine. Clin Orthop Relat Res 203:219–231PubMedGoogle Scholar
  54. 54.
    Kostuik JP (1988) Treatment of scoliosis in the adult thoracolumbar spine with special reference to fusion to the sacrum. Orthop Clin North Am 19(2):371–381PubMedGoogle Scholar
  55. 55.
    Devlin VJ, Asher MA (1996) Biomechanics and surgical principles of long fusions to the sacrum. Spine State Art Rev 10:515–544Google Scholar
  56. 56.
    Perra JH (1994) Techniques of instrumentation in long fusions to the sacrum. Orthop Clin North Am 25(2):287–299PubMedGoogle Scholar
  57. 57.
    Bridwell KH, Kuklo T, Edwards CCII et al (2004) Sacropelvic Fixation. Medtronic Sofamor Danek, MemphisGoogle Scholar
  58. 58.
    Potter BK, Kuklo TR, O’Brien MF (2004) Sacro-iliac fixation for treatment of high-grade spondylolisthesis. Semin Spine Surg 16:119–125CrossRefGoogle Scholar
  59. 59.
    Jost B, Cripton PA, Lund T, Oxland TR, Lippuner K, Jaeger P, Nolte LP (1998) Compressive strength of interbody cages in the lumbar spine: the effect of cage shape, posterior instrumentation and bone density. Eur Spine J 7(2):132–141PubMedCentralCrossRefPubMedGoogle Scholar
  60. 60.
    Ponnusamy KE, Iyer S, Gupta G, Khanna AJ (2011) Instrumentation of the osteoporotic spine: biomechanical and clinical considerations. Spine J 11(1):54–63CrossRefPubMedGoogle Scholar
  61. 61.
    Yu BS, Zhuang XM, Zheng ZM, Zhang JF, Li ZM, Lu WW (2010) Biomechanical comparison of 4 fixation techniques of sacral pedicle screw in osteoporotic condition. J Spinal Disord Tech 23(6):404–409CrossRefPubMedGoogle Scholar
  62. 62.
    Zhuang XM, Yu BS, Zheng ZM, Zhang JF, Lu WW (2010) Effect of the degree of osteoporosis on the biomechanical anchoring strength of the sacral pedicle screws: an in vitro comparison between unaugmented bicortical screws and polymethylmethacrylate augmented unicortical screws. Spine 35(19):E925–E931CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2013

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryNYU Hospital for Joint DiseasesNew YorkUSA
  2. 2.Department of Orthopaedic SurgeryNagoya City University Graduate School of Medical SciencesNagoyaJapan

Personalised recommendations