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REVIEW ARTICLE
Year : 2014  |  Volume : 5  |  Issue : 3  |  Page : 110-113  

Sacroiliac screw fixation: A mini review of surgical technique


1 Physician, University of Cartagena, Cartagena, Colombia
2 Neurosurgeon, Hospital CARI Barranquilla, Barranquilla, Colombia
3 Neurosurgeon, University of Cartagena, Cartagena, Colombia

Date of Web Publication7-Oct-2014

Correspondence Address:
Luis Rafael Moscote-Salazar
University of Cartagena, Cartagena de Indias
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-8237.142303

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   Abstract 

The sacral percutaneous fixation has many advantages but can be associated with a significant exposure to X-ray radiation. Currently, sacroiliac screw fixation represents the only minimally invasive technique to stabilize the posterior pelvic ring. It is a technique that should be used by experienced surgeons. We present a practical review of important aspects of this technique.

Keywords: Minimally invasive surgery, percutaneous screw fixation, sacrum


How to cite this article:
Alvis-Miranda HR, Farid-Escorcia H, Alcala-Cerra G, Castellar-Leones SM, Moscote-Salazar LR. Sacroiliac screw fixation: A mini review of surgical technique . J Craniovert Jun Spine 2014;5:110-3

How to cite this URL:
Alvis-Miranda HR, Farid-Escorcia H, Alcala-Cerra G, Castellar-Leones SM, Moscote-Salazar LR. Sacroiliac screw fixation: A mini review of surgical technique . J Craniovert Jun Spine [serial online] 2014 [cited 2019 Jul 18];5:110-3. Available from: http://www.jcvjs.com/text.asp?2014/5/3/110/142303


   Introduction Top


Sacroiliac screws (SISs) has been used since Vidal et al. [32] introduced its use in 1973. Since that, SIS has become a common technology in fixing pelvic posterior ring injuries. [11],[37] SIS has made important progress in the treatment of posterior pelvic ring injury during the past 20 years. However, some clinical reports showed that conventional SIS may not universally result in sufficiently stable fixation. [37]

Currently, SIS fixation represents the only minimally invasive technique to stabilize the posterior pelvic ring. [20] For that reason, it is steadily gaining popularity, becoming one of the most commonly used techniques. Some indications for this technique include sacroiliac joint dislocations, sacral fractures, certain iliac crescent fractures and combinations of those injuries. [4],[11] The sacrum, serving as the foundation of the spine, transmits the stress between spine and pelvis through sacroiliac joints. [35] Thus, the goal of surgical fixation is the reconstruction of the spine-pelvic-junction to allow early weight-bearing and to facilitate nursing care, particularly for multiple injured patients. [6]

To overcome the biomechanical limitations faced by the single iliac screw technique, the dual iliac screw technique was developed. [35] Have been demonstrated that the dual iliac screw technique provides good clinical results for patients with a partial or total sacrectomy with no iliac screw failure, [1],[7],[9] confirming the biomechanical advantage of dual over single iliac screw in restoring the stability of the lumbo-iliac fixation construct in vertical and rotational planes. [35] However, clinical practices caution that the dual iliac screw technique may increase bone stock loss, prominence of the instrumentation, and screw-rod connection difficulty as compared with the single iliac screw technique. [36]

The aim of this work is, through a nonexhaustive review of the literature expose current considerations about SIS fixation technique.


   The technique Top


Lengthened sacro-iliac screw

This technique obtains fixation by traversing bilateral sacroiliac joints and the sacral body, this technique can solve the problem of bilateral sacroiliac joint fractures and dislocations. [10],[25] In the past were commonly used two techniques, the oblique method of SIS placement, in which the screw is obliquely aligned, directed inferiorly to superiorly and posteriorly to anteriorly, and the transverse alignment of the SIS through the sacral ala on both the inlet and outlet views of the sacrum. With the first technique was an increased the risk of unrecognized anterior protrusion of screws beyond the sacral body, and with the second-technique results in a smaller secured area of the sacral isthmus bone. [20] The current procedure technique is the SIS under fluoroscopic observation with the standard Matta projections anterior-posterior (a.p.), inlet, outlet [Figure 1] and [Figure 2].
Figure 1: Computed tomography scan three-dimensional of sacral luxation

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Figure 2: Intraoperative radiography showing transverse alignment of SIS fixation

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Sacroiliac screw fixation is technically challenging and can be contraindicated depending on the shape of the sacrum. [15] The lack of direct visualization and limited tactile control complicate precise screw insertion. [13],[26] The surgeon has to decide if an extrapolated implant position will match a secure inner-bony position orienting on planar fluoroscopic images in different projections. In addition, image interpretation is aggravated by the high degree of shape variability of the upper sacrum. [20] This circumstance unavoidably results in increased X-ray exposure for the patient and the surgeon due to more frequent application of image intensifier. Aberrant screw or wire placement can lead to significant complications, including injury to the fifth-lumbar nerve root, sacral venous plexus, iliac vessels, or cauda equina. [24]

Iliac screws offer advantages of improved bio-mechanics. They permit iliac crest bone harvesting and have shown to have high-fusion rates, in long fusions and are valuable for the use in high-grade spondylolisthesis. [17] There may, however, be hardware prominence and exposure may be somewhat difficult. As well, they offer advantages for correction of pelvic obliquity and for revision surgery and do not violate the sacroiliac joint. Disadvantages may occur, as a result, of difficulties in insertion. [17]

Have been reported rates of implant malposition of up to 18-25%, [4],[11],[12],[25],[30] which are potentially associated with iatrogenic neurovascular lesions. Lengthened SIS is more applicable to repair surgery after first failure of the SIS fixation, [3] but overall SIS fixation is indicated in nondisplaced unstable sacroiliac joint injuries or sacral fractures. [19]

In the experimental setup, have been demonstrated that two ipsilateral screws provide more biomechanical stability than the one. [34],[38] However, using conventional fluoroscopy, many surgeons limit the placement of iliosacral screws to the pedicles of S1, as those of S2 are narrow and difficult to visualize [Figure 2]. [21]

The screws are placed through the outer table of the ilium, through the S1 joint and into the lateral sacrum. [23] This bone channel has been well-described and regularly used in pelvic trauma applications for screw placement. It has also been performed with an open and percutaneous technique. With the development of adjunctive devices for Cotrel-Dubosset instrumentation, a monoblock was developed to use this trajectory for screw fixation.

Recently, Pan et al. [22] have introduced a SIS fixation guide and evaluated its efficacy in fixation of sacroiliac joint fracture-dislocations, they found that the minimally invasive guide can eliminate discrepancies resulting from the surgeon's own sensory input when inserting screws under the guidance of computed tomography (CT), making percutaneous iliosacral screw fixation more accurate, safe and simple. The use of a guide can curtail the surgical time to about 14 min.

Radiological considerations

As previously mentioned, is widely used the fluoroscopy control for the placement of the screws. This leads the technique being highly dependent on fluoroscopic technician, and on the operator's ability not only to interpret the fluoroscopic images but also to control wire placement based on this interpretation. [24] Using the conventional fluoroscopy-based technique, the drilling can only be controlled in one projection at once; thus, the position of the screws must be followed and adjusted under fluoroscopy in a.p., inlet, outlet and lateral projections. All this result in increased radiation exposure for the patient and the surgeon. [5] Have been reported injuries to nerve roots and the gluteal vessels in up to 3-15% of cases using this method.

Navigation systems have been introduced for traumatological indications, especially in the field of spine and pelvic surgery [2],[8],[14],[27],[29],[31],[33] With the aim to increase precision of screw positioning, various techniques for CT-guided/computer-navigated screw positioning were described. [16],[18],[28],[30] The potential advantages of CT-guided placement of percutaneous hollow screws are that it is a simple operation, the screws are accurately located, there is less hemorrhage, minimal injuries and strong fixation is achieved. [22]

However, in the emergency room (ER) with patients in urgent need for early primary care, these time-consuming techniques are unsuitable. Thus, fluoroscopy provides a straightforward and inexpensive approach to intraoperative visualization. [21] Some techniques, such as Iso-C3D navigation demonstrates superiority to fluoroscopy navigation for SIS fixation in an experimental set-up designed to assess the accuracy. [5]


   Evidence Top


Comparing the stability of lengthened SIS and SIS for the treatment of bilateral vertical sacral fractures, Zhao et al. [37] in a finite element model of Tile C pelvic ring injury (bilateral type Denis II fracture of the sacrum) demonstrated that:

  • The stability of one lengthened SIS fixation in the S1 or S2 segment is superior to that of two bidirectional SIS in the same sacral segment
  • The stability of one lengthened SIS fixation in S1 and S2 segments, respectively, is superior to that of two bidirectional SIS fixation in S1 and S2 segments, respectively
  • The stability of one lengthened SIS fixation in S1 and S2 segments, respectively, is superior to that of one lengthened SIS fixation in the S1 or S2 segment
  • The stability of two bidirectional SIS fixation in S1 and S2 segments, respectively, is markedly superior to that of two bidirectional SIS fixation in the S1 or S2 segment and is also markedly superior to that of one SIS fixation in the S1 segment and one SIS fixation in the S2 segment
  • The vertical stability of the lengthened SIS or the SIS fixation in S2 is superior to that of S1
  • The rotational stability of the lengthened SIS or SIS fixation in S1 is superior to that of S2.



   Conclusions Top


Sacroiliac screw fixation is a commonly used procedure for iliosacral joint fracture-dislocations and sacral fractures. Currently, the standard technique is the percutaneous iliosacral screw fixation under conventional C-arm fluoroscopy that often exposes the patient to prolonged radiation. Unfortunately, even experienced surgeons can have a high rate of screw malposition and nerve and vessel injuries, being that the reason because SIS fixation should be performed under better technology control, but in the ER setting, this could be laborious and can finish in a loss of time for the patient treatment.

 
   References Top

1.Acharya NK, Bijukachhe B, Kumar RJ, Menon VK. Ilio-lumbar fixation - the Amrita technique. J Spinal Disord Tech 2008;21:493-9.  Back to cited text no. 1
    
2.Bale RJ, Kovacs P, Dolati B, Hinterleithner C, Rosenberger RE. Stereotactic CT-guided percutaneous stabilization of posterior pelvic ring fractures: A preclinical cadaver study. J Vasc Interv Radiol 2008;19:1093-8.  Back to cited text no. 2
    
3.Beaulé PE, Antoniades J, Matta JM. Trans-sacral fixation for failed posterior fixation of the pelvic ring. Arch Orthop Trauma Surg 2006;126:49-52.  Back to cited text no. 3
    
4.van den Bosch EW, van Zwienen CM, van Vugt AB. Fluoroscopic positioning of sacroiliac screws in 88 patients. J Trauma 2002;53:44-8.  Back to cited text no. 4
    
5.Citak M, Hüfner T, Geerling J, Kfuri M Jr, Gänsslen A, Look V, et al. Navigated percutaneous pelvic sacroiliac screw fixation: Experimental comparison of accuracy between fluoroscopy and Iso-C3D navigation. Comput Aided Surg 2006;11:209-13.  Back to cited text no. 5
    
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7.Dickey ID, Hugate RR Jr, Fuchs B, Yaszemski MJ, Sim FH. Reconstruction after total sacrectomy: Early experience with a new surgical technique. Clin Orthop Relat Res 2005;438:42-50.  Back to cited text no. 7
    
8.Frank M, Dedek T. Percutaneous iliosacral screw placement using a radiolucent drive. Acta Orthop Belg 2012;78:519-22.  Back to cited text no. 8
    
9.Fujibayashi S, Neo M, Nakamura T. Palliative dual iliac screw fixation for lumbosacral metastasis. Technical note. J Neurosurg Spine 2007;7:99-102.  Back to cited text no. 9
    
10.Gardner MJ, Routt ML Jr. Transiliac-transsacral screws for posterior pelvic stabilization. J Orthop Trauma 2011;25:378-84.  Back to cited text no. 10
    
11.Giannoudis PV, Papadokostakis G, Alpantaki K, Kontakis G, Chalidis B. Is the lateral sacral fluoroscopic view essential for accurate percutaneous sacroiliac screw insertion? An experimental study. Injury 2008;39:875-80.  Back to cited text no. 11
    
12.Gänsslen A, Hüfner T, Krettek C. Percutaneous iliosacral screw fixation of unstable pelvic injuries by conventional fluoroscopy. Oper Orthop Traumatol 2006;18:225-44.  Back to cited text no. 12
    
13.Hilgert RE, Finn J, Egbers HJ. Technique for percutaneous iliosacral screw insertion with conventional C-arm radiography. Unfallchirurg 2005;108:954, 956-60.  Back to cited text no. 13
    
14.Iguchi T, Ogawa K, Doi T, Miyasho K, Munetomo K, Hiraki T, et al. Computed tomography fluoroscopy-guided placement of iliosacral screws in patients with unstable posterior pelvic fractures. Skeletal Radiol 2010;39:701-5.  Back to cited text no. 14
    
15.Ilharreborde B, Breitel D, Lenoir T, Mosnier T, Skalli W, Guigui P, et al. Pelvic ring fractures internal fixation: Iliosacral screws versus sacroiliac hinge fixation. Orthop Traumatol Surg Res 2009;95:563-7.  Back to cited text no. 15
    
16.Konrad G, Zwingmann J, Kotter E, Südkamp N, Oberst M. Variability of the screw position after 3D-navigated sacroiliac screw fixation. Influence of the surgeon's experience with the navigation technique. Unfallchirurg 2010;113:29-35.  Back to cited text no. 16
    
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18.Kraus MD, Krischak G, Keppler P, Gebhard FT, Schuetz UH. Can computer-assisted surgery reduce the effective dose for spinal fusion and sacroiliac screw insertion? Clin Orthop Relat Res 2010;468:2419-29.  Back to cited text no. 18
    
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20.Mendel T, Radetzki F, Wohlrab D, Stock K, Hofmann GO, Noser H. CT-based 3-D visualisation of secure bone corridors and optimal trajectories for sacroiliac screws. Injury 2013;44:957-63.  Back to cited text no. 20
    
21.Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Posterior screw fixation in rotationally unstable pelvic ring injuries. Injury 2011;42:992-6.  Back to cited text no. 21
    
22.Pan WB, Liang JB, Wang B, Chen GF, Hong HX, Li QY, et al. The invention of an iliosacral screw fixation guide and its preliminary clinical application. Orthop Surg 2012;4:55-9.  Back to cited text no. 22
    
23.Polly DW Jr, Latta LL. Spinopelvic fixation biomechanics. Semin Spine Surg 2004;16:101-6.  Back to cited text no. 23
    
24.Riehl J, Widmaier J. A simulator model for sacroiliac screw placement. J Surg Educ 2012;69:282-5.  Back to cited text no. 24
    
25.Routt ML Jr, Kregor PJ, Simonian PT, Mayo KA. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma 1995;9:207-14.  Back to cited text no. 25
    
26.Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: Early complications of the percutaneous technique. J Orthop Trauma 1997;11:584-9.  Back to cited text no. 26
    
27.Sciulli RL, Daffner RH, Altman DT, Altman GT, Sewecke JJ. CT-guided iliosacral screw placement: Technique and clinical experience. AJR Am J Roentgenol 2007;188:W181-92.  Back to cited text no. 27
    
28.Sun YQ, Citak M, Kendoff D, Gansslen A, Krettek C, Hufner T. Navigated percutaneous placement of iliosacral screws using intra-operative three-dimensional imaging. Zhonghua Yi Xue Za Zhi 2008;88:3226-9.  Back to cited text no. 28
    
29.Tjardes T, Paffrath T, Baethis H, Shafizadeh S, Steinhausen E, Steinbuechel T, et al. Computer assisted percutaneous placement of augmented iliosacral screws: A reasonable alternative to sacroplasty. Spine (Phila Pa 1976) 2008;33:1497-500.  Back to cited text no. 29
    
30.Tonetti J, Cazal C, Eid A, Badulescu A, Martinez T, Vouaillat H, et al. Neurological damage in pelvic injuries: A continuous prospective series of 50 pelvic injuries treated with an iliosacral lag screw. Rev Chir Orthop Reparatrice Appar Mot 2004;90:122-31.  Back to cited text no. 30
    
31.Trumm CG, Rubenbauer B, Piltz S, Reiser MF, Hoffmann RT. Screw placement and osteoplasty under computed tomographic-fluoroscopic guidance in a case of advanced metastatic destruction of the iliosacral joint. Cardiovasc Intervent Radiol 2011;34 Suppl 2:S288-93.  Back to cited text no. 31
    
32.Vidal J, Allieu Y, Fassio B, Adrey J, Goalard C. Spondylolisthesis: Reduction with Harrington's rods. Rev Chir Orthop Reparatrice Appar Mot 1973;59:21-41.  Back to cited text no. 32
    
33.Wang MY, Williams S, Mummaneni PV, Sherman JD. Minimally invasive percutaneous iliac screws: Initial 24 case experience with CT confirmation. J Spinal Disord Tech 2012. [Epub ahead of print].  Back to cited text no. 33
    
34.Yinger K, Scalise J, Olson SA, Bay BK, Finkemeier CG. Biomechanical comparison of posterior pelvic ring fixation. J Orthop Trauma 2003;17:481-7.  Back to cited text no. 34
    
35.Yu BS, Zhuang XM, Zheng ZM, Li ZM, Wang TP, Lu WW. Biomechanical advantages of dual over single iliac screws in lumbo-iliac fixation construct. Eur Spine J 2010;19:1121-8.  Back to cited text no. 35
    
36.Yu BS, Zhuang XM, Li ZM, Zheng ZM, Zhou ZY, Zou XN, et al. Biomechanical effects of the extent of sacrectomy on the stability of lumbo-iliac reconstruction using iliac screw techniques: What level of sacrectomy requires the bilateral dual iliac screw technique? Clin Biomech (Bristol, Avon) 2010;25:867-72.  Back to cited text no. 36
    
37.Zhao Y, Li J, Wang D, Liu Y, Tan J, Zhang S. Comparison of stability of two kinds of sacro-iliac screws in the fixation of bilateral sacral fractures in a finite element model. Injury 2012;43:490-4.  Back to cited text no. 37
    
38.van Zwienen CM, van den Bosch EW, Snijders CJ, Kleinrensink GJ, van Vugt AB. Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures. J Orthop Trauma 2004;18:589-95.  Back to cited text no. 38
    


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