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Bryson XM, Pham NS, Hollyer I, Hu S, Rinsky LA, Vorhies JS. 3D CT modeling demonstrates the anatomic feasibility of S1AI screw trajectory for spinopelvic fixation in neuromuscular scoliosis. Spine Deform 2024; 12:933-939. [PMID: 38733488 DOI: 10.1007/s43390-024-00840-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 02/07/2024] [Indexed: 05/13/2024]
Abstract
PURPOSE In patients with neuromuscular scoliosis undergoing posterior spinal fusion, the S2 alar iliac (S2AI) screw trajectory is a safe and effective method of lumbopelvic fixation but can lead to implant prominence. Here we use 3D CT modeling to demonstrate the anatomic feasibility of the S1 alar iliac screw (S1AI) compared to the S2AI trajectory in patients with neuromuscular scoliosis. METHODS This retrospective study used CT scans of 14 patients with spinal deformity to create 3D spinal reconstructions and model the insertional anatomy, max length, screw diameter, and potential for implant prominence between 28 S2AI and 28 S1AI screw trajectories. RESULTS Patients had a mean age of 14.42 (range 8-21), coronal cobb angle of 85° (range 54-141), and pelvic obliquity of 28° (range 4-51). The maximum length and diameter of both screw trajectories were similar. S1AI screws were, on average, 6.3 ± 5 mm less prominent than S2AI screws relative to the iliac crests. S2AI screws were feasible in all patients, while in two patients, posterior elements of the lumbar spine would interfere with S1AI screw insertion. CONCLUSION In this cohort of patients with neuromuscular scoliosis, we demonstrate that the S1AI trajectory offers comparable screw length and diameter to an S2AI screw with less implant prominence. An S1AI screw, however, may not be feasible in some patients due to interference from the posterior elements of the lumbar spine.
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Affiliation(s)
- Xochitl M Bryson
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, USA
| | - Nicole S Pham
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, USA
| | - Ian Hollyer
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, USA
| | - Serena Hu
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, USA
| | - Lawrence A Rinsky
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, USA
| | - John S Vorhies
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 453 Quarry Rd, 3rd Floor, MC 5658, Palo Alto, CA, USA.
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Zhang HQ, Deng A, Guo CF, Sun Y, Li MJ. Multi-rod posterior correction only with halo-femoral traction for the management of adult neuromuscular scoliosis (> 100°) with severe pelvic obliquity: a minimum 5-year follow-up. J Orthop Surg Res 2023; 18:786. [PMID: 37858229 PMCID: PMC10585782 DOI: 10.1186/s13018-023-04285-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/14/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Many patients with neuromuscular scoliosis (NMS) experience a variety of difficult medical problems that aggravate the development effects of progressive scoliosis and pelvic obliquity (PO). The objective of the current study was to assess the safety and effectiveness of multi-rod posterior correction only (MRPCO) with halo-femoral traction (HFT) for the management of adult NMS (> 100°) with severe PO. METHODS From 2012 to 2017, 13 adult patients who suffered from NMS (> 100°) with severe PO underwent MRPCO with HFT. The radiography parameters in a sitting position, such as the coronal Cobb angle of the main curve, the PO and the trunk shift (TS), were measured at the preoperative, postoperative and final follow-up stages. The preoperative and final follow-up assessment of the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) was taken. RESULTS The average follow-up span was 68.15 ± 6.78 months. There was decreased postoperative coronal Cobb angle with an average mean of 125.24° ± 11.78° to 47.55° ± 12.10°, with a correction rate of 62.43%; the PO was reduced to 6.25° ± 1.63° from 36.93° ± 4.25° with a correction rate of 83.07%; the TS was reduced to 2.41 cm ± 1.40 cm from 9.19 cm ± 3.07 cm. There was significant improvement in all parameters compared to the preoperative data. The VAS score reduced from 4.77 ± 0.93 to 0.69 ± 0.75, and the ODI score reduced from 65.38 ± 16.80 to 28.62 ± 12.29 at the final follow-up. CONCLUSIONS Treatment of adult NMS (> 100°) with severe PO could be safe and effective with MRPCO with HFT. In order to obtain the optimum sitting balance, this could reduce the prevalence of complications and rectify the curvature and the correction of PO.
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Affiliation(s)
- Hong-Qi Zhang
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
| | - Ang Deng
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China.
| | - Chao-Feng Guo
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
| | - Yang Sun
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
| | - Meng-Jun Li
- Department of Spine Surgery and Orthopaedics, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, China
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Mun F, Vankara A, Suresh KV, Margalit A, Sponseller PD. Sacral-Alar-Iliac (SAI) Fixation in Patients With Previous Pelvic Osteotomy. Clin Spine Surg 2022; 35:E702-E705. [PMID: 35501910 DOI: 10.1097/bsd.0000000000001339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/09/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN This was a retrospective study. OBJECTIVE The purpose of this study was to investigate the technical challenges and outcomes of sacral-alar-iliac (SAI) fixation for scoliosis in patients who had previously undergone a pelvic osteotomy for hip dysplasia. SUMMARY OF BACKGROUND DATA Patients with neuromuscular disease are at high risk for developing hip dislocation and scoliosis. Surgical correction of one may affect the other. METHODS We reviewed the records of patients aged 18 years and below who underwent spinal fusion using SAI screws after having undergone a pelvic osteotomy, with ≥2-year follow-up. We recorded the SAI screw dimensions, time from osteotomy to SAI fixation, type of osteotomy, and any complications performing SAI fixation due to the pelvic osteotomy. Bivariate statistics were used to analyze the data with statistical significance defined as P -value <0.05. RESULTS Thirty-two patients were included. The average age was 10.3±3.2 years at pelvic osteotomy and 13.5±3.4 years at SAI fixation. Most patients had cerebral palsy (87.5%) and a unilateral Dega osteotomy (78.1%). Average screw dimensions were significantly shorter on the side of the osteotomy (66 vs. 72 mm, P <0.05). SAI screw placement was technically challenging in 8 patients (25%), due to pelvic distortion from the pelvic osteotomy. The use of a curved awl helped to find the intracortical channel. No patients had complications due to the SAI screw, and there were no significant differences in pelvic obliquity and major coronal curve correction. Two patients (6.3%) had screw lucency >2 mm around the SAI screw on the side of the pelvic osteotomy but no clinical symptoms. CONCLUSIONS SAI fixation in patients with previous pelvic osteotomy is technically challenging due to pelvic morphology and prior implants. Often, a shorter SAI screw is required on the side of the osteotomy. However, outcomes in this patient population are satisfactory, with no significant complications at a 2-year follow-up. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Frederick Mun
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Mun F, Vankara A, Suresh KV, Margalit A, Crasta N, Sponseller PD. Pelvic Osteotomy in Patients With Previous Sacral-Alar-Iliac (SAI) Fixation. J Pediatr Orthop 2022; 42:376-381. [PMID: 35522850 DOI: 10.1097/bpo.0000000000002166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients with neuromuscular disease are at high risk for developing hip dysplasia and scoliosis. The purpose of this study was to investigate the technical challenges and outcomes of pelvic osteotomy in patients with prior sacral-alar-iliac (SAI) fixation. METHODS We reviewed clinical and radiographic records of patients aged 18 years and below who underwent pelvic osteotomy after SAI fixation. We recorded technical challenges during the osteotomy, time from SAI fixation to osteotomy, type of osteotomy, migration index, and distance from the SAI screw to the acetabulum. A 2-sample Wilcoxon rank-sum test was used to assess the data. RESULTS Nineteen patients were included. Technical challenges were defined as having greater intraoperative fluoroscopy times and noted difficult osteotomy in the operative report. The mean time from SAI fixation to pelvic osteotomy was 2.2±1.5 years. For all 12 Chiari osteotomies, the ilium could not be laterally displaced; however, medial displacement of the distal segment of the osteotomy allowed adequate coverage. All 7 Dega osteotomies were performed by cutting the cortex at the tip of the SAI screw. The screw improved proximal leverage and provided a strong buttress for bone graft. The mean migration index before pelvic osteotomy was 59±19%, and at most recent follow-up was 13±4%. Twelve patients, who had a noted complicated osteotomy, had SAI screws that were ≤1.87 cm ( P <0.01) from the acetabulum and significantly increased intraoperative fluoroscopy time (1.76 vs. 1.18 min, P <0.01). CONCLUSIONS The presence of SAI screws may cause iliac osteotomies to be technically challenging if the tip of the SAI screw is ≤1.87 cm to the acetabulum. When initially implanting SAI screws in neuromuscular patients, surgeons should attempt to place screw tips ∼2 cm from the acetabulum in the event these patients require subsequent pelvic osteotomy. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Frederick Mun
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Ulusaloglu AC, Asma A, Bowen JR, Yorgova P, Howard JJ, Shrader MW, Shah SA. Prevalence and Risk Factors Associated With Pelvic Rod/Screw Radiographic Lucency Following Scoliosis Surgery in Spastic Cerebral Palsy: A Longitudinal Study. J Pediatr Orthop 2022; 42:e736-e741. [PMID: 35650685 DOI: 10.1097/bpo.0000000000002173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radiographic lucency around a smooth pelvic rod (Galveston/unit rod technique) or sacroiliac/iliac screw following spinal fusion in children with nonambulatory spastic cerebral palsy (CP) has been described as a "windshield wiper" phenomenon. We evaluated demographics, radiographs, and complications in 101 cases from a single center to determine prevalence, risk factors, and complications associated with persistent radiographic lucency from 1 to 5 years following spinal fusion. METHODS Inclusion criteria were diagnosis of nonambulatory spastic quadriplegic CP [Gross Motor Function Classification System (GMFCS) IV-V], under 18 years of age, scoliosis treated by posterior fusion from upper thoracic to sacrum with pelvic fixation (Galveston rod, iliac screw, or sacroiliac screw), adequate radiographs (preoperative, immediate postoperative, first-year, and second-year), and minimum 5-year follow-up. We evaluated demographics, radiographic parameters, comorbidities, scoliosis curve type, type of pelvic screw/rod, use of off-set connector, screw width, associated with posterior column osteotomy and/or additional anterior spinal release concurrent with posterior spine fusion, and infection over the follow-up period. Specific attention was given to the area and shape of the radiographic lucency. The logistic regression analysis was performed for continuous and categorical variables to define risk factors ( P =0.05). RESULTS In 101 patients, data were collected at mean intervals of 1-year, 2-year, and >5-year follow-up and were 12.9±1.5, 25.8±2.5, and 81.5±23.0 months, respectively. Prevalence of pelvic rod/screw radiographic lucency was unchanged at 33%, 35%, and 24% at 1-year, 2-year, and >5-year follow-up, respectively, and radiographic parameters did not change ( P >0.05). Furthermore, no risk factors or complications were associated with radiographic lucency around pelvic rods/screws ( P >0.05). CONCLUSION In patients with spastic nonambulatory CP who had scoliosis treated with posterior spinal fusion from upper thorax to pelvis, the prevalence of pelvic rod/screw lucency is high. Persistent lucency >2 mm around pelvic implants is not clinically significant, does not warrant advanced imaging, or indicate a complication if stable over time and wider distally than proximally. LEVEL OF EVIDENCE Level III.
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Mun F, Vankara A, Suresh KV, Margalit A, Kebaish KM, Sponseller PD. Sacral-Alar-Iliac (SAI) Fixation in Children With Spine Deformity: Minimum 10-Year Follow-Up. J Pediatr Orthop 2022; 42:e709-e712. [PMID: 35575763 DOI: 10.1097/bpo.0000000000002187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Sacral-alar-iliac (SAI) screws are utilized to achieve pelvic fixation in spine deformity patients. The primary purpose of this study is to investigate the long-term outcomes of pediatric patients with scoliosis treated with posterior spinal fusion and SAI fixation at 10-year clinical and radiographic follow-up. METHODS We reviewed the clinical and radiographic records of patients aged 18 years or below treated for scoliosis with posterior spinal fusion using SAI fixation. Pelvic obliquity and the major coronal curve were determined at the preoperative visit and 6-week, 1-year, 5-year, and 10-year postoperative visits. SAI screw-specific data collected included screw dimensions, rate of screw revision, pain at the SAI screw sites, presence of lucency >2 mm around the screw, screw loosening or breaking, and deep surgical site infections. RESULTS Ninety-seven of 151 patients (75%) were included. The average age at index surgery was 13.5±3.1 years, and the most common diagnosis was cerebral palsy (67%). The mean duration of follow-up was 11±3 years. The mean pelvic obliquity measured 20±8.0 degrees preoperatively, and 8.7±4.0 degrees at the 10-year follow-up. There were no significant difference in pelvic obliquity when comparing the 10-year follow-up visit with the 6-week postoperative follow-up. Average screw dimensions were 8.4×68.8 mm. By the 10-year follow-up, 4 patients (4%) had at least 1 SAI screw-related complication. Of these patients, 2 (2%) had pain at 1 SAI screw, 4 (4%) had lucency around the screw, and 3 (3%) had broken or loose screws. Two (2%) required SAI screw revision because of late deep wound infection, and underwent exchange with a longer screw. There were no intrapelvic protrusions, vascular, or neurological complications. CONCLUSIONS SAI screws are a safe and effective method for pelvic fixation in children with spinal deformity. The outcomes at ≥10 years are satisfactory, with low rates of long-term complications and excellent postoperative correction and subsequent maintenance of coronal curvature and pelvic obliquity over time. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Frederick Mun
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Banno T, Yamato Y, Oba H, Ohba T, Hasegawa T, Yoshida G, Arima H, Oe S, Mihara Y, Ushirozako H, Takahashi J, Haro H, Matsuyama Y. Preoperative pelvic obliquity: possible relation to postoperative coronal decompensation in thoracolumbar/lumbar adolescent idiopathic scoliosis. J Neurosurg Spine 2022; 36:193-202. [PMID: 34560635 DOI: 10.3171/2021.4.spine21265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pelvic obliquity is frequently observed in patients with adolescent idiopathic scoliosis with thoracolumbar/lumbar (TL/L) curve. This study aimed to assess pelvic obliquity changes and their effects on clinical outcomes of posterior fusion surgery. METHODS Data in 80 patients (69 with type 5C and 11 with type 6C adolescent idiopathic scoliosis) who underwent posterior fusion surgery were retrospectively analyzed. Pelvic obliquity was defined as an absolute pelvic obliquity angle (POA) value of ≥ 3°. The patients were divided into groups according to preoperative pelvic obliquity. Moreover, patients with preoperative pelvic obliquity were divided based on POA change from preoperative values versus 2 years postoperatively. Patients were divided based on the presence of selective or nonselective TL/L fusion. Radiographic parameters and clinical outcomes were compared between these groups. RESULTS Among 80 patients, 41 (51%) showed preoperative pelvic obliquity, and its direction was upward to the right for all cases. Coronal decompensation 2 years postoperatively was significantly elevated in patients with preoperative pelvic obliquity (p < 0.05). Thirty-two patients (40%) displayed pelvic obliquity 2 years postoperatively. Among 41 patients with preoperative pelvic obliquity, 22 patients (54%) were in the group with a decrease in POA, and 19 were in the group with no decrease. The group with no decrease in POA showed significant TL/L curve progression throughout the postoperative follow-up period. The patients with nonselective fusion showed a significantly lower incidence of pelvic obliquity at 2 years postoperatively. CONCLUSIONS Postoperative coronal decompensation more frequently occurred in patients with preoperative pelvic obliquity than in those without pelvic obliquity preoperatively. In addition, postoperative pelvic obliquity changes may be related to residual lumbar curve behavior.
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Affiliation(s)
- Tomohiro Banno
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Yu Yamato
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Hiroki Oba
- 2Department of Orthopedic Surgery, Shinshu University, Matsumoto, Nagano; and
| | - Tetsuro Ohba
- 3Department of Orthopedic Surgery, Yamanashi University, Chuo, Yamanashi, Japan
| | - Tomohiko Hasegawa
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Go Yoshida
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Hideyuki Arima
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Shin Oe
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Yuki Mihara
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Hiroki Ushirozako
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
| | - Jun Takahashi
- 2Department of Orthopedic Surgery, Shinshu University, Matsumoto, Nagano; and
| | - Hirotaka Haro
- 3Department of Orthopedic Surgery, Yamanashi University, Chuo, Yamanashi, Japan
| | - Yukihiro Matsuyama
- 1Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
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Suresh KV, Ikwuezunma I, Margalit A, Sponseller PD. Spinal Fusion with Sacral Alar Iliac Pelvic Fixation in Severe Neuromuscular Scoliosis. JBJS Essent Surg Tech 2021; 11:ST-D-20-00060. [PMID: 34650826 DOI: 10.2106/jbjs.st.20.00060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Neuromuscular scoliosis is characterized by rapid progression of curvature during growth and may continue to progress following skeletal maturity. Posterior spinal fusion in patients with cerebral palsy and severe scoliosis results in substantial improvements in health-related quality of life1. Correction of pelvic obliquity can greatly improve sitting balance, reduce pain, and decrease skin breakdown. The sacral alar iliac (SAI) technique has key advantages over prior techniques, including the Galveston and iliac-screw techniques. The SAI technique eliminates the need for subcutaneous muscle dissection over the iliac crest, does not require the use of connectors from the rod to the iliac screw, and decreases the risk of implant prominence2. Description We demonstrate how to perform posterior spinal fusion with SAI pelvic fixation in a patient with cerebral palsy. In correcting the scoliosis, we utilize the segmental 3-dimensional technique, which includes compression, distraction, transverse approximation to 1 rod at a time, and derotation around 2 rods. We also demonstrate SAI pelvic fixation with identification of the screw starting point on the lateral-caudal border of the first sacral foramen and trajectory toward the anterior inferior iliac spine. Alternatives Nonoperative alternatives include bracing, trunk support, contouring of sitting surfaces (such as wheelchairs), and physical therapy to slow curve progression during growth periods and delay the need for surgical treatment3,4. Decision-making is shared with the family following education about the risks and benefits. Families who are satisfied with the function of the child at baseline should not be persuaded into pursuing surgical treatment. Rationale Neuromuscular scoliosis can include difficulty sitting secondary to increased pelvic obliquity, along with poor trunk control and balance. Surgical intervention is considered in patients with curves exceeding approximately 50°, as these curves will often continue to progress even after maturity5. In patients with neuromuscular scoliosis, indications for pelvic fixation include pelvic obliquity of >15°, poor control of the trunk as indicated by lack of independent sitting or standing, and location of the apex of the curve in the lumbar spine. SAI screws are utilized as a low-profile option for pelvic fixation to avoid implant prominence and an increased risk of skin breakdown and infection, which are associated with traditional sacroiliac screws2,6. Expected Outcomes Miyanji et al. reported quality outcomes in patients with cerebral palsy and Gross Motor Function Classification Scores of ≥41. In that study, caregivers completed a validated disease-specific questionnaire grading the health-related quality of life of the patient preoperatively and at 1, 2, and 5 years postoperatively. Complication data were prospectively collected for each patient and preoperative outcome scores were compared at each of the postoperative time points. Survey scores at 1, 2, and 5 years postoperatively were significantly higher compared with baseline preoperative values.Sponseller et al. compared the 2-year postoperative radiographic parameters of 32 pediatric patients who underwent SAI fixation and 27 patients who underwent pelvic fixation with the sacroiliac technique2. Among patients who underwent SAI fixation, the mean correction of pelvic obliquity was 20° ± 11° (70% correction) and the mean Cobb angle 42° ± 25° (67%). Among patients who underwent pelvic fixation with the sacroiliac technique, those values were 10° ± 9° (50%) and 46° ± 16° (60%), respectively. SAI screws provided significantly better pelvic obliquity correction (p = 0.002) but no difference in Cobb correction or complications compared with other traditional techniques. Important Tips Family discussion prior to surgical treatment is paramount.Perform preoperative neurologic examination7.Examine the cranium carefully for a ventriculoperitoneal shunt or prior cranial reconstruction prior to cranial traction.Transcranial neuromonitoring may be useful. Use descending neural motor evoked potentials when no signals from transcranial monitoring are obtained8.Sink the SAI screw until it lines up with the S1 screw. Bury the SAI screw so it is not prominent.Measure rods longer in order to ensure adequate length for compression and distraction in correction of the pelvic obliquity.Use a T-square to verify adequate spinopelvic alignment9.Postoperatively, the use of incisional vacuum-assisted closure can decrease soiling in these patients. Acronyms and Abbreviations SAI = Sacral alar iliacCP = Cerebral palsyAIS = Adolescent idiopathic scoliosisSMA = Spinal muscular atrophyIONM = Intraoperative neuromonitoringGMFCS = Gross Motor Functional Classification SystemDNMEP = Descending neural motor evoked potentialTXA = Tranexamic acidFFP = Fresh frozen plasmaASIS = Anterior superior iliac spineAIIS = Anterior inferior iliac spinePJK = Proximal junctional kyphosis.
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Affiliation(s)
- Krishna V Suresh
- Department of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | - Ijezie Ikwuezunma
- Department of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | - Adam Margalit
- Department of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | - Paul D Sponseller
- Department of Pediatric Orthopaedics, Johns Hopkins University, Baltimore, Maryland
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Comparative radiological outcomes and complications of sacral-2-alar iliac screw versus iliac screw for sacropelvic fixation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2257-2270. [PMID: 33987735 DOI: 10.1007/s00586-021-06864-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 12/13/2020] [Accepted: 05/01/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare the outcomes of sacropelvic fixation (SPF) using sacral-2-alar iliac (S2AI) screw with SPF using iliac screw (IS). METHODS A comprehensive search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus was performed for comparative studies between S2AI and IS for SPF. Two independent investigators selected qualified studies and extracted data indispensably. With 95% confidence intervals (CI), the odds ratio (OR) was applied to dichotomous outcomes and standardized mean difference (SMD) was applied to continuous outcomes for each item. RESULTS We included data from thirteen studies involving 722 patients (S2AI, 357 patients; IS, 365 patients). In the pediatric population, the S2AI group had a smaller pelvic obliquity (PO) than the IS group at final follow-up (SMD, - 0.38; 95% CI, - 0.72 to - 0.04). Patients who underwent S2AI screws showed reduced rates of re-operation (S2AI, 13%; IS, 28%), implant failure (S2AI, 12%; IS, 26%) [screw loosening (S2AI, 8%; IS, 20%); screw breakage (S2AI, 2%; IS, 12%)], implant prominence (S2AI, 2%; IS, 14%), pseudarthrosis (S2AI, 3%; IS, 15%), wound infection (S2AI, 8%; IS, 22%) and less blood loss (S2AI, 2035.4 ml; IS, 2708.4 ml). CONCLUSION Radiological outcomes indicate an effective maintenance of the correction and arrest of progression of deformity by S2AI, which is equal or better than IS. SPF with S2AI screw has obviously lower incidence of postoperative complications and less blood loss. Given these advantages, the S2AI screw seems to be a beneficial alternative to IS.
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Ravindra VM, Mazur MD, Brockmeyer DL, Kraus KL, Ropper AE, Hanson DS, Dahl BT. Clinical Effectiveness of S2-Alar Iliac Screws in Spinopelvic Fixation in Pediatric Neuromuscular Scoliosis: Systematic Literature Review. Global Spine J 2020; 10:1066-1074. [PMID: 32875851 PMCID: PMC7645097 DOI: 10.1177/2192568219899658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVES To comprehensively review the S2-alar iliac (S2-AI) screw technique for pelvic fixation in pediatric neuromuscular scoliosis. METHODS Articles identified from the PubMed and EMBASE databases were reviewed for relevance and applicability, and the studies were summarized. RESULTS Eight articles met the inclusion criteria. A total of 277 pediatric patients underwent spinopelvic fixation using S2-AI fixation for neuromuscular scoliosis; the mean follow-up was 3 years (range = 0.75-6 years). Six articles had level III evidence (5 retrospective cohort studies, 1 observational study), and 2 articles had level IV evidence (case series). Wound complications occurred in 34 (12.2%) patients. Instrumentation complications occurred in 36 patients (13.0%), including lucency around the screw (6.5%), screw fracture (3.6%), disengaging of the set/screw or rod from the tulip head (2.8%), and screw displacement (0.7%). Three patients (1.1%) required reoperation for instrumentation failures. The overall reoperation rate-including 3 hardware replacements and 3 cases of L5-S1 pseudarthrosis-was 2.1%. The mean Cobb angle correction was 51.4°, and the mean pelvic obliquity correction was 14.8°; deformity correction was maintained at 3- and 5-year follow-ups. There were 10 (3.6%) cases of implant prominence/implant-related pain, 1 case of sacroiliac joint pain (resolved with longer screw placement), and no major neurological or vascular complications secondary to S2-AI screw placement. CONCLUSIONS This review suggests that the use of S2-AI screws in pediatric neuromuscular scoliosis is efficacious with a reasonable safety profile and provides a useful technique for pelvic fixation in children with scoliosis.
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Affiliation(s)
- Vijay M. Ravindra
- University of Utah, Salt Lake City, UT, USA,Baylor College of Medicine, Houston, TX, USA,Vijay M. Ravindra, Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT 84132, USA.
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