Minimally Invasive Sacroiliac Fixation for Extension of Fusion in Cases of Failed Lumbosacral Fusion

Robotic-Assisted Surgery and Navigation in Deformity Surgery

Deformity surgery is advancing quickly with the use of three-dimensional navigation and robotics. In spinal fusion, the use of robotics improves screw placement accuracy and reduces radiation, complications, blood loss, and recovery time. Currently, there is limited evidence showing that robotics is better than traditional freehand techniques. Most studies favoring robotics are small and retrospective due to the novelty of the technology in deformity surgery. Using these systems can also be expensive and time-consuming. Surgeons should use these advancements as tools, but not rely on them to replace surgical experience, anatomy knowledge, and good judgment.

Salvage of failed direct lateral sacroiliac joint fixation using a new percutaneous lateral-oblique transfixation technique with two variable-threaded screws: a multicenter case report of three cases

Background

The direct lateral trans-gluteal muscle splitting transiliac approach was popularized to fixate the sacroiliac joint (SIJ) using three cannulated triangular titanium implants (TTIs) wedges. Publications support efficacy of the direct lateral approach but a paucity of literature to help surgeons revise these implants when they fail. Intuitively the implants can be removed but require an open incision and dissection through the gluteal muscles and scar tissue which can lead to muscle and neurovascular injuries. Our objective was to evaluate the clinical outcome, measured by patient-reported Visual Analog Score (VAS), of three patients who had failed direct lateral SIJ fusions each using three implants and describe a revision technique using a new percutaneous lateral-oblique transfixation technique with two variable-threaded screws while preserving the original implants.

Case Description

Two separate orthopedic spine surgeons at different hospitals performed the technique using two SacroFuse® screws for SIJ revision fusion in three patients who had clinical symptoms and radiographic findings of SIJ pseudoarthrosis after direct lateral approach. One 61 years old male patient had a previous surgery with three lateral threaded screw implants. Two females with ages 47 and 40 years old had three TTI wedges. Follow-up from 10 to 26 months. Patients discharged home the same day. Mean procedure time of 20 minutes with blood loss less than five cc. Incision size was approximately 1 inch. Each patient had a 12 mm × 60 mm and a 12 mm × 50 mm screw filled with NanoFuse Biologics synthetic bioactive glass and demineralized bone matrix. Prior implants were left in place. There was an 89% decrease in mean VAS score of 9.5 to 1.

Conclusions

This is a clinically valuable report because until now there was no reconstructive surgery to revise direct lateral implants other than removal with potential neurovascular risks. This is the first article to demonstrate a lateral-oblique transfixation technique with two variable-threaded screws for successful salvage of SIJ pseudoarthrosis after direct lateral fixation without implant removal. The Sacrix technique achieved immediate stability and long-term fusion documented on computed tomography (CT) scan as early as 6 months.

Robotic navigation in spine surgery: Where are we now and where are we going?

Robotic navigation is a new and rapidly emerging niche within minimally invasive spine surgery. The robotic arms-race began in 2004 and has resulted in no less than four major robotic surgical adjuncts. Current Food and Drug Administration (FDA)-approved applications of robotic navigation are limited to pedicle screw instrumentation, but new indications and experimental applications are rapidly emerging. As with any new technology, robotic navigation must be vetted for clinical efficacy, efficiency, safety, and cost-effectiveness. Given the rapid advancements made on a yearly basis, it is important to make frequent and objective assessments of the available technology. Thus, the authors seek to provide the most up-to-date review of the history, currently available technology, learning curve, novel applications, and cost effectiveness of today's available robotic systems as it relates to spine surgery.