Operative Techniques in Spine Surgery

■ Furthermore, the infection rate associated with sacrope- lvic fixation alone is difficult to ascertain because these techniques are often combined with fusions of the mobile spine above which requires additional incisions and soft tissue dissection. ■ Infection rates associated with the Galveston L-rod have been reported to range from 3% to 10%. 9,21 ■ In a study of 81 patients treated with iliac screw fixation, the infection rate was reported as 4%. 15 ■ A study of 27 patients treated with the S2AI technique showed an infection rate of 0%. 27 ■ Significantly less dissection is required for the S2AI tech- nique, which may account for the lower infection rates reported with that procedure. ■ Nonunion and instrumentation failure ■ If bony fusion does not occur, the instrumentation is des- tined to fail, often through implant failure or breakage. ■ Augmentation of sacropelvic fixation with an anterior in- terbody lumbar fusion at L4–L5 and L5–S1 can optimize fusion stability and increase the chances of a successful fusion. 13,14,25 REFERENCES 1. Allen BL Jr, Ferguson RL. The Galveston technique for L rod instru- mentation of the scoliotic spine. Spine 1982;7(3)276–284. 2. Allen BL Jr, Ferguson RL. The Galveston technique of pelvic fixation with L-rod instrumentation of the spine. Spine 1984;9(4):388–394. 3. Broom MJ, Banta JV, Renshaw TS. Spinal fusion augmented by Luque-rod segmental instrumentation for neuromuscular scoliosis. J Bone Joint Surg Am 1989;71:32–44. 4. Camp JF, Caudle R, Ashmun RD, et al. Immediate complications of Cotrel-Dubousset instrumentation to the sacro-pelvis. A clinical and biomechanical study. Spine 1990;15(9):932–941. 5. Chang TL, Sponseller PD, Kebaish KM, et al. Low profile pelvic fixa- tion: anatomic parameters for sacral alar-iliac fixation versus tradi- tional iliac fixation. Spine 2009;34(5):436–440. 6. Cunningham BW, Lewis SJ, Long J, et al. Biomechanical evaluation of lumbosacral reconstruction techniques for spondylolisthesis: an in vitro porcine model. Spine 2002;27:2321–2327. 7. Devlin VJ, Boachie-Adjei O, Bradford DS, et al. Treatment of adult spinal deformity with fusion to the sacrum using CD instrumentation. J Spinal Disord 1991;4:1–14. 8. Emami A, Deviren V, Berven S, et al. Outcome and complications of long fusions to the sacrum in adult spine deformity: Luque-Galveston, combined iliac and sacral screws, and sacral fixation. Spine 2002;27(7): 776–786. 9. Gau YL, Lonstein JE, Winter RB, et al. Luque-Galveston procedure for correction and stabilization of neuromuscular scoliosis and pelvic obliquity: a review of 68 patients. J Spinal Disord 1991;4(4):399–410.

10. Jackson RP, McManus AC. The iliac buttress. A computed tomo- graphic study of sacral anatomy. Spine 1993;18(10):1318–1328. 11. Kebaish KM. Sacropelvic fixation: techniques and complications. Spine 2010;35(25):2245–2251. 12. Kebaish KM, Pull ter Gunne AF, Mohamed AS, et al. A new low profile sacropelvic fixation using S2 alar iliac (S2AI) screws in adult deformity fusion to the sacrum: a prospective study with minimum 2-year follow-up. Paper presented at: the North American Spine Soci- ety Annual Meeting, November 10–14, 2009, San Francisco, CA. 13. Kostuik JP, Errico TJ, Gleason TF. Techniques of internal fixation for degenerative conditions of the lumbar spine. Clin Orthop Relat Res 1986;(203):219–231. 14. Kostuik JP, Hall BB. Spinal fusions to the sacrum in adults with scolio- sis. Spine 1983;8(5):489–500. 15. Kuklo TR, Bridwell KH, Lewis SJ, et al. Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine 2001;26(18):1976–1983. 16. Lehman RA Jr, Kuklo TR, Belmont PJ Jr, et al. Advantage of pedicle screw fixation directed into the apex of the sacral promontory over bi- cortical fixation: a biomechanical analysis. Spine 2002;27(8):806–811. 17. Martin CT, Witham TF, Kebaish KM. Sacropelvic fixation: two case re- ports of a new percutaneous technique. Spine 2011;36(9):E618–E621. 18. McCord DH, Cunningham BW, Shono Y, et al. Biomechanical analysis of lumbosacral fixation. Spine 1992;17(8 suppl):S235–S243. 19. Mirkovic S, Abitbol JJ, Steinman J, et al. Anatomic consideration for sacral screw placement. Spine 1991;16(6 suppl):S289–S294. 20. Moshirfar A, Rand FF, Sponseller PD, et al. Pelvic fixation in spine sur- gery. Historical overview, indications, biomechanical relevance, and current techniques. J Bone Joint Surg Am 2005;87(suppl 2):89–106. 21. Nectoux E, Giacomelli MC, Karger C, et al. Complications of the Luque-Galveston scoliosis correction technique in paediatric cerebral palsy. Orthop Traumatol Surg Res 2010;96(4):354–361. 22. O’Brien JR, Matteini L, Yu WD, et al. Feasibility of minimally in- vasive sacropelvic fixation: percutaneous S2 alar iliac fixation. Spine 2010;35(4):460–464. 23. O’Brien JR, Yu WD, Bhatnagar R, et al. An anatomic study of the S2 iliac technique for lumbopelvic screw placement. Spine 2009;34(12): E439–E442. 24. O’Brien MF. Sacropelvic fixation in spinal deformity. In: Dewlad RL, ed. Spinal Deformities: The Text. New York: Thieme, 2003:601–614. 25. Ogilvie JW, Schendel M. Comparison of lumbosacral fixation devices. Clin Orthop Relat Res 1986;(203):120–125. 26. Peretz AM, Hipp JA, Heggeness MH. The internal bony architecture of the sacrum. Spine 1998;23(9):971–974. 27. Sponseller PD, Zimmerman RM, Ko PS, et al. Low profile pelvic fixation with the sacral alar iliac technique in the pediatric popu- lation improves results at two-year minimum follow-up. Spine 2010;35(20):1887–1892. 28. Wiggins GC, Ondra SL, Shaffrey CI. Management of iatrogenic flat- back syndrome. Neurosurg Focus 2003;15(3):E8. 29. Xu R, Ebraheim NA, Yeasting RA, et al. Morphometric evaluation of the first sacral vertebra and the projection of its pedicle on the poste- rior aspect of the sacrum. Spine 1995;20(8):936–940.

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