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Figure 9
lumbar vertebrae; however, caution should be used at higher levels because
the pars interarticularis becomes thinner and the pedicle diameter is smaller,
which substantially increases the technical difficulty of screw placement and
theoretically increases the risk of pars fracture or inadvertent cortical
perforation.
38
Axial (A) and sagittal (B) illustration demonstrating the
trajectories for medial to lateral cortical bone trajectory
(CBT) screws and traditional trajectory (TT) pedicle screws.
(Reproduced from Tortolani PJ, Stroh DA: Cortical bone trajectory
technique for posterior spinal instrumentation. J Am Acad Orthop Surg
2016;24[11]:755-761.)
Illustration demonstrating posterior and cross-sectional views of
Figure 10
traditional iliac screw fixation (A) and the S2-alar-iliac
trajectory (B).
Techniques using facet and translaminar screws were originally described
decades ago; however, the use of these techniques in posterior fixation has
recently received renewed attention. Although facet and translaminar screws
do not provide rigidity equivalent to that of pedicle screws, successful
outcomes have been reported when these alternative screw techniques were
used as adjuncts in anterior interbody fusion.
39
Iliac Fixation
Obtaining stable fixation and successful fusion across the lumbosacral
junction in long multilevel constructs historically has been challenging for
spine surgeons because of the largely cancellous nature of the S1 and S2
pedicles and the substantial forces concentrated on the transition zone from
the mobile spine to the relatively rigid pelvis. The addition of pelvic fixation
overcomes this challenge by placing fixation across the center of rotation of
the pelvis and out of the plane of the remainder of the instrumentation.
Initially, the Galveston technique involved the placement of an L-shaped rod
between the tables of the ilium.40 With the advent of modern segmental
instrumentation, the technique evolved to use screw fixation within the ilium.
Currently, multiple techniques are available to achieve fixation to the
pelvis. Classic iliac fixation uses a starting point in or just medial to the
posterior superior iliac spine. A long, large diameter screw is then inserted
between the tables of the ilium in a caudal (20°-45°) and lateral (30°-45°)
trajectory. Although this technique is relatively straightforward, it requires
lateral connectors to join to the medial pedicle screw construct. Iliac screws
are commonly removed because of symptomatic prominence. A more medial
starting point on the posterior superior iliac spine can reduce implant
prominence but makes connection of the remainder of the construct more
difficult. Recently, an S2 starting point that is 2 to 4 mm lateral and 4 to 8
mm caudal to the S1 foramen and a trajectory proceeding through the sacral
ala into the pelvis has gained popularity41 (Figure 10). In this S2-alar-iliac
technique, the screw tulips are aligned with the remainder of the construct
and are unlikely to be symptomatically prominent; however, because the
screws cross the sacroiliac joint, irritation or degeneration of the sacroiliac
joint can result. Recent evidence suggests that the technique is associated
with a lower revision rate.42 Biomechanical evaluation of both traditional
iliac fixation or S2-alar-iliac screw fixation has not demonstrated significant
differences in stiffness or load to failure.
43
Summary
Although the anatomy of the spine has not changed, the understanding of the
relationships between the structures that make up the spine and the changes
in these structures caused by aging, degeneration, and injury has advanced
considerably in recent years. This understanding has implications in the
diagnosis and treatment of spinal pathology and is essential knowledge for
any surgeon treating patients with common and often debilitating spinal
disorders and injuries.
Key Study Points
A detailed knowledge of spine anatomy is a prerequisite for safe and
effective nonsurgical and surgical treatment of patients with spine
pathology.
Growing evidence exists that the health and function of the multifidus
muscles has an effect on clinical function in the lumbar spine.
The freehand technique for thoracic pedicle screw instrumentation is safe
and effective. In patients with spine deformity, the relationship of the great
vessels to the spine may be altered.
The morphology and degenerative state of the vertebral end plate is an
important consideration when applying interbody instrumentation.
Techniques for lumbar and lumbosacral instrumentation are evolving.
Increasing evidence supports the safety and efficacy of the cortical bone
screw trajectory and S2-alar-iliac fixation.
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injury at T11 when a 40-mm screw was used, even if angular error was less than 10°.
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instrumentation. J Am Acad Orthop Surg 2016;24(11):755-761.
A detailed review of the technique and current state of the evidence for the application
of a cortical bone trajectory for posterior instrumentation of the lumbar spine is
presented.
spine. J Am Acad Orthop Surg 2016;24(6):357-364.
The authors present a detailed review of the history, technique, and outcomes of various
methods for posterior lumbar spine fixation, including pedicle, cortical, facet, and
translaminar screws.
scoliotic spine. Spine (Phila Pa 1976) 1982;7(3):276-284.
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complications than iliac screws in adult lumbosacropelvic fixation. Spine (Phila Pa
1976) 2017;42(3):E142-E149.
This retrospective review of outcomes of patients treated using S2-alar-iliac fixation or
traditional iliac screw fixation found that the S2-alar-iliac technique had lower rates of
revision and surgical site infection than the traditional fixation technique. Similar
clinical outcomes were reported for both techniques. Level of evidence: IV.
spinopelvic fixation constructs: Iliac screw versus S2-alar-iliac screw. Spine Deform
2016;4(1):10-15.
This cadaver biomechanical study reported no statistical difference in stiffness and
load-to-failure between S2-alar-iliac screws and traditional iliac screw fixation.
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