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Pozzi P, Morselli C, Cirullo A, Bassani R. Change in pelvic incidence due to sacral stress fracture following multilevel instrumented fusion. BMJ Case Rep 2024; 17:e256319. [PMID: 38471702 PMCID: PMC10936504 DOI: 10.1136/bcr-2023-256319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Multilevel-instrumented fusion is a common surgical technique used to treat adult spinal deformity (ASD), but it can occasionally lead to rare complications such as sacral insufficiency fractures. The impact of sacral fractures on spinopelvic parameters, particularly pelvic incidence (PI), has not been thoroughly investigated even though they have been documented in the literature. Here, we present a case of a patient who underwent a Th11-sacrum instrumented fusion for ASD. She underwent a revision surgery 18 months after the first procedure to treat proximal junctional pain brought on by a localised kyphosis of the rods. An asymptomatic sacral fracture was discovered during the radiological evaluation: the PI had increased from 71° to 103° between the 2 surgical procedures.
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Affiliation(s)
- Pierrenzo Pozzi
- 2° Spinal Surgery Unit, IRCCS Istituto Ortopedico Galeazzi, Milano, MI, Italy
| | - Carlotta Morselli
- 2° Spinal Surgery Unit, IRCCS Istituto Ortopedico Galeazzi, Milano, MI, Italy
| | - Agostino Cirullo
- 2° Spinal Surgery Unit, IRCCS Istituto Ortopedico Galeazzi, Milano, MI, Italy
| | - Roberto Bassani
- 2° Spinal Surgery Unit, IRCCS Istituto Ortopedico Galeazzi, Milano, MI, Italy
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2
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Chen K, Huang G, Wan Y, Yao S, Su Y, Li L, Guo X. Biomechanical study of different fixation constructs for anterior column and posterior hemi-transverse acetabular fractures: a finite element analysis. J Orthop Surg Res 2023; 18:294. [PMID: 37041549 PMCID: PMC10088117 DOI: 10.1186/s13018-023-03715-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 03/15/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND To compare the biomechanical properties and stability, using a finite element model, of four fixation constructs used for the treatment of anterior column and posterior hemi-transverse (ACPHT) acetabular fractures under two physiological loading conditions (standing and sitting). METHODS A finite element model simulating ACPHT acetabular fractures was created for four different scenarios: a suprapectineal plate combined with posterior column and infra-acetabular screws (SP-PS-IS); an infrapectineal plate combined with posterior column and infra-acetabular screws (IP-PS-IS); a special infrapectineal quadrilateral surface buttress plate (IQP); and a suprapectineal plate combined with a posterior column plate (SP-PP). Three-dimensional finite element stress analysis was performed on these models with a load of 700 N in standing and sitting positions. Biomechanical stress distributions and fracture displacements were analysed and compared between these fixation techniques. RESULTS In models simulating the standing position, high displacements and stress distributions were observed at the infra-acetabulum regions. The degree of these fracture displacements was low in the IQP (0.078 mm), as compared to either the IP-PS-IS (0.079 mm) or the SP & PP (0.413 mm) fixation constructs. However, the IP-PS-IS fixation construct had the highest effective stiffness. In models simulating the sitting position, high fracture displacements and stress distributions were observed at the regions of the anterior and posterior columns. The degree of these fracture displacements was low in the SP-PS-IS (0.101 mm), as compared to the IP-PS-IS (0.109 mm) and the SP-PP (0.196 mm) fixation constructs. CONCLUSION In both standing and sitting positions, the stability and stiffness index were comparable between the IQP, SP-PS-IS, and IP-PS-IS. These 3 fixation constructs had smaller fracture displacements than the SP-PP construct. The stress concentrations at the regions of quadrilateral surface and infra-acetabulum suggest that the buttressing fixation of quadrilateral plate was required for ACPHT fractures.
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Affiliation(s)
- Kaifang Chen
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, Hubei, 430022, People's Republic of China
| | - Guixiong Huang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, Hubei, 430022, People's Republic of China
| | - Yizhou Wan
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, Hubei, 430022, People's Republic of China
| | - Sheng Yao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, Hubei, 430022, People's Republic of China
| | - Yanlin Su
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, Hubei, 430022, People's Republic of China
| | - Lianxin Li
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, People's Republic of China
| | - Xiaodong Guo
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue No.1277, Wuhan, Hubei, 430022, People's Republic of China.
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de Andrada Pereira B, Lehrman JN, Sawa AGU, Lindsey DP, Yerby SA, Godzik J, Waguespack AM, Uribe JS, Kelly BP. Biomechanical effects of a novel posteriorly placed sacroiliac joint fusion device integrated with traditional lumbopelvic long-construct instrumentation. J Neurosurg Spine 2021; 35:320-329. [PMID: 34144523 DOI: 10.3171/2020.11.spine201540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE S2-alar-iliac (S2AI) screw fixation effectively ensures stability and enhances fusion in long-segment constructs. Nevertheless, pelvic fixation is associated with a high rate of mechanical failure. Because of the transarticular nature of the S2AI screw, adding a second point of fixation may provide additional stability and attenuate strains. The objective of the study was to evaluate changes in stability and strain with the integration of a sacroiliac (SI) joint fusion device, implanted through a novel posterior SI approach, supplemental to posterior long-segment fusion. METHODS L1-pelvis human cadaveric specimens underwent pure moment (7.5 Nm) and compression (400 N) tests in the following conditions: 1) intact, 2) L2-S1 pedicle screw and rod fixation with L5-S1 interbody fusion, 3) added S2AI screws, and 4) added bilateral SI joint fixation (SIJF). The range of motion (ROM), rod strain, and screw bending moments (S1 and S2AI) were analyzed. RESULTS S2AI fixation decreased L2-S1 ROM in flexion-extension (p ≤ 0.04), L5-S1 ROM in flexion-extension and compression (p ≤ 0.004), and SI joint ROM during flexion-extension and lateral bending (p ≤ 0.03) compared with S1 fixation. SI joint ROM was significantly less with SIJF in place than with the intact joint, S1, and S2AI fixation in flexion-extension and lateral bending (p ≤ 0.01). The S1 screw bending moment decreased following S2AI fixation by as much as 78% in extension, but with statistical significance only in right axial rotation (p = 0.03). Extending fixation to S2AI significantly increased the rod strain at L5-S1 during flexion, axial rotation, and compression (p ≤ 0.048). SIJF was associated with a slight increase in rod strain versus S2AI fixation alone at L5-S1 during left lateral bending (p = 0.048). Compared with the S1 condition, fixation to S2AI increased the mean rod strain at L5-S1 during compression (p = 0.048). The rod strain at L5-S1 was not statistically different with SIJF compared with S2AI fixation (p ≥ 0.12). CONCLUSIONS Constructs ending with an S2AI screw versus an S1 screw tended to be more stable, with reduced SI joint motion. S2AI fixation decreased the S1 screw bending moments compared with fixation ending at S1. These benefits were paired with increased rod strain at L5-S1. Supplementation of S2AI fixation with SIJF implants provided further reductions (approximately 30%) in the sagittal plane and lateral bending SI joint motion compared with fixation ending at the S2AI position. This stability was not paired with significant changes in rod or screw strains.
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Affiliation(s)
| | | | - Anna G U Sawa
- 1Department of Neurosurgery, Spinal Biomechanics Laboratory, and
| | | | | | - Jakub Godzik
- 3Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Juan S Uribe
- 3Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Brian P Kelly
- 1Department of Neurosurgery, Spinal Biomechanics Laboratory, and
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Sciubba D, Jain A, Kebaish KM, Neuman BJ, Daniels AH, Passias PG, Kim HJ, Protopsaltis TS, Scheer JK, Smith JS, Hamilton K, Bess S, Klineberg EO, Ames CP, the International Spine Study Group. Development of a Preoperative Adult Spinal Deformity Comorbidity Score That Correlates With Common Quality and Value Metrics: Length of Stay, Major Complications, and Patient-Reported Outcomes. Global Spine J 2021; 11:146-153. [PMID: 32875843 PMCID: PMC7882823 DOI: 10.1177/2192568219894951] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
STUDY DESIGN Retrospective review of a multicenter prospective registry. OBJECTIVES Our goal was to develop a method to risk-stratify adult spinal deformity (ASD) patients on the basis of their accumulated health deficits. We developed a novel comorbidity score (CS) specific to patients with ASD based on their preoperative health state and investigated whether it was associated with major complications, length of hospital stay (LOS), and self-reported outcomes after ASD surgery. METHODS We identified 273 operatively treated ASD patients with 2-year follow-up. We assessed associations between major complications and age, comorbidities, Charlson Comorbidity Index score, and Oswestry Disability Index score. Significant factors were used to construct the ASD-CS. Associations of ASD-CS with major complications, LOS, and patient-reported outcomes were analyzed. RESULTS Major complications increased significantly with ASD-CS (P < .01). Compared with patients with ASD-CS of 0, the odds of major complications were 2.8-fold higher (P = .068) in patients with ASD-CS of 1 through 3; 4.5-fold higher (P < .01) in patients with ASD-CS of 4 through 6; and 7.5-fold higher (P < .01) in patients with ASD-CS of 7 or 8. Patients with ASD-CS of 7 or 8 had the longest mean LOS (10.7 days) and worst mean Scoliosis Research Society-22r total score at baseline; however, they experienced the greatest mean improvement (0.98 points) over 2 years. CONCLUSIONS The ASD-CS is significantly associated with major complications, LOS, and patient-reported outcomes in operatively treated ASD patients.
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Affiliation(s)
| | - Amit Jain
- The Johns Hopkins University, Baltimore, MD, USA
| | - Khaled M. Kebaish
- The Johns Hopkins University, Baltimore, MD, USA,Khaled M Kebaish, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA.
| | | | - Alan H. Daniels
- The Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Han J. Kim
- Hospital for Special Surgery, New York, NY, USA
| | | | | | - Justin S. Smith
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kojo Hamilton
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shay Bess
- New York University, New York, NY, USA
| | - Eric O. Klineberg
- University of California Davis School of Medicine, Sacramento, CA, USA
| | - Christopher P. Ames
- University of California San Francisco School of Medicine, San Francisco, CA, USA
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Buell TJ, Yener U, Wang TR, Buchholz AL, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS. Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm. J Neurosurg Spine 2020; 33:225-236. [PMID: 32217798 DOI: 10.3171/2019.12.spine191148] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors' operative experience managing this complication, review pertinent literature, and propose a treatment algorithm. METHODS The authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication. RESULTS Nine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8-96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score -1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8-90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to-lumbar lordosis (LL) mismatch. CONCLUSIONS A high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5-S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.
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Affiliation(s)
- Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ulas Yener
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Tony R Wang
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Avery L Buchholz
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Chun-Po Yen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Mark E Shaffrey
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Christopher I Shaffrey
- 2Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
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Wang Q, Verrall I, Walker R, Tetsworth K, Drobetz H. U-type bilateral sacral fracture with spino-pelvic dissociation caused by epileptic seizure. J Surg Case Rep 2017; 2017:rjx043. [PMID: 28458849 PMCID: PMC5400439 DOI: 10.1093/jscr/rjx043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/17/2017] [Indexed: 12/02/2022] Open
Abstract
Sacral fracture with spino-pelvic dissociation is a rare and unstable injury caused by high-energy trauma, often with serious haemodynamic and neurological implications. Diagnosis is easily delayed or missed as it is often masked by severe associated injuries. Here, we present an unusual case of spino-pelvic dissociation sustained during a seizure episode in a young epileptic patient on long-term anticonvulsant therapy with previous thoracolumbar spinal arthrodesis. This unique case brings to light the need for clinicians to consider sacral fractures in patients presenting with low back pain with no preceding trauma who otherwise may have risk factors for pathological fractures.
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Affiliation(s)
- Qian Wang
- Department of Surgery, Austin Health, Heidelberg, Australia
| | - Ian Verrall
- Department of Orthopaedic Surgery, Mackay Base Hospital, Mackay, Australia
| | - Rowan Walker
- Department of Orthopaedic Surgery, Mackay Base Hospital, Mackay, Australia
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, Australia.,University of Queensland School of Medicine, St Lucia, Australia.,Queensland University of Technology Science and Engineering Faculty, Brisbane, Australia.,Orthopaedic Research Centre of Australia, Brisbane, Australia
| | - Herwig Drobetz
- Department of Orthopaedic Surgery, Mackay Base Hospital, Mackay, Australia.,James Cook University School of Medicine and Dentistry Mackay Campus, Mackay, Australia
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7
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Scemama C, D'astorg H, Guigui P. Sacral stress fracture after lumbar and lumbosacral fusion. How to manage it? A proposition based on three cases and literature review. Orthop Traumatol Surg Res 2016; 102:261-8. [PMID: 26796998 DOI: 10.1016/j.otsr.2015.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 09/21/2015] [Accepted: 11/16/2015] [Indexed: 02/02/2023]
Abstract
Sacral fracture after lumbosacral instrumentation could be a source of prolonged pain and a late autonomy recovery in old patients. Diagnosis remains difficult and usually delayed. No clear consensus for efficient treatment of this complication has been defined. Aim of this study was to determine how to manage them. Three patients who sustained sacral fracture after instrumented lumbosacral fusion performed for degenerative disease of the spine are discussed. History, physical examinations' findings and radiographic features are presented. Pertinent literature was analyzed. All patients complained of unspecific low back and buttock pain a few weeks after index surgery. Diagnosis was done on CT-scan. We always choose revision surgery with good functional results. Sacral stress fracture has to be reminded behind unspecific buttock or low back pain. CT-scan seems to be the best radiological test to do the diagnosis. Surgical treatment is recommended when lumbar lordosis and pelvic incidence mismatched.
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Affiliation(s)
- C Scemama
- Department of Reconstructive and Orthopaedic Surgery, Université René-Descartes, European Hospital Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France.
| | - H D'astorg
- Department of Reconstructive and Orthopaedic Surgery, Université René-Descartes, European Hospital Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France.
| | - P Guigui
- Department of Reconstructive and Orthopaedic Surgery, Université René-Descartes, European Hospital Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France.
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8
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Wang Y, Liu XY, Li CD, Yi XD, Yu ZR. Surgical treatment of sacral fractures following lumbosacral arthrodesis: Case report and literature review. World J Orthop 2016; 7:69-73. [PMID: 26807359 PMCID: PMC4716574 DOI: 10.5312/wjo.v7.i1.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/12/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
Sacral fractures following posterior lumbosacral fusion are an uncommon complication. Only a few case series and case reports have been published so far. This article presents a case of totally displaced sacral fracture following posterior L4-S1 fusion in a 65-year-old patient with a 15-year history of corticosteroid use who underwent open reduction and internal fixation using iliac screws. The patient was followed for 2 years. A thorough review of the literature was conducted using the Medline database between 1994 and 2014. Immediately after the revision surgery, the patient’s pain in the buttock and left leg resolved significantly. The patient was followed for 2 years. The weakness in the left lower extremity improved gradually from 3/5 to 5/5. In conclusion, the incidence of postoperative sacral fractures could have been underestimated, because most of these fractures are not visible on a plain radiograph. Computed tomography has been proved to be able to detect most such fractures and should probably be performed routinely when patients complain of renewed buttock pain within 3 mo after lumbosacral fusion. The majority of the patients responded well to conservative treatments, and extending the fusion construct to the iliac wings using iliac screws may be needed when there is concurrent fracture displacement, sagittal imbalance, neurologic symptoms, or painful nonunion.
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9
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Lindsey DP, Perez-Orribo L, Rodriguez-Martinez N, Reyes PM, Newcomb A, Cable A, Hickam G, Yerby SA, Crawford NR. Evaluation of a minimally invasive procedure for sacroiliac joint fusion - an in vitro biomechanical analysis of initial and cycled properties. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:131-7. [PMID: 24868175 PMCID: PMC4031207 DOI: 10.2147/mder.s63499] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Sacroiliac (SI) joint pain has become a recognized factor in low back pain. The purpose of this study was to investigate the effect of a minimally invasive surgical SI joint fusion procedure on the in vitro biomechanics of the SI joint before and after cyclic loading. METHODS SEVEN CADAVERIC SPECIMENS WERE TESTED UNDER THE FOLLOWING CONDITIONS: intact, posterior ligaments (PL) and pubic symphysis (PS) cut, treated (three implants placed), and after 5,000 cycles of flexion-extension. The range of motion (ROM) in flexion-extension, lateral bending, and axial rotation was determined with an applied 7.5 N · m moment using an optoelectronic system. Results for each ROM were compared using a repeated measures analysis of variance (ANOVA) with a Holm-Šidák post-hoc test. RESULTS Placement of three fusion devices decreased the flexion-extension ROM. Lateral bending and axial rotation were not significantly altered. All PL/PS cut and post-cyclic ROMs were larger than in the intact condition. The 5,000 cycles of flexion-extension did not lead to a significant increase in any ROMs. DISCUSSION In the current model, placement of three 7.0 mm iFuse Implants significantly decreased the flexion-extension ROM. Joint ROM was not increased by 5,000 flexion-extension cycles.
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Affiliation(s)
| | - Luis Perez-Orribo
- Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Nestor Rodriguez-Martinez
- Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Phillip M Reyes
- Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Anna Newcomb
- Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Alexandria Cable
- Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Grace Hickam
- Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Neil R Crawford
- Spinal Biomechanics Research Laboratory, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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10
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Yu Y, Zhu R, Zeng ZL, Jia YW, Wu ZR, Ren YL, Chen B, Ding ZQ, Cheng LM. The strain at bone-implant interface determines the effect of spinopelvic reconstruction following total sacrectomy: a strain gauge analysis in various spinopelvic constructs. PLoS One 2014; 9:e85298. [PMID: 24454839 PMCID: PMC3891848 DOI: 10.1371/journal.pone.0085298] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 11/25/2013] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There is still some controversy regarding the optimal biomechanical concept for spinopelvic stabilization following total sacrectomy for malignancy. Strains at specific anatomical sites at pelvis/sacrum and implants interfaces have been poorly investigated. Herein, we compared and analyzed the strains applied at key points at the bone-implant interface in four different spinopelvic constructs following total sacrectomy; consequently, we defined a balanced architecture for spinopelvic fusion in that situation. METHODS Six human cadaveric specimens, from second lumbar vertebra to proximal femur, were used to compare the partial strains at specific sites in a total sacrectomy model. Test constructs included: (1) intact pelvis (control), (2) sacral-rod reconstruction (SRR), (3) bilateral fibular flap reconstruction (BFFR), (4) four-rods reconstruction (FRR), and (5) improved compound reconstruction (ICR). Strains were measured by bonded strain gauges onto the surface of three specific sites (pubic rami, arcuate lines, and posterior spinal rods) under a 500 N axial load. RESULTS ICR caused lower strains at specific sites and, moreover, on stress distribution and symmetry, compared to the other three constructs. Strains at pubic rami and arcuate lines following BFFR were lower than those following SRR, but higher at the posterior spinal rod construct. The different modes of strain distribution reflected different patient's parameter-related conditions. FRR model showed the highest strains at all sites because of the lack of an anterior bracing frame. CONCLUSIONS The findings of this investigation suggest that both anterior bracing frame and the four-rods load dispersion provide significant load sharing. Additionally, these two constructs decrease the peak strains at bone-implant interface, thus determining the theoretical surgical technique to achieve optimal stress dispersion and balance for spinopelvic reconstruction in early postoperative period following total sacrectomy.
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Affiliation(s)
- Yan Yu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rui Zhu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- Julius Wolff Institut, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Zhi-Li Zeng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yong-Wei Jia
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhou-Rui Wu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi-Long Ren
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bo Chen
- School of Life Science and Technology, Tongji University, Shanghai, China
- Institute of Orthopaedics and Traumatology, Shanghai, China
| | - Zu-Quan Ding
- School of Life Science and Technology, Tongji University, Shanghai, China
| | - Li-Ming Cheng
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- * E-mail:
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11
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Meredith DS, Taher F, Cammisa FP, Girardi FP. Incidence, diagnosis, and management of sacral fractures following multilevel spinal arthrodesis. Spine J 2013; 13:1464-9. [PMID: 23623635 DOI: 10.1016/j.spinee.2013.03.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 10/29/2012] [Accepted: 03/08/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND Fractures of the sacrum are a rare complication following instrumented spinal fusion, with only 34 cases previously reported in the literature. Previous series have generally been limited to less than five cases. PURPOSE The purpose of this study is to determine the incidence of sacral fractures caudal to instrumented spinal fusion constructs, identify risk factors for fracture and for failure of conservative management, and describe strategies for surgical treatment of these fractures. STUDY DESIGN This is a retrospective review. PATIENT SAMPLE Patients undergoing instrumented posterior spinal arthrodesis between 2002 and 2011 were included in the sample. OUTCOME MEASURES Clinical and radiographic data from hospital and surgeon records comprise outcome measures. METHODS Methods include a review of clinical and radiographic data from a prospectively collected patient database recording all adjacent segment fractures during the study period. RESULTS Twenty-four patients developed sacral fractures caudal to instrumented spinal fusion constructs during the study period. The overall incidence was 6.1% and was significantly greater in fusions greater than four levels (14.5%). The mean time from index surgery to fracture was 4.3 months. Only one fracture was evident on plain radiography at the onset of symptoms. Computed tomography, magnetic resonance imaging, and nuclear scintigraphy can all be used to establish the diagnosis. Eight patients were successfully treated conservatively. The mean time to fracture union was 21 weeks. Anterolisthesis of the fracture greater than 2 mm and kyphotic angulation were significantly associated with failure of conservative management. Surgical intervention included posterior extension of the fusion construct to S2 and the iliac wings with sacroiliac joint fusion. In 10 cases, a combined anterior and posterior approach was used that consisted of either revision anterior lumbar interbody fusion or transsacral posterior lumbar interbody fusion. CONCLUSIONS Sacral fractures following instrumented posterior spinal fusion are an uncommon complication; that is often unrecognized on plain radiographs. Risk factors include osteoporosis and long spinal fusions. Anterolisthesis and kyphosis of the fracture is associated with failure of conservative management.
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Affiliation(s)
- Dennis S Meredith
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical Center, New York, NY 10021, USA.
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Lower preoperative Hounsfield unit measurements are associated with adjacent segment fracture after spinal fusion. Spine (Phila Pa 1976) 2013; 38:415-8. [PMID: 22926280 DOI: 10.1097/brs.0b013e31826ff084] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE To determine the association of Hounsfield unit (HU) measurements with adjacent segment fractures after spinal fusion. SUMMARY OF BACKGROUND DATA Adjacent segment fracture is a potentially devastating complication after spinal fusion surgery in osteoporotic patient. Recently, a technique for assessing bone mineral density using HU measurements from computed tomography was described and correlated with both dual-energy x-ray absorptiometry-assessed bone mineral density and compressive strength in an osseous model. METHODS Patients with adjacent segment fractures after spinal fusion were identified from a prospectively collected patient database and matched 1:1 with nonfracture controls on the basis of age, sex, and fusion construct. Minimum follow-up was 6 months. Patients with metabolic bone disease other than osteoporosis or those taking medications known to negatively alter bone strength were excluded. HU assessment was done according to the previously published protocol using the preoperative computed tomography. RESULTS Twenty patients had complete imaging data and could be matched to nonfracture controls. The groups were well matched with respect to age, sex, body mass index, and number of levels fused. Following the index surgical procedure, the fracture group had more positive sagittal balance than the control group (10.7 cm vs. 9.1 cm). Analysis of HU values at the fracture level showed a significantly lower value in the fracture group than in the controls (145.6 vs. 199.4, P = 0.006). Similarly, global assessment of HU across the thoracic and lumbar spines was significantly lower in the fracture group (139.9 vs. 170.1, P = 0.032). CONCLUSION HU was significantly lower both locally and globally in the fracture cohort. Because computed tomographic scans are frequently part of preoperative planning for spinal fusion, this information should be incorporated in preoperative planning. Studies to prospectively validate HU as a predictor of adjacent segment fracture risk and to assess the effect of increasing HU preoperatively with medications for osteoporosis are needed. LEVEL OF EVIDENCE 3.
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Sacral fractures after lumbosacral fusion: a characteristic fracture pattern. AJR Am J Roentgenol 2011; 197:184-8. [PMID: 21701029 DOI: 10.2214/ajr.10.5902] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the radiologic pattern of sacral fractures after lumbosacral fusion and to identify clinical characteristics relevant to the radiologic diagnosis. MATERIALS AND METHODS A search of CT, nuclear medicine, and MRI radiology reports over a 5-year period at our institution revealed a total of 23 patients with sacral fractures after lumbosacral fusion. Two radiologists reviewed all of the images to determine the sacral fracture pattern. The clinical records of these patients were reviewed for interval after surgery, fusion length, hardware, approach, preoperative diagnosis, symptoms, treatment, and risk factors. RESULTS All 23 sacral fractures were horizontal through the sacral body, involved the screw holes, and exited through the posterosuperior sacral alae. The fractures occurred within 3 months of fusion in 19 of 23 patients. All 23 patients had symptoms at the time of fracture. Seventeen of 23 fusions were long (more than four vertebrae). Four of 23 patients had osteoporosis. Eleven of 23 fractures healed without surgery, and 12 were managed with transiliac fixation. CONCLUSION Sacral fractures after lumbosacral fusion have a characteristic transverse pattern through the sacral screw holes that differs from the configuration of more common sacral insufficiency fractures. Most of these fractures occur within 3 months after surgery, and many of the patients need additional surgical fixation. Because few of the patients had osteoporosis and most underwent long fusion, the fractures might have been caused by hardware-related stress raisers in the sacrum.
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Adjacent segment disease after instrumented fusion for idiopathic scoliosis: review of current trends and controversies. ACTA ACUST UNITED AC 2010; 22:530-9. [PMID: 20075818 DOI: 10.1097/bsd.0b013e31818d64b7] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
STUDY DESIGN A literature-based review. OBJECTIVE To summarize the clinical and morphologic findings leading to diagnosis, the etiologic factors, and principles of management. To identify the strengths and limits of past studies. SUMMARY OF BACKGROUND DATA There are considerable controversies regarding etiologic factors, diagnosis, and management of adjacent segment disease in patients instrumented for idiopathic scoliosis. METHODS Summarized is past literature and, to some extent, personal experience of the authors. RESULTS Several factors participating to this complex pathophysiology are reported. The clinical presentation, occurring after symptom free interval, can vary, and modern morphologic investigations help for diagnosis. Management is often surgical and remains challenging. CONCLUSIONS Long-term consequences of spinal fusions are now major concerns, especially in young patients undergoing surgical correction for idiopathic scoliosis. Adjacent segment disease is defined by a combination of clinical symptoms and morphologic findings. Several etiologic factors have been reported, but need to be further studied to prevent and improve the surgical management of this complication.
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Abstract
STUDY DESIGN Case series. OBJECTIVE To report on the rare complication of sacral fractures after long instrumented thoracolumbar fusions to the sacrum. SUMMARY OF BACKGROUND DATA Rigid spinal fusion with instrumentation results in redistribution of forces in the spine that can cause the adjacent segments to degenerate and fail. Rarely in long thoraco-lumbosacral fusion, these forces may lead to sacral fractures; only 4 cases are reported in the literature. METHODS Five patients with sacral fractures are presented; one had the fusion performed at a different institution. Patients' characteristics, radiographic findings, and final operative treatment are discussed. RESULTS Sagittal imbalance after the index operation (thoraco-lumbosacral fusion), osteoporosis, and obesity were potentially associated factors. Initial nonoperative treatment failed to improve patients' symptoms. Surgery was performed at an average of 3.25 months (range, 2-8 months) in 4 patients, and soon after presentation in the patient operated elsewhere (presented 18 months after the sacral fracture). The signs of failed L5-S1 fusion, present in 3 patients, were considered to be additional surgical indication. At surgery the posterior instrumentation was extended to the pelvis. Both the fracture and the failed anterior interbody fusion were addressed through an anterior approach in 4 cases and in one case with a posterior ascending titanium cage spanning from S2 to L5. Sagittal balance was restored only in the last patient, where at the time of the revision operation a pedicle subtraction osteotomy was performed. Pain resolved in all patients after surgery and to the latest follow-up (range, 6-36 months). CONCLUSION Relapse of low back or buttock pain and leg pain after thoracolumbar fusion to the sacrum may be related to a sacral fracture, difficult to diagnose in conventional radiographs. Surgery should be considered in the presence of a concomitant L5-S1 pseudarthrosis and when symptoms do not improve with the nonoperative treatment.
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Abstract
STUDY DESIGN Retrospective review of sacral insufficiency fractures. OBJECTIVE Determine incidence of sacral insufficiency fractures after posterior lumbosacral fusion. Review the pertinent literature. Describe the ability of lumbopelvic fixation to restore the alignment of these fractures. SUMMARY OF BACKGROUND DATA Fractures of the sacrum are rare injuries that have been described at the caudal end of lumbopelvic constructs. Without a high index of suspicion, this entity can be overlooked, causing a diagnostic delay. METHODS Review of patients treated at our institution from 2002 to 2005. RESULTS Nine patients meet our inclusion criteria. Sacral insufficiency fractures were recognized on an average of 5 weeks in the 6 patients with the index procedure performed at our institution (Incidence of fracture with short segment instrumentation is 1.3%, whereas long segment fixation has an incidence of 3.1%). The other 3 referred patients had an average delay in diagnosis of 8 months. Two patients underwent immediate fracture stabilization and fusion. The remaining 7 patients were initially treated nonoperatively. Four patients abandoned bracing an average of 3.3 months after initiation of treatment. For all of the surgical candidates, preoperative kyphosis measured 9.7 degrees and anterolisthesis averaged 10 mm. Postoperative measurement improved to a mean kyphosis of 2.3 degrees and mean displacement of 1.2 mm. All operatively treated fractures healed and the patients regained their ambulatory capacity. CONCLUSION Sacral insufficiency fractures are an uncommon complication of segmental posterior lumbosacral fixation in osteoporotic patients. They are potentially unstable fractures and kyphosis and displacement may contribute to persistent problems of pain and postural malalignment. The diagnosis may be difficult and should be considered in the differential diagnosis in patients who do not improve during the postoperative course. Lumbopelvic fixation is a useful salvage treatment modality for patients who fail nonoperative treatment.
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Hsieh PC, Ondra SL, Wienecke RJ, O'Shaughnessy BA, Koski TR. A novel approach to sagittal balance restoration following iatrogenic sacral fracture and resulting sacral kyphotic deformity. J Neurosurg Spine 2007; 6:368-72. [PMID: 17436929 DOI: 10.3171/spi.2007.6.4.15] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓The authors describe the use of sacral pedicle subtraction osteotomy (PSO) with multiple sacral alar osteotomies for the correction of sacral kyphosis and pelvic incidence and for achieving sagittal balance correction in cases of fixed sagittal deformity after a sacral fracture.
In this paper, the authors report on a novel technique using a series of sacral osteotomies and a sacral PSO to correct a fixed sagittal deformity in a patient with a sacral fracture that had healed in a kyphotic position. The patient sustained this fracture after a previous surgery for multilevel instrumented fusion. Preoperative and postoperative radiographic studies are reviewed and the clinical course and outcome are presented.
Experts agree that the pelvic incidence is a fixed parameter that dictates the morphological characteristics of the pelvis and affects spinopelvic orientation and sagittal spinal alignment. An increased pelvic incidence is associated with a higher degree of spondylolisthesis in the lumbosacral junction, and increased shear forces across this junction. The authors demonstrate that the pelvic incidence can be altered and corrected with a series of sacral osteotomies to improve sacral kyphosis, compensatory lumbar hyperlordosis, and sagittal balance.
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Affiliation(s)
- Patrick C Hsieh
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern Memorial Hospital, Northwestern University, Chicago, Illinois, USA.
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Khan MH, Smith PN, Kang JD. Sacral insufficiency fractures following multilevel instrumented spinal fusion: case report. Spine (Phila Pa 1976) 2005; 30:E484-8. [PMID: 16103844 DOI: 10.1097/01.brs.0000174272.63548.89] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case series. OBJECTIVE To report a series of patients in whom sacral insufficiency fractures developed following multilevel spinal fusion with instrumentation. SUMMARY OF BACKGROUND DATA Rigid spinal fusion with instrumentation results in abnormal distribution of forces in the spine. These forces have the potential to cause failure of adjacent segments, especially in older, osteopenic individuals. Sacral insufficiency fractures following lumbar-sacral fusion may be the result of these abnormal forces. However, this complication is not well described in the literature. METHODS Three patients who sustained sacral fractures after instrumented lumbar-sacral fusion performed for degenerative disease of the spine are discussed. History, physical examination findings, and radiographic features are presented, along with a brief review of the pertinent literature. RESULTS All 3 patients in our series started complaining of new-onset buttock pain a few weeks after their operative procedure. Radiographic examination revealed that they had transverse sacral fractures just below the fusion instrumentation. Nonoperative, conservative treatment was performed. At final follow-up, the fractures had healed completely and the patients' complaints had resolved. CONCLUSION Patients who complain of new-onset buttock pain following multilevel lumbar-sacral fusion with instrumentation should be evaluated for sacral insufficiency fractures, especially if they have been sitting for prolonged periods. Conservative treatment seems to be sufficient.
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Affiliation(s)
- Mustafa H Khan
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Koh YD, Kim JO, Lee JJ. Stress fracture of the pelvic wing-sacrum after long-level lumbosacral fusion: a case report. Spine (Phila Pa 1976) 2005; 30:E161-3. [PMID: 15770169 DOI: 10.1097/01.brs.0000155634.12696.02] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report of transverse stress fracture of the pelvic wing-sacrum after long-level lumbosacral fusion. OBJECTIVE To report this rare complication of long-level lumbosacral fusion. SUMMARY OF BACKGROUND DATA There are a number of well-described complications of instrumented lumbosacral fusion, including delayed stress fracture of the pelvis. A bilateral pelvic wing-sacrum transverse stress fracture after long-level lumbosacral fusion has not been previously reported to our knowledge. METHODS Radiography and computed tomography were used to confirm the diagnosis. Long lumbosacral fusion and a pelvic wing-sacrum fracture were shown. RESULTS A 48-year-old woman underwent several revision spinal surgeries for collapse or instability occurring at the adjacent levels. She presented with low back and bilateral buttock pain with slow progression after last surgery. A bilateral transverse pelvic wing-sacrum stress fracture was found on plain radiographs 7 months later. CONCLUSIONS Stress fracture of bilateral pelvic wing-sacrum can occur as a potential source of late pain after long fusions of the lumbosacral spine. A better understanding of the related biomechanical forces and preoperative risk factors may identify patients at risk and may aid in surgical planning. There are few reports of pelvic stress fracture as a complication of lumbosacral fusion, and it is typically described as a late occurrence. We present the occurrence of a bilateral pelvic wing-sacrum transverse stress fracture, not previously discussed to our knowledge.
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Affiliation(s)
- Young-Do Koh
- Department of Orthopaedic Surgery, Ewha Woman's University, Seoul, Korea.
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Bednar DA, Al-Tunaib W. Failure of reconstitution of open-section, posterior iliac-wing bone graft donor sites after lumbar spinal fusion. Observations with implications for the etiology of donor site pain. 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 2005; 14:95-8. [PMID: 15365797 PMCID: PMC3476672 DOI: 10.1007/s00586-004-0769-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2003] [Revised: 06/01/2004] [Accepted: 06/04/2004] [Indexed: 11/28/2022]
Abstract
The objective of this cohort study--conducted at a regional trauma unit in southern Ontario, Canada--was to review the imaging history of open-section, iliac-wing bone graft donor sites in lumbar fusion patients. Intervention entailed review of available X-ray and CT scan images for all patients undergoing lumbar fusion with iliac autograft in the senior author's practice over a 4-year period. Outcome was radiographic confirmation of the absence of bony reconstitution at the iliac harvest site. Of 239 primary fusions performed, 209 complete imaging records were available for review. The images of a further 20 patients who had surgery with the senior author prior to the study period and who presented at the office in the first half of 2000 were also assessed. All cases showed persistence of the iliac donor harvest site defect. Only minimal marginal sclerosis to suggest attempted remodeling was observed. We conclude that iliac-wing bone graft donor sites do not remodel. Given that iliac harvesting is known to increase strain in the pelvis, and that lumbosacral stabilization increases stress in the pelvis, permanent deficiency of iliac bone stock at donor harvest site may be a factor in both primary donor site pain and the observed high frequency of this problem in lumbosacral fusion patients.
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Affiliation(s)
- Drew A Bednar
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, c/o 414 Victoria Avenue North #M-9, Hamilton, Ontario, L8L 5G8, Canada.
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Khanna AJ, Kebaish KM, Ozdemir HM, Cohen DB, Gonzales RA, Kostuik JP. Sacral Insufficiency Fracture Surgically Treated by Fibular Allograft. ACTA ACUST UNITED AC 2004; 17:167-73. [PMID: 15167330 DOI: 10.1097/00024720-200406000-00001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sacral insufficiency fractures have been known to occur distally after long instrumentation to the sacrum. Most such fractures are treated nonoperatively, but surgery is indicated for patients who have nonunions, persistent pain, neurologic deficits, or gross displacement. The current report elucidates the potential complication of sacral fracture after long lumbar arthrodesis, reviews the pertinent literature, presents three patients with sacral fractures after long instrumented lumbar spinal arthrodesis to the sacrum, and describes a new surgical technique for stabilizing such fractures. One patient was treated nonoperatively, and two patients were treated with arthrodesis from a posterior approach and augmentation with a strut fibular allograft. All three patients were followed to radiographic and clinical union. The authors conclude that sacral fracture is a potential complication after a long lumbar arthrodesis. Nonoperative techniques are often successful, but when they are not, a new technique using fibular allografts can be successful.
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Affiliation(s)
- A Jay Khanna
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD 21224-2780, USA
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Schwend RM, Sluyters R, Najdzionek J. The pylon concept of pelvic anchorage for spinal instrumentation in the human cadaver. Spine (Phila Pa 1976) 2003; 28:542-7. [PMID: 12642759 DOI: 10.1097/01.brs.0000049925.58996.66] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Human cadavera morphometric analysis of the iliac columns and biomechanical implant testing of traditional Galveston technique compared to intrailiac instrumentation of the entire iliac column. OBJECTIVES To describe the anatomy of the iliac columns and to evaluate the strength in forward flexion of a large implant spanning the entire column length compared to standard Galveston technique. SUMMARY OF BACKGROUND DATA We have observed substantial and straight columns of bone in the pelvis, connecting the acetabula to the sacrum, which may allow for improved spinopelvic instrumentation. METHODS Twenty adult cadaveric pelves were used. Each specimen was oriented in the computed tomography scanner to obtain a cross-section of the iliac columns, which begin from 2 cm caudal to the posterior iliac spines and end above the acetabula at the anterior inferior iliac spines. Two different instrumentation techniques were used. Standard Galveston pelvic fixation with paired 6.25-mm diameter rods extending 8 cm into the pelvis (Group 1) was compared to paired 8-mm diameter, 15-cm long custom implants, placed within the length of the entire iliac columns and connected to 6.25-mm spinal rods (Group 2). Both constructs had two rigid cross-links connecting the rods. Testing in forward flexion was performed for each construct with the MTS model 881 at 5 N/sec until failure occurred. RESULTS The rectangular shaped iliac columns averaged 15.2 (SD 0.8) cm in length, 2.5 (SD 0.3) cm in width and were consistently straight. The iliac column orientation as viewed in the transverse plane was 22 degrees laterally directed from the midsagittal plane. For the Galveston technique, failure with a flexion force occurred at a mean of 682 (SD 217) N. The iliac column implants failed at a mean of 2153 (SD 1370) N (P < 0.004). CONCLUSION The human adult pelvis has substantial and straight columns of bone extending from 2 cm below the posterior iliac spine, traversing above the sciatic notch, and ending at the anterior iliac spine. The shape resembles a weight-bearing long bone such as the tibia. Analogous to the architectural pylon, in this cadaver model, large implant instrumentation of the entire length of these pelvic columns provides at least three times stronger anchorage for spinal instrumentation compared to standard Galveston technique.
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Affiliation(s)
- Richard M Schwend
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Carrie Tingley Hospital, Albuquerque, New Mexico 87102, USA.
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Early Sacral Stress Fracture after Reduction of Spondylolisthesis and Lumbosacral Fixation: Case Report. Neurosurgery 2002. [DOI: 10.1097/00006123-200212000-00024] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Fourney DR, Prabhu SS, Cohen ZR, Gokaslan ZL, Rhines LD. Early Sacral Stress Fracture after Reduction of Spondylolisthesis and Lumbosacral Fixation: Case Report. Neurosurgery 2002. [DOI: 10.1227/01.neu.0000309130.60150.26] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Daryl R. Fourney
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Sujit S. Prabhu
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Zvi R. Cohen
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Ziya L. Gokaslan
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Laurence D. Rhines
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Mathews V, McCance SE, O'Leary PF. Early fracture of the sacrum or pelvis: an unusual complication after multilevel instrumented lumbosacral fusion. Spine (Phila Pa 1976) 2001; 26:E571-5. [PMID: 11740374 DOI: 10.1097/00007632-200112150-00027] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of a series of cases with a complication of instrumented lumbosacral fusion. OBJECTIVES To present a previously undescribed complication, early sacral or pelvic stress fracture, after instrumented lumbosacral fusion and to identify the risk factors associated with this complication. BACKGROUND There are a number of well-described complications of instrumented lumbosacral fusion, including delayed stress fracture of the pelvis. Early sacral or pelvic stress fracture after instrumented lumbosacral fusion has not been previously reported, to the authors' knowledge. METHODS The authors present three cases of early stress fracture occurring at 2-4 weeks after surgery in patients who underwent instrumented multilevel lumbosacral fusions for degenerative lumbosacral disease. RESULTS Two patients had sacral fracture, which to the authors' knowledge, has not been previously reported. Risk factors included lumbosacral instrumentation and fusion, osteoporosis in elderly women, and iliac crest bone graft procurement. All patients were treated conservatively, with restricted ambulation and gradual return to activity. CONCLUSION This complication can cause significant morbidity and a delay in the patient's return to function. A better understanding of the related biomechanical forces and preoperative risk factors may identify patients at risk and may aid in surgical planning and in expectations of postoperative recovery.
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Affiliation(s)
- V Mathews
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York, USA
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