Preoperative planning and safe intraoperative placement of iliosacral screws under fluoroscopic control

OBJECTIVE: Preoperative planning of the starting point and safe trajectory for iliosacral screw (SI screw) fixation using CT scans for safe and accurate fluoroscopically controlled percutaneous SI screw placement. INDICATIONS: Transalar and transforaminal sacral fractures. SI joint disruptions and fracture-dislocations. Non- or minimally displaced spinopelvic dissociation injuries. CONTRAINDICATIONS: Transiliac instabilities. Sacral fractures with neurological impairment requiring decompression. Relevant residual displacement after closed reduction attempts. Insufficient fluoroscopic visualization of the anatomical landmarks of the upper sacrum. SURGICAL TECHNIQUE: Preoperative planning of the starting point and the safe screw trajectory using CT scans and two-dimensional multiplanar reformation tools. Fluoroscopically guided identification of the starting point using the lateral view according to preoperative planning. Advancing the guidewire under fluoroscopic control using inlet and outlet views according to the planned trajectory. Predrilling and placement of 6.5 mm cannulated screws. POSTOPERATIVE MANAGEMENT: Weightbearing as tolerated using crutches. Immediate CT scan in case of postoperative neurological impairment. Generally no screw removal. RESULTS: Fifty-nine screws were placed in 34 patients using the described technique. There were 2 cases of screw malpositioning (anatomical landmarks inadequately identified and fluoroscopically controlled SI screw fixation should thus not have been performed at all; in a case with sacral dysmorphism, preoperative planning suggested a posterior and/or caudal S1 starting point, respectively, but intraoperatively, selection of a different starting point and screw trajectory resulted in screw malpositioning with iatrogenic L5 nerve palsy).