Iliac screw placement in neuromuscular scoliosis using anatomical landmarks and uniplanar anteroposterior fluoroscopic imaging with postoperative CT confirmation

Clinical article

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  • 1 Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas;
  • 2 Division of Pediatric Neurosurgery, Floating Children's Hospital, Department of Neurosurgery, Tufts University, Boston, Massachusetts; and
  • 3 Division of Pediatric Neurosurgery, Riley Children's Hospital, Department of Neurosurgery, Indiana University, Indianapolis, Indiana
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Object

Neuromuscular scoliosis is a challenging pathology to treat. Surgical correction can involve long fusion constructs extending to the pelvis. The deformity inherent in these patients makes it difficult to obtain adequate lateral intraoperative radiographs for traditional image-guided placement of iliac screws.

Methods

A clinical and radiographic assessment of 14 patients with neuromuscular spinal deformity was conducted. From 2007 to 2013, 12 of these patients (mean age 14.25 years, range 10–20 years) underwent long spinal instrumentation (mean 15 levels, range 10–18 levels) and fusion to the pelvis, and 2 underwent placement of a growing rod construct with iliac screw placement at a single institution. The average length of follow-up was 33.7 months (range 6–64 months). Iliac screws were placed after identifying the posterior superior iliac spine and using only anteroposterior fluoroscopy (view of the inlet of the pelvis), rather than the technique of direct palpation of the sciatic notch. The accuracy of iliac screw placement was assessed with routine postoperative CT.

Results

A total of 12 patients had 24 screws placed as part of a long-segment fusion to the pelvis, and 2 patients had two iliac screws placed as part of a growing rod construct for neuromuscular scoliosis. There were no iliac screw misplacements, and no complications directly related to the technique of iliac screw placement. For cases of definitive fusion (n = 12), the average coronal Cobb angle of patients with neuromuscular spinal deformity measured 62° before surgery and 44.3° immediately after surgery. The average preoperative thoracic kyphosis and lumbar sagittal lordosis measured 37.3° and 60.7°, respectively. Immediately after surgery, the thoracic and lumbar angles measured 30° and 41.1°, respectively. At last follow-up, the average coronal Cobb angle was maintained at 45.1°, and the thoracic and lumbar sagittal angles were maintained at 32.8° and 45.3°, respectively.

Conclusions

A less invasive technique for iliac screw placement can be performed safely with a low likelihood of screw misplacement. This technique offers the biomechanical advantages of iliac fixation without the soft tissue exposure typically needed for safe screw insertion. The technique relies on identification of the posterior superior iliac spine and high quality anteroposterior fluoroscopic imaging for a view of the pelvic inlet.

Abbreviation used in this paper:rhBMP-2 = recombinant human bone morphogenetic protein-2.

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Contributor Notes

Address correspondence to: Andrew Jea, M.D., Texas Children's Hospital, 6621 Fannin St., CCC 1230.01, 12th Floor, Houston, TX 77030. email: ahjea@texaschildrens.org.

Please include this information when citing this paper: published online November 22, 2013; DOI: 10.3171/2013.10.PEDS13300.

  • 1

    Allen BL Jr, & Ferguson RL: The Galveston technique of pelvic fixation with L-rod instrumentation of the spine. Spine (Phila Pa 1976) 9:388394, 1984

    • Search Google Scholar
    • Export Citation
  • 2

    Barsdorf AI, , Sproule DM, & Kaufmann P: Scoliosis surgery in children with neuromuscular disease: findings from the US National Inpatient Sample, 1997 to 2003. Arch Neurol 67:231235, 2010

    • Search Google Scholar
    • Export Citation
  • 3

    Chaput CD, , George K, , Samdani AF, , Williams JI, , Gaughan J, & Betz RR: Reduction in radiation (fluoroscopy) while maintaining safe placement of pedicle screws during lumbar spine fusion. Spine (Phila Pa 1976) 37:E1305E1309, 2012

    • Search Google Scholar
    • Export Citation
  • 4

    Cleveland M, , Bosworth DM, & Thompson FR: Pseudarthrosis in the lumbosacral spine. J Bone Joint Surg Am 30A:302312, 1948

  • 5

    Farcy JP, , Rawlins BA, & Glassman SD: Technique and results of fixation to the sacrum with iliosacral screws. Spine (Phila Pa 1976) 17:6 Suppl S190S195, 1992

    • Search Google Scholar
    • Export Citation
  • 6

    Gitelman A, , Joseph SA Jr, , Carrion W, & Stephen M: Results and morbidity in a consecutive series of patients undergoing spinal fusion with iliac screws for neuromuscular scoliosis. Orthopedics [epub ahead of print] 2008

    • Search Google Scholar
    • Export Citation
  • 7

    König B, , Stöckle U, , Sati M, , Nolte LP, & Haas NP, Virtual fluoroscopy: safe zones for pelvic screw fixations. Delp SL, , DiGoia AM, & Jaramaz B: Medical Image Computing and Computer-Assisted Intervention—MICCAI 2000 Heidelberg, Springer, 2000. 12151219

    • Search Google Scholar
    • Export Citation
  • 8

    Master DL, , Son-Hing JP, , Poe-Kochert C, , Armstrong DG, & Thompson GH: Risk factors for major complications after surgery for neuromuscular scoliosis. Spine (Phila Pa 1976) 36:564571, 2011

    • Search Google Scholar
    • Export Citation
  • 9

    McMaster MJ: Anterior and posterior instrumentation and fusion of thoracolumbar scoliosis due to myelomeningocele. J Bone Joint Surg Br 69:2025, 1987

    • Search Google Scholar
    • Export Citation
  • 10

    Modi HN, , Woo Suh S, , Song HR, , Hyuk Yang J, & Jajodia N: Evaluation of pelvic fixation in neuromuscular scoliosis: a retrospective study in 55 patients. Int Orthop 34:8996, 2010

    • Search Google Scholar
    • Export Citation
  • 11

    Peelle MW, , Lenke LG, , Bridwell KH, & Sides B: Comparison of pelvic fixation techniques in neuromuscular spinal deformity correction: Galveston rod versus iliac and lumbosacral screws. Spine (Phila Pa 1976) 31:23922399, 2006

    • Search Google Scholar
    • Export Citation
  • 12

    Phillips JH, , Gutheil JP, & Knapp DR Jr: Iliac screw fixation in neuromuscular scoliosis. Spine (Phila Pa 1976) 32:15661570, 2007

  • 13

    Roy-Camille R, , Saillant G, & Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res 203 717, 1986

    • Search Google Scholar
    • Export Citation
  • 14

    Schildhauer TA, , McCulloch P, , Chapman JR, & Mann FA: Anatomic and radiographic considerations for placement of transiliac screws in lumbopelvic fixations. J Spinal Disord Tech 15:199205, 2002

    • Search Google Scholar
    • Export Citation
  • 15

    Tumialán LM, & Mummaneni PV: Long-segment spinal fixation using pelvic screws. Neurosurgery 63:3 Suppl 183190, 2008

  • 16

    Wang MY, , Ludwig SC, , Anderson DG, & Mummaneni PV: Percutaneous iliac screw placement: description of a new minimally invasive technique. Neurosurg Focus 25:2 E17, 2008

    • Search Google Scholar
    • Export Citation
  • 17

    Wang MY, , Williams S, , Mummaneni PV, & Sherman JD: Minimally invasive percutaneous iliac screws: initial 24 case experience with CT confirmation. J Spinal Disord Tech [epub ahead of print] 2012

    • Search Google Scholar
    • Export Citation
  • 18

    Zahi R, , Vialle R, , Abelin K, , Mary P, , Khouri N, & Damsin JP: Spinopelvic fixation with iliosacral screws in neuromuscular spinal deformities: results in a prospective cohort of 62 patients. Childs Nerv Syst 26:8186, 2010

    • Search Google Scholar
    • Export Citation

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