Elsevier

Journal of Clinical Neuroscience

Volume 23, January 2016, Pages 146-148
Journal of Clinical Neuroscience

Technical Note
Image-guided percutaneous internal fixation of sacral fracture

https://doi.org/10.1016/j.jocn.2015.08.011Get rights and content

Highlights

  • Percutanous fixation of sacral fractures requires precision to avoid neurovascular injury.

  • Stereotactic navigation may aid in accurate placement of internal fixation.

  • The O-arm provides multidimensional imaging to readily facilitate intraoperative navigation.

Abstract

Percutaneous iliosacral screw placement is a technically challenging procedure with a significant complication profile for misplaced screws. The use of stereotactic image guidance has been shown to provide superior accuracy in the placement of spinal instrumentation. Here, the authors describe a novel application of O-arm technology (Medtronic Sofamor Danek, Memphis, TN, USA) to help safely place iliosacral screws for the treatment of a traumatic sacral fracture.

Introduction

Percutaneous iliosacral screw placement is a popular technique to treat unstable fractures of the sacrum and sacroiliac joint, as it utilizes small incisions and subsequently minimizes blood loss [1]. However, the procedure is technically demanding, requiring a high degree of precision to provide optimal reduction and fixation of the fracture and to avoid serious neurovascular injury [2], [3]. Many authors recommend carefully assessing preoperative CT scans to help in operative planning by allowing examination of the specific fracture anatomy and potential anatomic variants that may place the lumbosacral nerves and iliac vasculature at risk. High-quality intraoperative fluoroscopy delivered by the O-arm (Medtronic Sofamor Danek, Memphis, TN, USA) has previously been described to provide superior localization and accuracy of instrumentation placement, thus avoiding the vital structures frequently found on preoperative scans. However, such technology has mostly been discussed for the placement of pedicle screws, and its use for the internal fixation of sacral fractures has not been described [4], [5], [6], [7]. Thus, in this report, we describe the use of O-arm fluoroscopy for the accurate placement of iliosacral screws in the treatment of a traumatic sacral fracture.

Section snippets

Case report

A 17-year-old male presented to our service after he was struck by a car when crossing the street. On presentation, he complained of severe lower back and buttock pain and was unable to ambulate. He had bruising around his buttocks and hips and was extremely tender to touch around the sacral area. On examination, he was neurologically intact. CT imaging was significant for bilateral sacral fractures (Fig. 1). Given that the patient could not ambulate due to his pain, it was decided to take him

Discussion

Preoperative CT scans have historically been combined with intraoperative fluoroscopic imaging to confirm the surgical level and to avoid vulnerable neurovascular anatomy. However, the high degree of anatomical resolution obtained by such CT scans is often lost due to anatomical movement and changes in alignment caused by positioning onto the operative table, potentially decreasing the accuracy of pedicle screw placement. In comparison to standard intraoperative fluoroscopy, the cone-beam CT

Conflicts of Interest/Disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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