Tejwani Nirmal C, Raskolnikov Dima, McLaurin Toni, Takemoto Richelle
Department of Orthopaedics, NYU Hospital for Joint Diseases, New York, NY.
Am J Orthop (Belle Mead NJ). 2014 Nov;43(11):513-6.
We sought to determine whether computed tomography (CT) is an accurate tool for evaluation of reduction, prediction of neurologic deficit, and evaluation of need for revision surgery in unstable pelvic ring injuries treated with percutaneous sacroiliac (SI) screw fixation and whether any neural foramen penetration violation is safe. Using medical records and radiographic data, we retrospectively evaluated 46 patients with 51 fractures or widenings of the SI joint that were surgically treated with percutaneous SI screw fixation, either alone or associated with anterior fixation. Using the Young and Burgess classification, there were 3 vertical shear injuries, 13 lateral compression injuries, 17 anterior-posterior injuries, 7 sacral fractures, and 6 combination or unclassifiable pelvic injuries. Satisfactory reduction was obtained in all cases. All patients had postoperative CT scans, and 23 of 51 screws had some foramen penetration with an average of 3.3 mm (range, 1.4-7.0 mm). After percutaneous screw fixation, 10 of 46 patients had postoperative neurologic deficit, 4 of which were unchanged from preoperative evaluation. Of the 6 patients with new or worsened neurologic deficit, CT showed neural foramen penetration of 2.1 and 7.0 mm in 2 patients. Both patients underwent screw revision, resulting in improved neurologic deficit. The remaining 4 patients did not have foramen penetration; their neurologic function improved, with full return at 6 weeks without screw removal. Neural foramen penetration documented with CT did not correlate with neurologic deficit unless the penetration was greater than 2.7 mm. Postoperative CT showing neural foramen penetration was the cause of revision surgery in 2 of 10 patients with postoperative neurologic deficit after percutaneous SI screw fixation. Based on these findings, we recommend postoperative CT only in those cases where there is new neurologic deficit and screw removal if foramen penetration is greater than 2.1 mm. We also describe a new "safe zone" for screw insertion encompassing the superior 2 mm of the sacral foramen with adequate pelvic reduction.
我们试图确定计算机断层扫描（CT）是否是评估经皮骶髂（SI）螺钉固定治疗不稳定骨盆环损伤复位情况、预测神经功能缺损以及评估翻修手术必要性的准确工具，以及任何神经孔穿透是否安全。利用病历和影像学数据，我们回顾性评估了46例患者，这些患者有51处SI关节骨折或增宽，均接受了经皮SI螺钉固定手术治疗，可单独使用或联合前路固定。根据Young和Burgess分类，有3例垂直剪切损伤、13例侧方压缩损伤、17例前后位损伤、7例骶骨骨折以及6例复合型或无法分类的骨盆损伤。所有病例均获得了满意的复位。所有患者均进行了术后CT扫描，51枚螺钉中有23枚有一定程度的神经孔穿透，平均穿透3.3毫米（范围为1.4 - 7.0毫米）。经皮螺钉固定后，46例患者中有10例出现术后神经功能缺损，其中4例与术前评估相比无变化。在6例出现新的或加重的神经功能缺损的患者中，CT显示2例患者的神经孔穿透分别为2.1毫米和7.0毫米。这2例患者均接受了螺钉翻修，神经功能缺损得到改善。其余4例患者没有神经孔穿透；他们的神经功能有所改善，6周时完全恢复且未取出螺钉。CT记录的神经孔穿透与神经功能缺损无关，除非穿透大于2.7毫米。术后CT显示神经孔穿透是10例经皮SI螺钉固定术后出现神经功能缺损患者中2例翻修手术的原因。基于这些发现，我们建议仅在出现新的神经功能缺损的情况下进行术后CT检查，若神经孔穿透大于2.1毫米则取出螺钉。我们还描述了一个新的螺钉插入“安全区”，该区域包括骶骨孔上方2毫米且骨盆复位良好的区域。
