Nguyen James H, Buell Thomas J, Wang Tony R, Mullin Jeffrey P, Mazur Marcus D, Garces Juanita, Taylor Davis G, Yen Chun-Po, Shaffrey Christopher I, Smith Justin S
J Neurosurg Spine. 2019 Feb 1;30(5):635-643. doi: 10.3171/2018.9.SPINE18239. Print 2019 May 1.
Recent literature describing complications associated with spinopelvic fixation with iliac screws in adult patients has been limited but has suggested high complication rates. The authors' objective was to report their experience with iliac screw fixation in a large series of patients with a 2-year minimum follow-up.
Of 327 adult patients undergoing spinopelvic fixation with iliac screws at the authors' institution between 2010 and 2015, 260 met the study inclusion criteria (age ≥ 18 years, first-time iliac screw placement, and 2-year minimum follow-up). Patients with active spinal infection were excluded. All iliac screws were placed via a posterior midline approach using fluoroscopic guidance. Iliac screw heads were deeply recessed into the posterior superior iliac spine. Clinical and radiographic data were obtained and analyzed.
Twenty patients (7.7%) had iliac screw-related complication, which included fracture (12, 4.6%) and/or screw loosening (9, 3.5%). No patients had iliac screw head prominence that required revision surgery or resulted in pain, wound dehiscence, or poor cosmesis. Eleven patients (4.2%) had rod or connector fracture below S1. Overall, 23 patients (8.8%) had L5-S1 pseudarthrosis. Four patients (1.5%) had fracture of the S1 screw. Seven patients (2.7%) had wound dehiscence (unrelated to the iliac screw head) or infection. The rate of reoperation (excluding proximal junctional kyphosis) was 17.7%. On univariate analysis, an iliac screw-related complication rate was significantly associated with revision fusion (70.0% vs 41.2%, p = 0.013), a greater number of instrumented vertebrae (mean 12.6 vs 10.3, p = 0.014), and greater postoperative pelvic tilt (mean 27.7° vs 23.2°, p = 0.04). Lumbosacral junction-related complications were associated with a greater mean number of instrumented vertebrae (12.6 vs 10.3, p = 0.014). Reoperation was associated with a younger mean age at surgery (61.8 vs 65.8 years, p = 0.014), a greater mean number of instrumented vertebrae (12.2 vs 10.2, p = 0.001), and longer clinical and radiological mean follow-up duration (55.8 vs 44.5 months, p < 0.001; 55.8 vs 44.6 months, p < 0.001, respectively). On multivariate analysis, reoperation was associated with longer clinical follow-up (p < 0.001).
Previous studies on iliac screw fixation have reported very high rates of complications and reoperation (as high as 53.6%). In this large, single-center series of adult patients, iliac screws were an effective method of spinopelvic fixation that had high rates of lumbosacral fusion and far lower complication rates than previously reported. Collectively, these findings argue that iliac screw fixation should remain a favored technique for spinopelvic fixation.
近期关于成年患者髂骨螺钉用于脊柱骨盆固定相关并发症的文献有限，但提示并发症发生率较高。作者的目的是报告他们在一大系列患者中使用髂骨螺钉固定且至少随访2年的经验。
2010年至2015年间在作者所在机构接受髂骨螺钉脊柱骨盆固定的327例成年患者中，260例符合研究纳入标准（年龄≥18岁，首次置入髂骨螺钉，且至少随访2年）。排除有活动性脊柱感染的患者。所有髂骨螺钉均通过后路中线入路在透视引导下置入。髂骨螺钉头部深深埋入髂后上棘。获取并分析临床和影像学数据。
20例患者（7.7%）发生与髂骨螺钉相关的并发症，包括骨折（12例，4.6%）和/或螺钉松动（9例，3.5%）。没有患者出现需要翻修手术或导致疼痛、伤口裂开或外观不佳的髂骨螺钉头部突出。11例患者（4.2%）在S1以下发生棒或连接器骨折。总体而言，23例患者（8.8%）发生L5 - S1假关节。4例患者（1.5%）发生S1螺钉骨折。7例患者（2.7%）发生伤口裂开（与髂骨螺钉头部无关）或感染。再次手术率（不包括近端交界性后凸）为17.7%。单因素分析显示，与髂骨螺钉相关的并发症发生率与翻修融合显著相关（70.0%对41.2%，p = 0.013）、固定节段数更多（平均12.6节对10.3节，p = 0.014）以及术后骨盆倾斜度更大（平均27.7°对23.2°，p = 0.04）。腰骶部交界相关并发症与平均固定节段数更多相关（12.6节对10.3节，p = 0.014）。再次手术与手术时平均年龄较小（61.8岁对65.8岁，p = 0.014）、平均固定节段数更多（12.2节对10.2节，p = 0.001）以及临床和影像学平均随访时间更长（分别为55.8个月对44.5个月，p < 0.001；55.8个月对44.6个月，p < 0.001）相关。多因素分析显示，再次手术与更长的临床随访时间相关（p < 0.001）。
既往关于髂骨螺钉固定的研究报告了非常高的并发症和再次手术率（高达53.6%）。在这个大型单中心成年患者系列中，髂骨螺钉是一种有效的脊柱骨盆固定方法，腰骶部融合率高且并发症发生率远低于既往报告。总体而言，这些发现表明髂骨螺钉固定仍应是脊柱骨盆固定的首选技术。
