Trends in Lumbosacral-Pelvic Fixation Strategies

We sought to better understand the current decision-making criteria and surgical strategies for pelvic fixation in spinal surgery.

A 28-question survey was distributed to an international group of practicing spine surgeons. Questions included training, practice type, criteria for using pelvic fixation, and strategies for pelvic fixation, including the type and technique employed.

Of the 56 responders, 32% were neurosurgeons, and 67% were affiliated with academic institutions. Factors that most influenced the use of pelvic fixation were 3-column osteotomy (3CO), high-grade spondylolisthesis, and L5 to S1 pseudarthrosis. Most report using a single point of pelvic fixation per side for the following: deformity 4+ levels without 3CO (55%) and spondylolisthesis grade 3 (59%). The upper instrumented vertebra threshold for pelvic fixation in degenerative pathology was L2 (70%) or L3 (16%). Most surgeons chose 2 points of fixation per side in the setting of 4 or more levels with 3CO (69%) and revision of at least 3 levels (68%). The predominant (77.6%) fixation preference was S2-alar-iliac screws. Surgeons report using navigation (70%), fluoroscopy (23%), free hand (21%), and robot-assisted (7%) for screw placement. The most common pelvic screw diameter and length were 8.5 mm and 90 mm, respectively. A 5% to 10% pelvic fixation revision rate was reported, primarily for instrumentation failure or pseudarthrosis.

This survey-based study highlights factors influencing surgeons' decisions on pelvic instrumentation. While complex corrections or revisions often require robust fixation, variability arises in simpler cases, influenced by factors like age, obesity, and bone quality.