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CT-Guided Iliosacral Screw Placement: Technique and Clinical Experience

Robert L. Sciulli1, Richard H. Daffner1, Daniel T. Altman2, Gregory T. Altman2 and Jeffrey J. Sewecke2

1 Department of Diagnostic Radiology, Allegheny General Hospital, 320 E North Ave., Pittsburgh, PA 15212-4772.
2 Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA 15212.


Figure 1
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  		Fig. 1 —Photograph shows patient position and radiopaque catheter (arrow) placed over hip as marker.

 

Figure 2
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  		Fig. 2A —Determination of depth and screw length. CT image shows skin marker and wide sacroiliac joint.

 

Figure 3
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  		Fig. 2B —Determination of depth and screw length. CT image with two measurements. A = skin distance to iliac bone, B = screw length needed.

 

Figure 4
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  		Fig. 3 —Photograph shows basic equipment. Top to bottom, surgical power drill, cannulated (hollow) screwdriver, depth measurer (not used), cannulated drill bit, cannulated screw with washer, trocar in screw, trocar.

 

Figure 5
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  		Fig. 4 —Photograph shows trocar position (arrow).

 

Figure 6
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  		Fig. 5A —Insertion of pilot bit and trocar. Photograph shows drill and pilot bit inserted over cannula.

 

Figure 7
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  		Fig. 5B —Insertion of pilot bit and trocar. CT image shows trocar advanced through ilium into sacrum.

 

Figure 8
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  		Fig. 6 —Photograph shows cannulated screw driven by hand over trocar.

 

Figure 9
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  		Fig. 7A —Progress of screw across sacroiliac joint. CT image shows screw through ilium.

 

Figure 10
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  		Fig. 7B —Progress of screw across sacroiliac joint. CT image shows screw entering sacrum.

 

Figure 11
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  		Fig. 7C —Progress of screw across sacroiliac joint. CT image shows final screw position. Upper sacroiliac joint is slightly narrower than in A and B.

 

Figure 12
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  		Fig. 8A —Lateral compression injury. Radiograph shows widening of right sacroiliac joint (asterisk) and fractures of superior and inferior pubic arches.

 

Figure 13
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  		Fig. 8B —Lateral compression injury. CT image before screw placement. Artifacts from external fixator are evident.

 

Figure 14
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  		Fig. 8C —Lateral compression injury. CT image shows final position of screw. Sacroiliac joint is no longer wide.

 

Figure 15
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  		Fig. 9A —Lateral compression injury. Radiograph shows fractures of left superior and inferior pubic arches and body of right pubic bone. Disruption (asterisk) of left sacral arcuate lines is evident.

 

Figure 16
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  		Fig. 9B —Lateral compression injury. Preoperative CT image shows fracture through body of left sacrum. Bone fragment is evident in left sacral foramen.

 

Figure 17
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  		Fig. 9C —Lateral compression injury. CT image after screw placement shows left-sided sacral fracture stabilized.

 

Figure 18
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  		Fig. 9D —Lateral compression injury. Postoperative radiograph shows screw in place.

 

Figure 19
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  		Fig. 10A —Readjustment of trocar position. CT image shows trocar placed too far anteriorly.

 

Figure 20
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  		Fig. 10B —Readjustment of trocar position. CT image shows desired trajectory marked below trocar (arrow). This distance can be measured directly with CT.

 

Figure 21
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  		Fig. 10C —Readjustment of trocar position. CT image shows screw in desired position.

 

Figure 22
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  		Fig. 11A —Misplaced screw that had been inserted under fluoroscopic guidance in operating room. CT image shows tip of left screw (arrow) in L5 disk space.

 

Figure 23
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  		Fig. 11B —Misplaced screw that had been inserted under fluoroscopic guidance in operating room. CT image after removal of misplaced screw under CT guidance shows correct position of new screw.

 

Figure 24
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  		Fig. 11C —Misplaced screw that had been inserted under fluoroscopic guidance in operating room. CT image shows position of second correctly placed screw.

 

Figure 25
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  		Fig. 11D —Misplaced screw that had been inserted under fluoroscopic guidance in operating room. Radiograph shows three iliosacral screws. Patient had undergone stabilization of pubic symphysis with surgical plate and screws at same time iliosacral screws were placed in operating room.

 

Figure 26
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  		Fig. 12A —Loss of reduction. Radiograph after iliosacral screw placement shows screw has backed out of sacrum. Washer (arrow) is in original position.

 

Figure 27
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  		Fig. 12B —Loss of reduction. CT image after placement of longer screw. Tip crosses midline of sacrum.

 

Figure 28
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  		Fig. 12C —Loss of reduction. Postoperative radiograph shows two sacral screws in place. Patient also underwent stabilization of pubic symphysis.

 

Figure 29
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  		Fig. 13A —Lateral compression injury. Same patient as in Figure 8A, 8B, 8C. Radiograph shows wide sacroiliac joint with screw in place. External fixator pin is in right iliac wing.

 

Figure 30
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  		Fig. 13B —Lateral compression injury. Same patient as in Figure 8A, 8B, 8C. CT image shows sacroiliac joint closed after placement of another screw.

 

Figure 31
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  		Fig. 13C —Lateral compression injury. Same patient as in Figure 8A, 8B, 8C. CT image shows additional screw placed on right and screw on left. Artifacts are from external fixator.

 

Figure 32
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  		Fig. 13D —Lateral compression injury. Same patient as in Figure 8A, 8B, 8C. Radiograph shows three screws in place. Both sacroiliac joints are closed.

 

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