Study on the risk of injury to the middle sacral artery during the fixation of S<sub>1</sub> vertebra with three cortical fixation techniques _West China Medical Journal

Authors：

WAN Shengyu ,  LIN Xu , WANG Xiangyu , ZENG Jun , ZHONG Zeli , WU Chao , TAN Lun

NO.1 Department of Orthopaedics, the Fourth People’s Hospital of Zigong, Zigong, Sichuan 643000, P. R. China;

Corresponding author：

LIN Xu, Email: med_linxu@163.com

Keywords：

Sacrum; Middle sacral artery; Pedicle screw; Anatomy

DOI：

10.7507/1002-0179.201808051

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ObjectiveTo investigate the distance between the screw-out point and the middle sacral artery, and evaluate the safety when the S₁ pedicle screw placed by the three cortical fixation techniques.MethodsFrom March to June 2018, randomized CT scan data of 98 adult pelvic angiography were selected to measure the distance from the middle sacral artery to the anterior edge of the vertebral body (a) and the distance from the middle sacral artery to the midline of the vertebral body (b). S₁ screw entry point was set as the intersection of lines where extension of S₁ facet joint inferior margin and lateral margin cross over. Introversion angles of 10, 15, 20, and 25° were used; the distance between the screw insertion point and the middle sacral artery (d) was measured.ResultsThe middle sacral artery was usually located on the left side of the upper endplate plane of S₁. The distance a was (5.40±2.95) mm in 49 males and (4.43±2.32) mm in 49 females, and the difference between the males and females was not statistically significant (t=1.818, P=0.72). The distance b was (12.07±5.42) mm in 45 males and (14.12±4.88) mm in 48 females, and the difference between the males and females was not statistically significant (t=–1.914, P=0.59). The distance d was (12.67±6.00), (9.40±5.17), (7.50±3.76), and (8.10±3.64) mm when the nail was placed at a common internal inclination of 10, 15, 20, and 25°. The differences in the distance d at a common internal inclination of 10° vs. 15°, 10° vs. 20°, 10° vs. 25°, and 15° vs. 20° were all statistically significant (t=16.828, 11.609, 6.073, 6.254; P<0.008 3); there was no statistically significant difference in that at 15°vs. 25°, or 20° vs. 25° (t=2.034, –1.723; P>0.05).ConclusionBy analyzing the relationship between the middle sacral artery and the upper endplate plane of the S₁ vertebra, the risk of middle artery injury is small while the biomechanical stability of the screw is increased when using the Lenham method.

Citation： WAN Shengyu, LIN Xu, WANG Xiangyu, ZENG Jun, ZHONG Zeli, WU Chao, TAN Lun. Study on the risk of injury to the middle sacral artery during the fixation of S₁ vertebra with three cortical fixation techniques . West China Medical Journal, 2018, 33(9): 1106-1109. doi: 10.7507/1002-0179.201808051 Copy

1.	Lehman RA Jr, Kuklo TR, Belmont PJ Jr, et al. Advantage of pedicle screw fixation directed into the apex of the sacral promontory over bicortical fixation: a biomechanical analysis. Spine (Phila Pa 1976), 2002, 27(8): 806-811.
2.	Ergur I, Akcali O, Kiray A, et al. Neurovascular risks of sacral screws with bicortical purchase: an anatomical study. Eur Spine J, 2007, 16(9): 1519-1523.
3.	Sae-Jung S, Khamanarong K, Woraputtaporn W, et al. Awareness of the median sacral artery during lumbosacral spinal surgery: an anatomic cadaveric study of its relationship to the lumbosacral spine. Eur Spine J, 2015, 24(11): 2520-2524.
4.	郑延波, 刘胜, 刘丰春, 等. 腰₅骶₁ 椎间盘前入路髓核摘除术的应用解剖学研究. 中国医学影像技术, 2004, 20(4): 601-603.
5.	赵臣银, 王泽军, 范松青. 骶正中动脉和骶正中静脉的测量及临床意义. 实用医学杂志, 2005, 21(20): 2258-2259.
6.	Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res, 1986(203): 99-112.
7.	Kostuik JP, Errico TJ, Gleason TF. Techniques of internal fixation for degenerative conditions of the lumbar spine. Clin Orthop Relat Res, 1986(203): 219-231.
8.	Krag MH. Biomechanic of thoraco lumbarspinal fixation: a review. Spine, 1991, 16: 584-587.
9.	Smith SA, Abitbol JJ, Carlson GD, et al. The effects of depth of penetration, screw orientation, and bone density on sacral screw fixation. Spine (Phila Pa 1976), 1993, 18(8): 1006-1010.
10.	Carlson GD, Abitbol JJ, Anderson DR, et al. Screw fixation in the human sacrum. An in vitro study of the biomechanics of fixation. Spine (Phila Pa 1976), 1992, 17(Suppl6): S196-S203.
11.	Kim YY, Ha KY, Kim SI, et al. A study of sacral anthropometry to determine S₁ screw placement for spinal lumbosacral fixation in the Korean population. Eur Spine J, 2015, 24(11): 2525-2529.
12.	Fairbank JC, Pynsent PB. The oswestry disability index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
13.	Bernhardt M, Swartz DE, Clothiaux PL, et al. Posterolateral lumbar and lumbosacral fusion with and without pedicle screw internal fixation. Clin Orthop Relat Res, 1992(284): 109-115.
14.	Horowitch A, Peek RD, Thomas JC Jr, et al. The wiltse pedicle screw fixation system. Early clinical results. Spine (Phila Pa 1976), 1989, 14(4): 461-467.
15.	Horton WC, Holt RT, Muldowny DS. Controversy. Fusion of L₅-S₁ in adult scoliosis. Spine (Phila Pa 1976), 1996, 21(21): 2520-2522.
16.	Zheng Y, Lu WW, Zhu Q, et al. Variation in bone mineral density of the sacrum in young adults and its significance for sacral fixation. Spine (Phila Pa 1976), 2000, 25(3): 353-357.
17.	Hadjipavlou AG, Nicodemus CL, al-Hamdan FA, et al. Correlation of bone equivalent mineral density to pull-out resistance of triangulated pedicle screw construct. J Spinal Disord, 1997, 10(1): 12-19.
18.	Pfeiffer M, Hoffman H, Goel VK, et al. In vitro testing of a new transpedicular stabilization technique. Eur Spine J, 1997, 6(4): 249-255.
19.	Matsukawa K, Yato Y, Kato T, et al. Cortical bone trajectory for lumbosacral fixation: penetrating S-1 endplate screw technique: technical note. J Neurosurg Spine, 2014, 21(2): 203-209.
20.	Hsieh JC, Drazin D, Firempong AO, et al. Accuracy of intraoperative computed tomography image-guided surgery in placing pedicle and pelvic screws for primary versus revision spine surgery. Neurosurg Focus, 2014, 36(3): E2.
21.	Truumees E. Sacral pedicle screw (S₁ promontory) placement. Vaccaro//AR, 2003: 160-162.
22.	Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976), 1990, 15(1): 11-14.
23.	陈文俊, 邱勇, 王斌, 等. 青少年特发性脊柱侧凸椎弓根螺钉的误置模式及危险因素. 中华外科杂志, 2009, 47(22): 1725-1727.
24.	Senaran H, Shah SA, Gabos PG, et al. Difficult thoracic pedicle screw placement in adolescent idiopathic scoliosis. J Spinal Disord Tech, 2008, 21(3): 187-191.
25.	谢加兴, 刘金伟, 丁自海, 等. 腹腔镜前路 L₅~S₁ 椎间盘手术的血管解剖观察. 中国临床解剖学杂志, 2007, 25(6): 644-646.

1. Lehman RA Jr, Kuklo TR, Belmont PJ Jr, et al. Advantage of pedicle screw fixation directed into the apex of the sacral promontory over bicortical fixation: a biomechanical analysis. Spine (Phila Pa 1976), 2002, 27(8): 806-811.
2. Ergur I, Akcali O, Kiray A, et al. Neurovascular risks of sacral screws with bicortical purchase: an anatomical study. Eur Spine J, 2007, 16(9): 1519-1523.
3. Sae-Jung S, Khamanarong K, Woraputtaporn W, et al. Awareness of the median sacral artery during lumbosacral spinal surgery: an anatomic cadaveric study of its relationship to the lumbosacral spine. Eur Spine J, 2015, 24(11): 2520-2524.
4. 郑延波, 刘胜, 刘丰春, 等. 腰₅骶₁ 椎间盘前入路髓核摘除术的应用解剖学研究. 中国医学影像技术, 2004, 20(4): 601-603.
5. 赵臣银, 王泽军, 范松青. 骶正中动脉和骶正中静脉的测量及临床意义. 实用医学杂志, 2005, 21(20): 2258-2259.
6. Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res, 1986(203): 99-112.
7. Kostuik JP, Errico TJ, Gleason TF. Techniques of internal fixation for degenerative conditions of the lumbar spine. Clin Orthop Relat Res, 1986(203): 219-231.
8. Krag MH. Biomechanic of thoraco lumbarspinal fixation: a review. Spine, 1991, 16: 584-587.
9. Smith SA, Abitbol JJ, Carlson GD, et al. The effects of depth of penetration, screw orientation, and bone density on sacral screw fixation. Spine (Phila Pa 1976), 1993, 18(8): 1006-1010.
10. Carlson GD, Abitbol JJ, Anderson DR, et al. Screw fixation in the human sacrum. An in vitro study of the biomechanics of fixation. Spine (Phila Pa 1976), 1992, 17(Suppl6): S196-S203.
11. Kim YY, Ha KY, Kim SI, et al. A study of sacral anthropometry to determine S₁ screw placement for spinal lumbosacral fixation in the Korean population. Eur Spine J, 2015, 24(11): 2525-2529.
12. Fairbank JC, Pynsent PB. The oswestry disability index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
13. Bernhardt M, Swartz DE, Clothiaux PL, et al. Posterolateral lumbar and lumbosacral fusion with and without pedicle screw internal fixation. Clin Orthop Relat Res, 1992(284): 109-115.
14. Horowitch A, Peek RD, Thomas JC Jr, et al. The wiltse pedicle screw fixation system. Early clinical results. Spine (Phila Pa 1976), 1989, 14(4): 461-467.
15. Horton WC, Holt RT, Muldowny DS. Controversy. Fusion of L₅-S₁ in adult scoliosis. Spine (Phila Pa 1976), 1996, 21(21): 2520-2522.
16. Zheng Y, Lu WW, Zhu Q, et al. Variation in bone mineral density of the sacrum in young adults and its significance for sacral fixation. Spine (Phila Pa 1976), 2000, 25(3): 353-357.
17. Hadjipavlou AG, Nicodemus CL, al-Hamdan FA, et al. Correlation of bone equivalent mineral density to pull-out resistance of triangulated pedicle screw construct. J Spinal Disord, 1997, 10(1): 12-19.
18. Pfeiffer M, Hoffman H, Goel VK, et al. In vitro testing of a new transpedicular stabilization technique. Eur Spine J, 1997, 6(4): 249-255.
19. Matsukawa K, Yato Y, Kato T, et al. Cortical bone trajectory for lumbosacral fixation: penetrating S-1 endplate screw technique: technical note. J Neurosurg Spine, 2014, 21(2): 203-209.
20. Hsieh JC, Drazin D, Firempong AO, et al. Accuracy of intraoperative computed tomography image-guided surgery in placing pedicle and pelvic screws for primary versus revision spine surgery. Neurosurg Focus, 2014, 36(3): E2.
21. Truumees E. Sacral pedicle screw (S₁ promontory) placement. Vaccaro//AR, 2003: 160-162.
22. Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976), 1990, 15(1): 11-14.
23. 陈文俊, 邱勇, 王斌, 等. 青少年特发性脊柱侧凸椎弓根螺钉的误置模式及危险因素. 中华外科杂志, 2009, 47(22): 1725-1727.
24. Senaran H, Shah SA, Gabos PG, et al. Difficult thoracic pedicle screw placement in adolescent idiopathic scoliosis. J Spinal Disord Tech, 2008, 21(3): 187-191.
25. 谢加兴, 刘金伟, 丁自海, 等. 腹腔镜前路 L₅~S₁ 椎间盘手术的血管解剖观察. 中国临床解剖学杂志, 2007, 25(6): 644-646.

West China Medical Journal

Study on the risk of injury to the middle sacral artery during the fixation of S₁ vertebra with three cortical fixation techniques

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West China Medical Journal

Study on the risk of injury to the middle sacral artery during the fixation of S1 vertebra with three cortical fixation techniques

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Study on the risk of injury to the middle sacral artery during the fixation of S₁ vertebra with three cortical fixation techniques