What is the treatment for lumbopelvic fixation?

Lumbopelvic Fixation Treatment

Lumbopelvic fixation is indicated for unstable pelvic ring injuries with posterior instability, particularly rotationally unstable (APC-II, LC-II) and vertically unstable (APC-III, LC-III, VS, CM) fracture patterns, with spinopelvic fixation offering the benefit of immediate weight bearing in patients with vertically unstable sacral fractures. 1

Indications for Lumbopelvic Fixation

• Posterior pelvic ring instability requiring anatomic fracture reduction and stable internal fixation 1
• Vertically unstable sacral fractures (including U-type fractures) where immediate weight bearing is desired 1, 2
• Complex sacral fractures requiring closed reduction to restore pelvic incidence 2
• Multidirectional instability of the posterior pelvic ring and lumbopelvic junction 3
• Long spinal arthrodesis (five or more vertebral levels) extending to the sacrum 4
• High-grade spondylolisthesis requiring correction 4
• Correction of lumbar deformity and pelvic obliquity 4

Timing of Surgical Intervention

• Hemodynamically unstable and coagulopathic patients should be successfully resuscitated before proceeding with definitive pelvic fracture fixation (Grade 1B) 1
• Hemodynamically stable patients can safely undergo early definitive pelvic fracture fixation within 24 hours post-injury (Grade 2A) 1
• Definitive pelvic fracture fixation should be postponed until after day 4 post-injury in physiologically deranged polytrauma patients (Grade 2A) 1
• Initial "damage control" external fixation may be used for hemodynamically unstable patients, with delayed definitive internal fixation once the patient is stabilized 1

Surgical Techniques

Spinopelvic Fixation

• Triangular lumbopelvic fixation combines vertical fixation between lumbar vertebral pedicles and the ilium with horizontal fixation (iliosacral screw or transiliacal plate) 3
• Iliac screws are directed from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS) 3
• The posterior superior iliac spine-anterior inferior iliac spine path provides the largest bony canal lengths (141 mm in males, 129 mm in females) 5
• S2-alar-iliac screws offer advantages of less implant prominence and inline placement with proximal spinal anchors 4

Anterior Fixation

• Pubic symphysis plating is the modality of choice for anterior fixation of "open book" injuries with a pubic symphysis diastasis > 2.5 cm (APC-II, APC-III) (Grade 1A) 1
• Selected lateral compression patterns with rotational instability (LC-II, LC-III) benefit from adjunctive, temporary external fixation in conjunction with posterior pelvic ring fixation (Grade 2A) 1

Minimally Invasive Approach

• Minimally invasive lumbopelvic fixation has shown promising results with less morbidity compared to traditional open procedures 2
• Transiliac screws can be placed under fluoroscopic control using standard lateral and obturator oblique-outlet views 5
• Minimally invasive techniques may reduce wound-related complications while still providing adequate stability 2, 3

Advantages of Lumbopelvic Fixation

• Allows for closed reduction to restore pelvic incidence 2
• Provides stability for immediate full weight bearing after surgery 2, 3
• Decreases load to the sacrum and SI joint by transferring axial loads from the lumbar spine directly to the ilium 3
• Reduces prolonged immobilization and associated complications 2, 3

Potential Complications and Management

• Wound-related complications may occur, especially with pre-existing Morell-Lavalée lesions 3
• Hardware prominence can cause local irritation and pain, which can be reduced with screw head recession into the PSIS 3
• Late mechanical complications may occur several years after surgery, requiring long-term follow-up 6
• Hardware removal is often necessary after fracture healing, typically 3-5 months after index surgery 2

Special Considerations

• Thorough surgical preparation and operative logistics are required due to the complexity of iliac screw placement 3
• Elderly patients may require special attention to bone quality and fixation methods 7
• Open fractures require thorough debridement and appropriate antibiotic coverage 7

Lumbopelvic fixation is a powerful method for achieving lumbosacral arthrodesis and treating unstable pelvic ring injuries. The technique chosen should be based on fracture pattern, patient factors, and surgeon experience, with the goal of achieving anatomic reduction and stable fixation to allow early functional rehabilitation and decrease long-term morbidity 1, 4.