Transsacral Fixation Is Linked to High Fusion Rate and Improved Quality of Life in Adult Scoliosis

Neel Anand, MD, and Isador H. Lieberman, MD, Comment

Peer Reviewed

Use of minimally invasive transsacral fixation resulted in fusion in nearly 90% of adults with scoliosis as well as improved health-related quality of life and a relatively low complication rate, according to a 2014 retrospective chart review published in Clinical Orthopaedics and Related Research.

adult lumbar scoliosisIn the study, a total of 92 patients with spinal deformity underwent fusion of ≥3 levels that extended across the lumbosacral junction. Photo Source:“Transsacral approach could be considered in select cases as a method to obtain L5-S1 fusion in patients requiring long segment arthrodesis,” lead author Neel Anand, MD, told SpineUniverse. However, more recent evidence suggests that ALIF at L5-S1 is preferred over transsacral fixation, as the latter approach helps obtain more lordosis and reliable arthrodesis, Dr. Anand said. Dr. Anand is Clinical Professor of Surgery and Director of Spine Trauma at Cedars-Sinai Medical Center in Los Angeles, California.

This change in protocol away from transsacral fixation and toward ALIF at L5-S1 “was instituted in the middle of 2011, and a study comparing the results of the new protocol to the old protocol have been accepted and will be published soon in Spinal Deformity.”

The reason for the protocol change was twofold, Dr. Anand said. First, “when we critically studied the sagittal parameters, we noted a number of patients with less than optimal sagittal balance,” Dr. Anand explained.1 “We believe this may be due to the inability to create lordosis with this technique, and an ALIF creates more reliable arthrodesis. Today, we do an ALIF with a minimal 2-inch incision for L5-S1.”

Secondly, “we also started seeing late presentations of non-union in patients who had transsacral fixation, and subsequent to the publication of this paper, we had three more of the patients in the study show loosening of their sacral screws on CT scan,” Dr. Anand said. “This may be due to the very rigid fixation that the screw provides, and a longer followup revealed more non-unions. For this reason, we have transitioned to an ALIF at L5-S1 for a reliable arthrodesis. We have also added iliac fixation all done in a minimally invasive manner.”

Retrospective Study Design

In the 2014 study, a total of 92 patients with spinal deformity underwent fusion of ≥3 levels that extended across the lumbosacral junction. Of this group 46 (82%) underwent transsacral fusion (L5-S1) at the bottom of the long construct without supplemental pelvic fixation, and had at least 2 years of followup data. A majority of the patients (n=33) had degenerative scoliosis, and others had idiopathic or iatrogenic scoliosis (n=9 and n=4, respectively). The procedures were performed by a senior spine surgeon at a single tertiary academic center.

Solid fusion at L5-S1 occurred in 41 of the 46 patients (89%). Significant improvement in mean scores on the Oswestry Disability Index, Short Form-36, and visual analog scale were reported (P<0.001, P<0.001, and P=0.001, respectively).


Eight patients (17%) had complications that were directly related to transsacral fixation: 5 patients had pseudoarthrosis and 3 had superficial wound dehiscence. Seven other patients had other complications that were related to other minimally invasive techniques used to correct spinal deformity.

Study Limitations

“The study does suffer from many deficiencies that limit the utility of this study in deciding on the value of the transsacral fixation technique in adult deformity surgery,” commented Isador H. Lieberman, MD, Director of the Scoliosis & Spine Tumor Center, Texas Back Institute, Texas Health Presbyterian Hospital Plano, Plano, Texas.

“There is abundant literature, both biomechanical and clinical, to support the use of a transsacral technique under certain clinical circumstances. Unfortunately, this study does not meet the contemporary scientific rigors to add to that body of knowledge,” Dr. Lieberman said.

“The most significant limitation is the fact that the outcome of spinal reconstruction for adult deformity is dependent on many variables and, combined with a retrospective review as is presented here, the benefits attributable to a less invasive lumbosacral fusion approach cannot be fully or independently evaluated,” Dr. Lieberman said.

“In addition, the authors do not evaluate in any way the restoration of lumbosacral lordosis using this technique, thereby further limiting the value of this study,” Dr. Lieberman told SpineUniverse. “With recent contemporary experience, surgeons now realize the importance of restoring the lordotic angle at the lumbosacral junction. The use of transsacral fixation and fusion to restore that lordosis requires pre-operative appreciation and planning, as well as exacting intra-operative execution of the plan,” Dr. Lieberman concluded.

Transsacral Fixation Should Be Reserved for Patients With Good Sagittal Balance

“I believe, based on our experience, transsacral fixation at the bottom of a long fusion is a viable option, but should be reserved for patients with good sagittal balance and preferably augmented with iliac fixation and or posterior arthrodesis of the L5-S1 segment,” Dr. Anand concluded. “If transsacral fixation is used, these patients should be followed up for a long time to detect non-unions.”

Updated on: 10/01/19
Continue Reading
Minimally Invasive Surgery for Adolescent Idiopathic Scoliosis Shows Same Efficacy as Open Approach with Less Transfusion Needs
Neel Anand, MD
Clinical Professor of Surgery and Director of Spine Trauma
Cedars-Sinai Spine Center
Los Angeles, CA
Isador H. Lieberman, MD, MBA, FRCSC
Orthopaedic and Spinal Surgeon
Texas Back Institute
Plano, TX

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