Evaluation of the true lateral fluoroscopic projection for the relation of the S1 recess/foramen to safe corridors in transiliac-transsacral screw placement in human cadaveric pelves

Percutaneous screw fixation is a widely used treatment for posterior pelvic ring injuries. Transiliac-transsacral screw fixation has demonstrated superior biomechanical properties over bilateral sacroiliac screws, particularly in the minimally displaced bilateral sacral fractures. Screw placement under fluoroscopic control is still common, while CT navigation is gaining popularity. However, the accurate placement of screws within a safe zone is essential to avoid neurovascular complications.

An anatomical study using human cadaveric pelves was conducted to assess radiological landmarks and determine a safe zone in relation to the S1 recess/foramen for transiliac-transsacral screw placement.

Fourteen pelves were evaluated. Ten pelves were classified as having a satisfactory corridor for screw placement, while four were deemed to have an impossible or high-risk corridor. A safe zone was defined based on the diagonal bisector of the S1 vertebral body, ICD and anterior cortex.

The study findings suggest that lateral fluoroscopic projection can determine a safe entry point for screw placement. Understanding the anatomy and landmarks on lateral fluoroscopic images is crucial for successful screw placement and avoiding complications.

The S1 body diagonal is consistently located anterior to the S1 recess in lateral fluoroscopic projections, providing a potential safe corridor for transiliac-transsacral screw placement at the S1 level in nondysmorphic pelves. Further research is needed to confirm these findings with CT imaging and evaluate the technical feasibility of screw placement.