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The trajectory started at more medial points than that of the conventional sacral pedicle screw technique, was directed straight forward in the axial plane without convergence, and penetrated the middle of the sacral endplate. 21, 22 Similarly, the sacral CBT technique was adopted to engage with denser sacral bone. For the thoracic spine, less steep and less divergent screw trajectories were made. 20 The trajectory was directed about 20°–25° cranially and 10° laterally along the inferior border of the pedicle toward the posterior half of the superior endplate. In accordance with a previous morphometric study, the entry point for lumbar CBT was made at the lateral aspect of the pars interarticularis, which corresponded to a 5- or 7-o’clock orientation in the pedicle. The SAI screw trajectory was directed so as to penetrate the cortical wall of the SI joint through the superior rim of the sciatic notch toward the anterior inferior iliac spine. The starting point of the SAI screw is 1 mm lateral and 1 mm inferior to the S1 dorsal foramen, 8 which is harmoniously in line with the entry points of cranial screws. During the procedure, the surgeons verified the accuracy of the entry point position and trajectory direction for screw placement using fluoroscopic support ( Fig. Through a midline incision over the corresponding vertebrae, the paraspinal muscles were dissected to expose the entry points of the SAI and CBT screws.
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The objective of this study was to report a case series to assess the feasibility of the combination of SAI and CBT fixation techniques. One of the benefits of this combination is that their entry points are relatively medial in position, and harmoniously in line so as to avoid technical problems for rod placement, such as the need for complicated rod bending and use of an offset connector. These innovative spinal instrumentation techniques have been developed as promising solutions for both screw fixation and minimal invasiveness however, to the best of our knowledge, there has been no report on the combination of these two SAI and CBT fixation techniques in clinical practice. 14–16 Recent clinical studies have demonstrated that the CBT technique is significantly less invasive and leads to improved clinical outcomes compared with the conventional technique.
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12, 13 Another benefit of using the CBT is its minimal invasiveness due to a reduced need for muscle dissection and preservation of the superior adjacent facet joints because CBT screws can have a divergent trajectory from a more medial and caudal starting point. 11, 12 Biomechanical studies have shown that CBT screws can achieve superior fixation in comparison with conventional pedicle screws by engagement with denser regions within the vertebra. Similar to this novel SI fixation technique, during the last decade, the cortical bone trajectory (CBT) showed increasing popularity as a new alternative to the conventional transpedicular trajectory. 7, 8 Some authors have reported the clinical outcomes using SAI screws, including lower rates of reoperation, surgical site infection, and symptomatic screw prominence. 6 Compared with classic iliac screws, SAI screws are less prominent, requiring significantly reduced muscle dissection and showing superior biomechanical performance. 3, 4 The path of SAI screws starts from a medialized point away from the iliac crest, crosses the sacroiliac (SI) joint (therefore gripping the double cortical layer), and extends sufficiently anterolateral to the sacral pivot point, advocated by McCord et al., 5 allowing for the placement of longer and larger screws. To improve anchoring to the lumbosacral region, the sacral-alar-iliac (SAI) screw technique has been introduced in both pediatric and adult populations. 1 Especially in the surgical management of adult spinal deformity, achieving sagittal global alignment through realizing spinopelvic harmony is essential for improving the quality of life, and surgeons need to achieve sacral anchoring for satisfactory resistance to cantilever force. From an anatomical point of view, the lumbosacral junction is one of the challenging spinal regions because of significant mechanical forces, poor sacral bone quality, complex anatomy, and proximity to major visceral structures, often leading to pseudarthrosis, hardware failure, and loss of correction.
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T here is a growing demand for rigid lumbosacral fixation due to an increase in varieties of spinal pathologies in the aging population.