SURGICAL ONCOLOGY AND RECONSTRUCTION Anatomic Considerations for Posterior Iliac Crest Bone Procurement Somsak Sittitavornwong, DDS, DMD, MS, * D. Scott Falconer, DDS, MD,y Rakesh Shah, MD, DMD,z Nathan Brown, MD, DMD, x and R. Shane Tubbs, MS, PA-C, PhDk Purpose: The aim of this study was to identify the relative anatomic locations of relevant vital structures at risk for injury during posterior iliac crest bone graft procurement. Materials and Methods: Twenty-one cadavers yielded 39 intact posterior ilia for dissection. The poste- rior superior iliac spine (PSIS) was used as the primary reference landmark. Measurements were made to the medial branch of the superior cluneal nerves, the superior branch of the middle cluneal nerves, the sciatic notch, and the superior gluteal vessels. Distances from the spinal midline to the superior cluneal nerves were recorded. Results: The average distances from the PSIS to the superior and middle cluneal nerves, greater sciatic notch, and superior gluteal vessels were 5.7 cm (standard deviation, 1.22 cm), 6.55 cm (standard deviation, 1.53 cm), 5.3 cm (standard deviation, 0.71 cm), and 5.4 cm (standard deviation, 0.95 cm), respectively. The most medial superior cluneal nerve was identified at 3.0 to 4.9 cm from the PSIS in 23% of cases, at 5.0 to 6.9 cm from the PSIS in 61.5% of cases, and farther than 7.0 cm from the PSIS in 15.4% of cases. Conclusions: This study illustrates that the most medial superior cluneal nerve is often closer to the PSIS than previously described and the same holds true for the greater sciatic notch and superior gluteal vessels. Knowledge of the anatomic locations of these important structures should allow the surgeon to avoid or decrease the complication rate of bone procurement from the posterior ilium. Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:1777-1788, 2013 Autogenous bone is an ideal graft material for osseous reconstruction, providing biologic substrates critical for osteoinduction, osteoconduction, and osteogene- sis. The posterior iliac crest is an excellent site of pro- curement, affording the ability to yield a large available volume of corticocancellous bone graft for use in mul- tiple applications. The posterior iliac crest has been re- ported to yield 100 to 125 mL of noncompressed corticocancellous bone, or a 5-  5-cm cortical block. 1 This is significantly more bone than from the anterior iliac crest, which yields approximately 50 mL of non- compressed corticocancellous bone, or a 3-  5-cm cortical block. 1 The advent of autogenous bone grafting in the early 20th century started the search for potential donor sites. Dick 2 originally published a procurement technique for the posterior iliac crest bone graft (PICBG) in the ortho- pedic literature in 1946 for the repair of long bone de- fects, fracture nonunion, spinal fusion, and arthrodesis of various joints. In 1950, Dingman 3 described the use of the PICBG for the repair of facial and cranial defects. Since then, multiple articles have been written describ- ing the anatomy, procurement techniques, complica- tions, and applications of the PICBG in the orthopedic, spine, and maxillofacial literatures. 1,3,4-10 There are many vital structures surrounding the surgi- cal access for PICBG, including the superior (L1 to L3) and middle (S1 to S3) cluneal cutaneous nerves, the sci- atic nerve, and the superior gluteal vessels. With these structures in the vicinity of the posterior ilium, potential morbidity of the posterior iliac approach may occur. Received from the Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL. *Assistant Professor. yResident. zFormer Resident. xFormer Resident. kDirector of Research, Pediatric Neurosurgery, Children’s Hospital, Birmingham, AL. Address correspondence and reprint requests to Dr Sittitavornwong: Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, 456 School of Dentistry Building, 1919, 7th Avenue South, Birmingham, AL 35294; e-mail: sjade@uab.edu Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons 0278-2391/13/00298-X$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.03.008 1777