SPINE Volume 27, Number 7, pp 776–786 ©2002, Lippincott Williams & Wilkins, Inc. Outcome and Complications of Long Fusions to the Sacrum in Adult Spine Deformity Luque-Galveston, Combined Iliac and Sacral Screws, and Sacral Fixation Arash Emami, MD, Vedat Deviren, MD, Sigurd Berven, MD, Jason A. Smith, MD, Serena S. Hu, MD, and David S. Bradford, MD Study Design. A retrospective study of adults with long fusion to the sacrum using three different fixations was performed. Objective. To compare the long-term clinical results and complications associated with three methods of lum- bosacral fixation for adult spine deformities: Luque- Galveston, combined iliac and sacral screws, and sacral screws. Summary of Background Data. The preferred tech- nique for long fusion to the sacrum is controversial, and surgery for adult deformity is fraught with significant technical difficulties and high complication rates. No clin- ical study compares the long-term outcome of long fusion to the sacrum using these different methods of lumbosa- cral fixation. Methods. This study included 54 consecutive patients who underwent elective combined anterior and posterior surgical reconstruction for adult spine deformity with a minimum follow-up period of 2 years. The patients were divided into three groups on the basis of the surgical method used for the posterior spine instrumentation. Group 1 consisted of 11 patients with smooth L-rod and segmental sublaminar wire instrumentation (Luque- Galveston technique). Group 2 consisted of 36 patients with posterior Isola segmental instrumentation and com- bined iliac and sacral screws. Group 3 consisted of 12 patients with Isola segmental instrumentation using bi- cortical sacral screws. Five patients were revised to an- other fixation group, giving a total of 59 cases. Radio- graphic, clinical results, and long-term outcome data were obtained using the modified Scoliosis Research So- ciety (SRS) outcome instrument. Results. There were 26 late complications. Pseudar- throsis developed in 10 patients, requiring revision sur- gery: 4 (36%) in the Group 1, 5 (14%) in Group 2, and 1 (8.5%) in Group 3. Comparison of the modified SRS out- comes showed no difference among the groups. The av- erage SRS grand total score was 73.4% for Group 1, 70.9% for Group 2, and 62.6% for Group 3. Overall, 76% of the patients were satisfied with their outcome. The pres- ence of perioperative complications or pseudarthrosis significantly correlated with a lower satisfaction score (P = 0.012 and P = 0.048, respectively). Sagittal plane decompensation significantly correlated with a higher pain score (P = 0.035). Patients with prior surgeries scored lower on the self-image questions than patients with no prior surgery (P = 0.007). Conclusions. Attention to sagittal balance is critical in these patients. Revision surgery is as safe and effective as primary surgery. According to the current findings, the Luque-Galveston fixation technique has an unacceptably high rate of pseudarthrosis, and this method is not rec- ommended for adult deformities. Currently, the authors are using bicortical and triangulated sacral screws with an anterior interbody support in patients with good bone stock, but only when the spine balance is restored. Oth- erwise, they recommend using iliac fixation, although there is a higher rate of painful hardware, requiring removal. [Key words: adult deformity, complications, fu- sion to sacrum, outcome] Spine 2002;27:776 –786 Long fusion to the sacrum in adult spine deformity pre- sents a challenging surgical dilemma. Fusion to the sa- crum in the management of adult, nonparalytic defor- mity is indicated in cases involving a fixed lumbosacral curve, lumbosacral pain, degenerative disease, spinal ste- nosis below a prior fusion, or those involving pseudar- throsis. However, these long fusions often are associated with high rates of complications such as pseudarthrosis, sagittal deformity, and instrumentation failure. 5,14,20 These complications are thought to result from inade- quacy of sacral bone stock, unfavorable biomechanics of a long lever arm at the lumbosacral junction, distraction instrumentation, decompensation in the absence of mo- bile compensatory segments, and the large number of segments requiring arthrodesis. 5,6,8,9,14,15,18,20 Although newer instrumentation techniques and combined ante- rior and posterior surgery have improved fusion rates, the ideal method for long fusion to the sacrum remains a controversial topic. Options for posterior fixation to the sacrum include sacral screws with or without extension to the ilium. A historical review of the literature shows high com- plication rates and high pseudarthrosis rates for these long fusions. In 1983, Kostuik and Hall 14 reported a 40% incidence of pseudarthrosis with Harrington rods and sacral hooks. Using a similar technique, Balderston et al 5 reported a rate of only 28% for good results with single-stage posterior fusion to the sacrum. Failures re- sulted from pseudarthrosis, decompensation, or loss of lumbar lordosis. Subsequent studies have shown that correction of the deformity and anterior fusion per- From the University of California, San Francisco, Department of Or- thopaedic Surgery, San Francisco, California. Acknowledgment date: November 2, 2000. First revision date: July 12, 2001. Acceptance date: August 8, 2001. Device status/drug statement: The submitted manuscript does not con- tain information about medical devices or drugs. Conflict of interest: No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this report. 776