SURGICAL TECHNIQUE
Novel Technique for Sacral Alar-Iliac (S2AI) Fixation
Nicholas S. Andrade, BS, Louis Okafor, MD, and Brian J. Neuman, MD
Objective: To provide reasoning and steps for the placement of
sacral alar-iliac (S2AI) screws for pelvic arthrodesis to aid oss-
eous lumbosacral fusion.
Summary of Background Data: Studies support lower rates of
screw breakage and need for revision surgery or hardware re-
moval for S2AI screws compared with traditional iliac bolts, as
well as low rates of pseudoarthrosis and arthritis associated with
this hardware placement.
Materials and Methods: A case video of S2AI placement dem-
onstrates our operative technique and is accompanied by pro-
cedural description of surgical maneuvers.
Results and Surgical Techniques: One patient underwent lum-
bosacral fusion surgery aided by S2AI-mediated pelvic fixation.
Conclusions: The present technique utilizing S2AI screws pro-
vides for successful pelvic fixation to aid in lumbosacral fusion,
with no need for subcutaneous tissue dissection and improved
outcomes compared with traditional iliac bolts.
Key Words: S2AI, spinal deformity, pelvic fixation, sacral alar-iliac
(Clin Spine Surg 2018;31:373–376)
PELVIC FIXATION
Pelvic fixation is the immobilization of the sacroiliac
(SI) joint commonly used to aid osseous lumbosacral fu-
sion. In 1933, Ralph Ghormley of the Mayo Clinic iden-
tified a major cause of lower back pain to be strain across
the lumbosacral junction. Moreover, Ghormley traced his
strain to flexion moment and cantilever forces resulting
from the interaction of the mobile spine with the immobile
pelvis. Lumbosacral fixation was developed to treat this
persistent pain and spondylosis. By the 1940s, screws
across the SI junction were developed to aid this lumbo-
sacral arthrodesis.
There are numerous indications for pelvic fixation.
A long spinal arthrodesis, especially one spanning ≥ 5
Received for publication May 30, 2017; accepted July 24, 2017.
From the Department of Orthopaedic Surgery, Johns Hopkins Uni-
versity School of Medicine, Baltimore, MD.
Brian Neuman receives a research grant from Depuy / Synthes which does
not pertain to this study.
The authors declare no conflict of interest.
Reprints: Brian J. Neuman, MD, Johns Hopkins University, 601 N Caroline,
St JHOC 5241, Baltimore, MD 21287 (e-mail: bneuman7@jhmi.edu).
Supplemental Digital Content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal's Website, www.jspinaldisorders.com.
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Clin Spine Surg  Volume 31, Number 9, November 2018
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vertebral levels, and 3-column osteotomies are the primary
indication for the procedure. Other indications include
local lumbosacral fixation in the presence of osteoporosis,
sacral fractures that result in SI dislocation, and correc-
tions to lumbar deformity or pelvic obliquity in pediatrics
with neuromuscular deformities. In addition, pelvic fix-
ation is beneficial in patients with high-grade spondylo-
listhesis across the lumbosacral joint, as it aids in reducing
shear loads on sacral screws.
Despite its commonality, pelvic fixation remains an
area of challenge to spine surgeons. This is due to poor sacral
bone quality, the complex anatomy of the region, and the
extremely large biomechanical forces experienced by the
lumbosacral junction. This ultimately results in high rates of
instrumentation-related complications that cause pain to the
patient and often require revision surgery.
ILIAC BOLTS APPROACH
Iliac bolts are one of the most commonly used in-
struments in pelvic fixation. Iliac bolts are independent
anchors placed in the ilium and connected to the sacrum
with rods using pedicle screws and hooks. The trajectory
for placement begins at the posterior superior iliac spine
(PSIS) and ends at the anterior superior iliac spine,
allowing for a screw length of 100 mm in adults on
average. Iliac bolt placement is associated with a rela-
tively low rate of nonunion compared with other com-
monly used techniques, although the instrument choice is
not without disadvantages. Iliac bolt placement requires
substantial dissection of subfascial tissue to expose the
PSIS. This extensive dissection predisposes the patient to
higher rates of infection. Kuklo et al1 found that in a
sample of 81 patients over a 2-year period, 4% experi-
enced infection of the surgical site. The choice of the PSIS
starting point results in implant prominence leading to
long-term problems. Tsuchiya et al2 found that 23 of 67
iliac bolt recipients required removal surgery after
5 years. Clearly, any instrumentation that could mini-
mize these negative outcomes without significantly
decreasing fusion potential would be a preferred choice in
pelvic fixation.
SACRAL ALAR-ILIAC (S2AI) SCREW APPROACH
S2AI screw placement offers an alternative to iliac
bolts with little to no sacrifice in primary outcome quality.
First proposed in 2007, S2AI screw placement begins at
the sacral ala, midway between the S1 and S2 dorsal
foramina. This is in line with the starting point of the S1
pedicle screw, eliminating the need for modular con-
nectors. S2AI screws are safe for placement in both adults
and children and, like iliac bolts, they are associated with
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Andrade et al Clin Spine Surg  Volume 31, Number 9, November 2018

relatively low rates of pseudoarthrosis. Importantly, However, this infection rate is not seen in S2AI-aided
studies have also shown that S2AI screws offer good fu- fixation due to the less extensive dissection. For example,
sion potential across the lumbosacral junction. Sponseller et al6 found that 0 of 27 S2AI screw recipients
developed infection. Another common complication is
BENEFITS OF THE S2AI APPROACH AND injury to adjacent structures of the pelvis. Specific to S2AI
CURRENT TECHNIQUE placement, there is risk of damaging the superior gluteal
artery and/or sciatic nerve through breaching the sciatic
S2AI screw use features a number of advantages
notch. However this is rare and is the result of continued
over iliac bolts. First, the starting point at the sacral ala as
advancement, despite encountering difficulty during
opposed to the PSIS eliminates the need to dissect sub-
placement. The curved gearshift method described in the
cutaneous tissue of the iliac crest or sacral paraspinous
present paper provides a simpler way to adjust advance-
muscles. This results in a substantially lower potential for
ment in this case. As mentioned previously, implant
infection. The sacral ala starting point additionally results
prominence is another complication of pelvic fixation.
in less screw prominence and thus less pain and discomfort
This is primarily the result of a PSIS starting position, and
from instrumentation. The S2AI approach also leaves the
results in screws needing to be removed surgically in many
iliac crest instrument free, so there is no interference with
cases. The use of S2AI screws, placed beginning at the
iliac crest bone harvesting. Placement is in line with the
sacral ala, thus alleviates this risk.
proximal L5 and S1 anchors, and is of technical ease.
Furthermore, S2AI screws can be placed through mini-
mally invasive methods percutaneously. PROCEDURE
Good outcomes have been found with the S2AI
The procedure described here is demonstrated in the
approach. Strike et al3 examined screw breakage and other
accompanying video (Video, Supplemental Digital Con-
complications at 5 years follow-up in 51 patients. Among
tent 1, http://links.lww.com/CLINSPINE/A40). This pro-
102 screws, 6 were broken (in 4 patients) after 5 years, all
cedure is performed with the patient in standard prone
of which were <7 mm in diameter. All broken screws were
position on an open Jackson table. The procedure is begun
asymptomatic, and none required revision surgery. No
at a point 2 to 4 mm lateral and 4 to 8 mm distal to the S1
arthritis, SI fusion, or pseudoarthrosis at the L5–S1 level
dorsal sacral foramen. This is about center between the S1
was observed in any of the patients. Joshi et al4 followed
and S2 foramina, and laterally in line with the S1 screw
up on 80 children with spinal deformity surgery. Pelvic
(Fig. 1) (0:04). Once the starting position is confirmed, a
obliquity correction was successful with S2AI screw
burr hole is drilled (0:14). A long-handled curved gearshift
placement (77%; 26 ± 13 to 6 ± 4 degrees). Nine patients
is used to place the S2AI screw, beginning with the curve
had screw fractures, all of which were in the necks of
facing with the tip facing inferolateral so that it curves over
screws <8 mm in diameter. All broken screws were
the greater sciatic notch (Fig. 2) (0:21). Angling cranially
asymptomatic and none required revision surgery. Pseu-
and caudally, the gearshift is aimed just cranial to the distal
doarthrosis at the L5–S1 level was observed in 3 patients,
portion of the PSIS as it is advanced (0:35). The overall
who received subsequent revision surgery.
trajectory for this advancement is ∼40 degrees to the
Curved gearshift-aided S2AI screw placement also
horizontal plane, and 20 to 30 degrees caudally. After 50 to
offers procedural advantages. Placement is simpler than
60 mm of advancement, it will become more difficult to
with traditional iliac bolts for it does not require the use of
advance the gearshift due to encountering the SI joint.
connecting washers, but instead a single rod for successful
Once the SI joint is crossed, resistance will lessen. At this
fixation. The sacral ala starting point has also been shown
point, the gearshift is removed and the path is filled with a
to be comparably reproducible to the PSIS in a compu-
sounder to ensure that no floor or walls of the ilium were
terized tomographic scan study5. The curved gearshift it-
breached during the advancement (0:58). Once this is
self solves one of the few problems with S2AI placement:
confirmed, the gearshift is returned and advanced further
difficulty in advancing the screw due to encountering the
to at least 90 mm in a slow, progressive manner (1:08). It is
cortex of the ilium by allowing for rotation. Finally, the
important during this advancement to ensure that no
procedure can be performed with or without radiographic
increase in resistance is encountered, as this is indicative of
guidance. If radiograph use is not desired, the curved
a wall or floor collision. If resistance is met, the collision is
gearshift can be used to maneuver around encountered
either with the lamellar bone bordering the greater sciatic
difficulties in advancement.
notch or the lamellar bone of the anterior portion of the
iliac wing. In this case, the gearshift is turned to 180
POSSIBLE PROCEDURAL COMPLICATIONS degrees with the tip passing dorsally, so that the tip is now
IN PELVIC FIXATION facing superolateral (Fig. 3, large) (1:22). This maneuver
Pelvic fixation surgery is associated with some prevents breaching the greater sciatic notch. The gearshift
complications, though the use of the S2AI approach is then advanced further toward a depth of 90 mm, again in
ameliorates many of them. First, dissection of tissue to a slow, progressive manner, noting any encountered
place instrumentation comes with a risk of wound prob- resistance. If resistance is met again, the collision is with
lems or infection. As stated prior, an infection rate as high the volar aspect of the iliac wing. In this case, the gearshift
as 4% has been reported with the use of iliac bolts1. is rotated to 90 degrees with the tip passing dorsally, so

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Clin Spine Surg  Volume 31, Number 9, November 2018
FIGURE 1. Starting position for screw placement. The starting
position (circle) is approximately center between the S1 and S2
dorsal foramina, with a trajectory just superior to the distal
portion of the PSIS (arrow) towards just above the anterior
inferior iliac spine.
that the tip is now facing posterolateral (Fig. 3, small)
(1:28). This maneuver prevents breaching the volar aspect
of the ilium. The gearshift is then advanced further to the
desired 90 mm depth (Fig. 4) (1:34). A sounder is then
again used to ensure that no floor or walls of the ilium were
breached during the advancement, and to measure the
FIGURE 2. Entrance with gearshift. The tip is pointing infero-
lateral so that it will curve over the greater sciatic notch.
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Technique for Sacral Alar-Iliac (S2AI) Fixation
FIGURE 3. Gearshift rotations to avoid breaching bone. To
avoid breaching the greater sciatic notch, if resistance is met,
the gear shift is rotated so the tip is facing superolateral and
then passes just cranial to the sciatic notch (large). To avoid
breaching the volar aspect of the ilium, the gearshift is rotated
dorsally and should advance with ease (small).
length of the screw to be placed (1:43). Once confirmed, a
long K-Wire is measured to the length of the screw to be
placed and is entered into the tract (2:05). Tapping for the
S2AI screw is then begun at 1 mm less than screw diameter,
with the K-Wire ensuring proper trajectory (2:14). The
K-Wire is also checked periodically for freedom of motion.
Shortly before completion of the tapping process, the
K-Wire is removed to minimize breakage. Tapping to
appropriate depth is then finished and the tapper is
removed (2:49). A sounder is then used once again to
FIGURE 4. Final gearshift position after advancement. The
gearshift extends from between the S1 and S2 dorsal foramina
to just superior to the anterior inferior iliac spine.
www.clinicalspinesurgery.com | 375
Andrade et al
FIGURE 5. Final position of sacral alar-iliac screw. The screw
successfully immobilizes the sacroiliac junction to aid lumbo-
sacral fusion.
ensure no breaches have occurred and to confirm the
length of the screw (2:56). A K-Wire is then entered into
the tract and used to place the designated diameter in-
length screw (3:17). On an average, the screw will be > 90
mm in length and > 9 mm in diameter. Again, the K-Wire
is checked periodically to ensure freedom of motion. When
screw placement is nearly completed, the K-Wire is
removed to minimize breakage (3:53). Once the screw
is in place (Fig. 5), computed radiographic fluoroscopy is
used to confirm positioning on Anteroposterior iliac
oblique view (4:32) and teardrop view (4:47). After the
procedure, patients undergo standard postoperative
management for lumbar fusion surgery.
Note: a first time user of this procedure may elect to use
computed radiographic fluoroscopy through each step to
confirm positioning during advancement of the gearshift.
PEARLS AND PITFALLS
Pearls
 The technique for placing S2AI screws is of technical
ease and result in good alignment with lumbosacral
screws.
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Clin Spine Surg  Volume 31, Number 9, November 2018
 There is no need for subcutaneous dissection to expose
the PSIS, unlike with the use of iliac bolts
 There is less need for later removal of instrumentation
due to decreased implant prominence.
Pitfalls
 There is no clear understanding to date of possible
downsides to crossing the SI joint.
 There is a learner’s curve for placing the S2AI screws
without fluoroscopic guidance, though first time users
may simply use fluoroscopy until they are comfortable
placing the screws without it.
CONCLUSIONS
In summary, the present approach to pelvic fixation,
a curved gearshift-guided S2AI placement, offers many
advantages over the use of iliac bolts. The choice of the
sacral ala starting point leads to better patient outcomes.
It provides the opportunity for bigger screws and con-
sequently less loosening and breakages. Moreover, the
lack of implant prominence eliminates the potential need
for later removal surgery. The degree of soft tissue dis-
section necessary is also much lesser, leading to lower in-
fection rates. Finally, the procedure is of technical ease
and reproducibility, resulting in successful alignment with
lumbosacral screws.
REFERENCES
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sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine
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2. Tsuchiya K, Bridwell KH, Kuklo TR, et al. Minimum 5-year analysis
of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac
screws) for spinal deformity. Spine (Phila Pa 1976). 2006;31:303–308.
3. Strike SA, Hassanzadeh H, Naef F, et al. Sacropelvic fixation using
the S2 alar-iliac (SAI) screws in adult deformity surgery: a prospective
study with minimum five-year follow-up. Presented as a Poster Exhibit
at the 48th Annual Meeting of the Scoliosis Research Society, Lyon,
France. 2013.
4. Joshi R, Kebaish KM, Sponseller PD. Sacral-alar iliac fixation in
pediatric deformity: two to five-year follow-up. Paper Presented at the
47th Annual Meeting of the Scoliosis Research Society, Chicago, IL.
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5. Chang TL, Sponseller PD, Kebaish KM, et al. Low profile pelvic
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