title: The influence of injecting an epidural contrast agent into the sacral canal on the fluoroscopic visibility of bony landmarks for sacroiliac screw fixation: a feasibility study.
abstract: OBJECTIVE
  In sacroiliac screw fixation of unstable pelvic injuries in geriatric patients, poor bone quality often obscures important bony landmarks in fluoroscopic images. The authors analyzed the feasibility of injecting a transhiatal contrast agent (CA) into the sacral canal to improve fluoroscopic visualization in the sacral epidural space.
  
  
  METHODS
  Eight fresh cadaveric whole-body specimens from human donors whose mean age at the time of death was 78 years (range 69-87 years) were used. First, to identify bony landmarks without CA enhancement, the authors acquired fluoroscopy images of the native sacral canal, using lateral, inlet, and outlet projections. Through puncture of the sacral hiatus, 8-10 ml of CA was injected into the epidural space. Fluoroscopy images were then acquired in the standard pelvic views to identify the bony landmarks. To assess the effect of the CA enhancement, visibility of the landmarks was assessed before and after CA injection. Each identified landmark was scored as 1, and summative landmark scores of up to 10 were determined for each specimen.
  
  
  RESULTS
  The cadaveric specimens were representative of bone structures in the geriatric population. In all specimens, epidural CA injection enhanced the fluoroscopic visualization of the sacral canal and of the S-1 foramina. The enhancement increased the total bony landmark score from 5.9 (range 4-8) without CA injection to 8.1 (range 6-10) after CA injection. Considering only intrasacral landmarks, the score was increased from 1.5 to 3.
  
  
  CONCLUSIONS
  Injection of a transhiatal epidural CA improves fluoroscopic imaging of the sacral canal and of the neural foramina. Hence, this technique could be applied to help the surgeon identify anatomical landmarks during sacroiliac screw fixation in geriatric patients.
authors.affiliation: Department of Trauma Surgery, Friedrich-Schiller-University, Jena; 
authors.forename: Thomas
authors.initials: T
authors.lastname: Mendel
authors.forename: Florian
authors.initials: F
authors.lastname: Radetzki
authors.forename: Stefan
authors.initials: S
authors.lastname: Schwan
authors.forename: Gunther Olaf
authors.initials: GO
authors.lastname: Hofmann
authors.forename: Felix
authors.initials: F
authors.lastname: Goehre
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001863:Bone Screws; D002102:Cadaver; D003287:Contrast Media / Q000009:adverse effects; D004824:Epidural Space / Q000601:surgery*; D005240:Feasibility Studies; D005471:Fluoroscopy / Q000379:methods; D005593:Fracture Fixation, Internal; D006801:Humans
chemical_list: D003287:Contrast Media
keywords: CA = contrast agent; SI = sacroiliac; epidural contrast agent injection; fluoroscopy; pelvic injury in the elderly; sacral; sacral hiatus; sacroiliac screw fixation