Neurovascular Relationships of S2AI Screw Placement: Anatomic Study

The S2 alar-iliac (S2AI) screw is a modification of the traditional iliac fixation technique and has surgical and biomechanical benefits. However, there are significant regional neurovascular structures along the path of such screws. Therefore the current anatomic study was performed to better elucidate these relationships. Using fluoroscopy, S2AI screws were placed in 2 adult cadavers through a standard posterior midline exposure. The screw insertion point was placed 10 mm lateral to a line bisecting the S1 and S2 foramina, adjacent to the sacroiliac joint. Using 30- to 40-degree lateral angulation from the midline and 20- to 30-degree caudal angulation, a pedicle probe was directed toward the anterior inferior iliac spine. The final trajectory was positioned to sit 1−2 cm superior to the greater sciatic foramen. Lastly, the screws and surrounding bone were drilled in order to visualize both lateral and medial neurovascular relationships. Removing the bone around the S2AI-screw illustrated the close relationship to the medial (internal) neurovascular structures including the obturator nerve, lumbosacral trunk, sacral plexus and, specifically, the S1 ventral ramus and iliac vein and artery. By removing the outer cortex of the ilium, the close relationship to the superior gluteal artery, vein, and nerve was observed. In addition, we were able to identify the proximity to the iliopsoas muscle and internal iliac vessels. A comprehensive knowledge of the surrounding neurovascular anatomy relevant to S2AI screw placement can decrease patient morbidity and allow spine surgeons to better diagnose potential postoperative complications. •Studies detailing the anatomy and relationships to vulnerable neurovascular structures using the S2AI technique are lacking.•Vascular structures including the superior gluteal artery and internal iliac vein/artery are potentially at risk.•The sciatic nerve, obturator nerve, and lumbosacral plexus can be injured.•Fluoroscopic guidance is recommended to prevent misplacement during the procedure.