Sacral Dysmorphism Increases the Risk of Superior Gluteal Artery Injury in Percutaneous Sacroiliac Joint Fusion: Case Report and Literature Review

Abstract

Sacroiliac (SI) joint dysfunction is a significant contributor to low back pain. Percutaneous SI joint fusion is a minimally invasive procedure that can provide excellent pain relief for patients, but it is not without complications, especially in patients with abnormal lumbosacral anatomy. We report the case of a 71-year-old man with sacral dysmorphism who had a painful SI joint that was refractory to conservative therapy. After undergoing an elective percutaneous SI joint fusion, he was discharged in stable condition. He returned in a delayed fashion with a large subgluteal hematoma. Imaging revealed disruption of a branch of the superior gluteal artery (SGA). Surgical exploration and ligation of the SGA were undertaken. Sacral dysmorphism affects SI joint fusion procedures by altering sacral anatomy and the safe zones for SI joint implants. Variations in lumbosacral anatomy can also alter the course of the SGA and adjacent nerves. Due to the wide prevalence of sacral dysmorphism, especially in the setting of low back pain, pre-surgical planning to avoid iatrogenic injuries must be considered with advanced imaging studies such as a computed tomography angiogram of the pelvis or catheter-based angiogram, or alternative surgical approaches to the SI joint must be taken.

Successful coil embolization of a ruptured pseudoaneurysm of the superior gluteal artery after a percutaneous awake robot-assisted sacroiliac joint fusion: illustrative case

“…This highlights the importance of early recognition and appropriate surgical management of SGA injuries, leading to successful outcomes in this case. 11 In our case, the patient experienced an SGA pseudoaneurysm after awake robot-assisted sacroiliac screw insertion because of direct damage from the robotic screw driver during screw placement. This was believed to have occurred because of the lack of a protective sleeve for the screwdriver or because the robot effector was not docked directly on bone and hence the injury was likely attributable to soft tissue dissection or direct injury by the screws or taps.…”

“…This highlights the importance of early recognition and appropriate surgical management of SGA injuries, leading to successful outcomes in this case. 11 …”

“…Delayed cases of SGA injuries have also been observed. Maxwell et al 11 reported a case of SGA damage treated with successful open repair in a patient who had presented with symptoms and imaging findings suggestive of SGA damage. Despite initial consultation with interventional radiology, the decision was made to perform open exploration and hematoma evacuation because of worsening symptoms and anemia.…”

Safety and Preliminary Effectiveness of Lateral Transiliac Sacroiliac Joint Fusion by Interventional Pain Physicians: A Retrospective Analysis

“…However, major bleeding during a lateral SIJ fusion procedure has been reported. 24 A good understanding of the 3D osseous anatomy and appropriate imaging are critical to minimize these types of injuries.…”

Topographic localization of the sacroiliac joint and superior gluteal artery branches on the posterolateral ilium

“…Additionally, mapping of the distribution of neurovascular structures on the posterolateral ilium is helpful in avoiding iatrogenic injuries during SIJ screw insertions (Abdul‐Jabbar et al, 2018; Altman et al, 1999; Kang et al, 2015; Marmor et al, 2010; Yilmaz et al, 2018; Zhao et al, 2018). Several studies, including some recent ones emphasizing the significance of variability of vascular structures over the ilium, have reported incidences of iatrogenic injury to the superior gluteal artery (SGA) as a major concern with screw fixation surgeries (Altman et al, 1999; Collinge et al, 2005; Hartensuer et al, 2020; Li et al, 2020; Maxwell et al, 2021).…”