Neuronavigated placement of iliosacral screws in sacral fractures: an additional tool in the spine surgeon's arsenal.

Iliosacral screw fixation is a cornerstone technique for stabilizing posterior pelvic ring injuries, particularly vertical sacral wing fractures and sacroiliac joint disjunctions. Although traditionally performed under fluoroscopic guidance, conventional two-dimensional (2D) imaging exposes both patients and surgical teams to significant radiation and carries a non-negligible risk of screw malposition, with potential injury to neural and vascular structures. The integration of intraoperative three-dimensional (3D) neuronavigation represents a major technological advance that enhances the accuracy, safety, and reproducibility of this demanding procedure. This article describes a simplified, standardized, and reproducible technique for percutaneous iliosacral screw placement using 3D neuronavigation, specifically tailored for spine and trauma surgeons. The navigation system is used to preoperatively and intraoperatively define optimal entry points, safe screw trajectories, and appropriate screw lengths, ensuring preservation of sacral foramina and neural elements. A neuronavigated drill guide or navigated Jamshidi needle is employed to insert K-wires, followed by the placement of two to three partially or fully threaded cannulated screws with washers, depending on fracture morphology and biomechanical objectives. Intraoperative 3D image acquisition is systematically performed to verify final screw positioning before closure, allowing immediate correction if necessary. Close interdisciplinary collaboration with orthopedic surgeons is emphasized to address pelvic ring injuries comprehensively, considering both posterior and anterior stability. An intraoperative video of an illustrative clinical case accompanies this description to demonstrate the step-by-step workflow and technical nuances of the procedure. In conclusion, neuronavigated iliosacral screw fixation provides a safe, reliable, and reproducible solution for posterior pelvic ring stabilization. By improving surgical precision, reducing radiation exposure, and shortening the learning curve, this technique represents a valuable addition to the modern spine surgeon's armamentarium and has the potential to become a new standard of care for complex sacral fractures.