Spine - 2026-08-26 - Journal Article
Reoperation in Long Lumbar Constructs with and Without Iliac Fixation: A Registry Study.
Majid K, Chang RN, Asefi S, Royse KE, Harris JE, Bains RS, Tabaraee E
Topics
Key Takeaway
Iliac fixation in multilevel lumbosacral fusion (>4 levels) reduced long-term all-cause reoperation risk by 37% (HR 0.63) and nonunion-related reoperation by 70% (HR 0.30) over a mean 6.3-year follow-up.
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Summary
This registry study asked whether iliac fixation reduces reoperation risk in adults undergoing primary elective multilevel lumbosacral fusion (>4 levels) for degenerative pathology. Using multivariable Cox regression on 1,301 patients from a large integrated healthcare registry (2009–2023), iliac fixation was associated with reduced long-term all-cause reoperation (HR 0.63, 95% CI 0.43–0.92) and nonunion-related reoperation (HR 0.30, 95% CI 0.13–0.67), with 10-year crude rates of 26.0% vs. 31.1%. No significant difference in ASD-related reoperation was observed, and the protective effect was absent in the early postoperative period.
Key Limitation
Retrospective registry design cannot exclude confounding by indication, as patient-level factors driving the surgeon's choice to add iliac fixation (e.g., osteoporosis, obesity, greater deformity) are not fully captured or adjusted for.
Original Abstract
STUDY DESIGN
Retrospective cohort study.
OBJECTIVE
To evaluate the association between iliac fixation and long-term reoperation risk in patients undergoing multilevel lumbosacral fusion for degenerative pathology.
SUMMARY OF BACKGROUND DATA
Spinopelvic fixation using iliac screws is commonly employed to improve construct stability in long lumbar fusions involving the sacrum. While biomechanical benefits are well established, clinical evidence regarding long-term reoperation risk and failure mechanisms in degenerative populations remains limited.
METHODS
We identified adult patients undergoing primary elective multilevel lumbosacral fusion (>4 levels) between 2009 and 2023 from a large integrated healthcare spine registry by using iliac fixation. Primary outcome was all-cause reoperation. Secondary outcomes included reoperation for adjacent segment disease (ASD), nonunion, and hardware-related complications. We used Multivariable Cox proportional hazards regression models adjusted for patient and surgical factors to evaluate reoperation risk. Time-stratified analyses addressed nonproportional hazards.
RESULTS
A total of 1,301 patients were included, including 483 with iliac fixation and 818 without. Mean follow-up was 6.3 years. At 10 years, crude all-cause reoperation incidence was 26.0% with iliac fixation versus 31.1% without. Iliac fixation was associated with reduced long-term all-cause reoperation risk (>1 y) (HR 0.63, 95% CI 0.43-0.92, P=0.018), but not early reoperation risk. Nonunion-related reoperation risk was significantly lower with iliac fixation (HR 0.30, 95% CI 0.13-0.67, P=0.004). No significant differences were observed in ASD-related reoperation risk.
CONCLUSIONS
In patients undergoing multilevel lumbosacral fusion for degenerative pathology, iliac fixation was associated with significantly lower long-term reoperation risk, driven primarily by reduced nonunion-related reoperation. These findings support the role of iliac fixation in improving long-term construct durability.
LEVEL OF EVIDENCE
III.