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Reoperation in Long Lumbar Constructs with and Without Iliac Fixation

Spine · 26 Aug 2026

Rigour40/100
Clinical60/100
Impact†53/100

† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.

Why it matters

This informs whether spine surgeons should extend fixation to the pelvis in long degenerative lumbar fusions to reduce late nonunion-related reoperation.

The evidence

This retrospective registry study compared 483 patients who got iliac screws with 818 who did not during long (>4 level) lumbosacral fusions for degenerative spine disease, following them for a mean of 6.3 years (up to 10 years). After one year, patients with iliac fixation had a lower risk of any reoperation (HR 0.58, 95% CI 0.40-0.85) and a much lower risk of reoperation for nonunion (HR 0.30, 95% CI 0.13-0.67), but there was no difference in reoperation within the first year, for adjacent segment disease, or for hardware failure/removal.

All-cause reoperation (>1 year): Hazard ratio 0.58 (95% CI 0.4 to 0.85; units not reported). The interval favours the first group; the size of the benefit needs clinical interpretation.

Why this rigour score?

Retrospective cohortDesign starting point: 29.6

40/ 100

Raised the score

  • Compared against current standard of care+3.4
  • 76-month follow-up+3.4

Lowered the score

    No negative adjustments recorded.

    Methods at a glance

    Recorded assessment
    • Confounding adjustmentMultivariable regression
    • Covariate balance confirmedNot met
    • Outcome assessors blindedNot reported
    • Comparable start of follow-upMet
    • Adequate statistical powerNot reported
    • Prospective registrationNot met

    Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.

    See the full score breakdown
    Study design starting point
    29.6
    Aligned time zero
    +2.5
    Compared against current standard of care
    +3.4
    76-month follow-up
    +3.4
    Journal prior (not an observed method)
    +1
    Final rigour score rounded
    40 / 100

    Study design sets the starting point and a ceiling of 72. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.

    Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.

    For journal club

    1.Given that the benefit of iliac fixation appears driven almost entirely by reduced nonunion, should surgeons reserve iliac screws for patients at highest risk of pseudarthrosis rather than using them routinely in all long constructs?

    2.Does the finding that unilateral iliac fixation performed as well as bilateral fixation (with fewer implants) support de-escalating to a single iliac screw in appropriate patients?

    Original publication title

    Reoperation in Long Lumbar Constructs with and Without Iliac Fixation

    Read original paper