If fusing a young patient (adolescent or young adult) to L3 or L4, it
is wise to preserve the distal third of the ilium bilaterally. It is
very likely that such a patient will require to extent the fusion to
the sacrum in future. If the distal ilium is preserved, then
sacropelvic fixation can be achieved more conveniently.
There are several issues involved with deciding whether to stop at L5
or the sacrum. Many investigators have stated that if L5 is
deep-seated, that significant breakdown at L5-Sl is not likely to
occur. "Deep-seated" has been defined as big transverse processes and
the L5 segment sitting below the intercristal line.
It is not a good idea to stop at L5, and fusion should be extended to
the sacrum, if L5-S1 segment has one of the followings:
Spondylolisthesis,
Previous laminectomy,
Foraminal stenosis.
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