Complex multilevel lumbar spine fractures with transverse sacral fracture
Abstract and Figures
We report an unusual and complex case of spinal trauma in a 17-year-old boy who presented with a transverse sacral fracture associated with multiple-level lumbar fractures, paraparesis, and bladder involvement. A two-stage surgery was performed. The lumbar spine fractures were treated with posterior instrumented correction of displacements, followed by anterior instrumentation and fusion. The sacral fracture was left untreated. At 5-year followup, the patient had complete neurological recovery except for the right L5 root function. The long-segment lumbar fusion and the untreated displaced sacral fracture contributed to spinal imbalance, due to which the patient is now able to stand only in a crouched posture. Determining the optimal treatment for the case is presented due to the relative rarity of transverse sacral fracture and paucity of evidence-based treatment approaches. In patients with associated lumbar spine fractures that require extension of instrumentation to the upper lumbar spine, it is critical to restore sacropelvic alignment to achieve spinal balance. Adequate reduction of sacropelvic anatomy can be achieved with iliac screw fixation.
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... In the presence of no progressive deficit or normal neurological status, performing surgery only for decompression has no clear benefits. In these cases, address de spinal canal may be performed if surgery must be done for other reasons, like deformity correction [10,22,23,31,32,38]. When decision is for decompression, although kyphosis reduction can indirectly restore spinal canal diameter, additional laminectomy is preferable by allowing exploration of the nerve roots and adequate inventory of damages. ...
... Different stabilization techniques have been applied in operative management of SPD, such as Harrington rods, ilio-sacral screws, rods or transiliac plates, osteosynthesis transsacral plates, and pedicular screws [10,22,24,25,31,38,42,45,47,48]. From all of them, bilateral lumbopelvic fixation is emerging as the technique of choice due to its biomechanical superiority. ...
... Recently, latest study about percutaneous bilateral lumbopelvic fixation in 17 patients with SPD presented good outcomes, highlighting the difficulty and importance of intraoperative bifemoral skeletal traction combined with direct reduction maneuvers in kyphosis deformity reduction [54]. As discussed above, despite the great advantages of minimally invasive surgery, not all SPD patterns are eligible for percutaneous reduction [10,21,22,26,31,38,43,44]. Furthermore, when sacral laminectomy is necessary, another surgical approach should be done [10,18,22,23,[31][32][33]44], adding hours and blood loss to a procedure that, as minimally invasive, should not have. ...
Introduction
Spondylopelvic dissociation is an uncommon and complex injury that results from high-energy trauma with axial overloading through the sacrum. Due to the life-threatening nature of these injuries, standard Advanced Trauma Life Support® (ATLS) protocol must be used in the trauma setting as part of the initial management of these patients. The key to diagnosis is a good physical exam coupled with high level of suspicion. Radicular neurological deficits commonly are present in spondylopelvic dissociation (L5’s roots) and should be documented for future evaluations. Radiographic views and CT-scan is preferred for the diagnosis.
Biomechanics and Classification
The authors briefly describe the anatomy and biomechanics of the pelvis, and present the main classifications used to define this rare lesion.
Treatment
Discussion about setting the boundaries of surgical stabilization, if there is still a role for conservative treatment, the importance of the initial treatment and the timing of intervention. Decompression is mandatory in the presence of canal compromise and progressive neurological deficit, regardless of biomechanical criteria for surgery. Kyphotic deformity occurs at the site of sacral transverse fracture and also reduces anteroposterior pelvis diameter. The technique of reduction and posterior surgical stabilization is emphasized. If residual kyphosis remains after bilateral lumbopelvic fixation by shifting of the lower sacral segment, we use S2 and/or S3 screws connected to transitional rods to additional reduction. An illustrated case is shown.
Complications
The infection of the wound and the failure of the implants are the most frequent complications of this surgical treatment.
Conclusion
Posterior stabilization is widely recognized as crucial in the treatment of pelvic disruptions. The concept of circumferential restoration of pelvic ring by bilateral lumbopelvic fixation and anterior fixation seems to be a nice option to increase stabilization and avoid bone misalignment.
... The lumbar spine is an important component that transmits the upper body weight to the lower limbs. The lumbar spine has a high incidence of diseases such as spondylolisthesis, fractures and disc degeneration due to a large range of motion and stress concentration [17][18][19][20]. Spinal cord decompression combined with dual screw-rod fixation through a single posterior approach has achieved satisfactory curative effects in the treatment of the above diseases and has been widely used in clinical practice [21]. ...
Background:
Although various surgical methods are used to treat lumbosacral tuberculosis, no unified surgical approach exists. Thus, exploring an optimal operation method has substantial clinical importance. Evaluate the initial stability of a new surgical method, a one-stage anterior debridement and cage implantation combined with anterior-lateral fixation by a dual screw-rod construct, in the treatment of lumbosacral tuberculosis and provide biomechanical support for its further promotion in clinical applications.
Methods:
Fifteen fresh human lumbosacral spine specimens without fractures, deformities or osteoporosis were randomly divided into intact (I), anterior fixation (AF) and posterior fixation (PF) groups. All AF and PF group specimens had subtotal resections of the L5 vertebra and adjacent discs, while the I group specimens were kept intact. Then, titanium cages were implanted in the surgical site and a dual screw-rod construct was fixed anterior-laterally in the AF group, while the PF group specimens were fixed posteriorly with only the dual screw-rod construct. Mechanical tests were conducted for initial stability evaluations.
Results:
The load at the maximum displacement (5 mm) or rotation angle (5 °) was less for the I group specimens than for the AF and PF group specimens in all directions (P < 0.05). The load at the maximum displacement (5 mm) was greater for the AF group specimens than for the PF group specimens in flexion, lateral bending and axial compression (P < 0.05) and lower than in the PF group specimens in extension (P < 0.05). In torsion, there was no difference between the loads in the AF and PF groups at the maximum rotation angle (5 °) (P > 0.05).
Conclusions:
The proposed surgical approach can provide better immediate stability than anterior debridement with posterior dual screw-rod fixation in the treatment of lumbosacral tuberculosis in flexion, lateral bending and axial compression.
... The left lateral pedicle of S2 was instrumented using the Mirkovic technique. 24 Screws were inserted in S3, with medial orientation. In this vertebra, the intersection between a vertical line through the sacral foramina and a transverse line between the dorsal foramen of S2 and S3 was used as the entry point for the screw (Figure 2). ...
Spinopelvic instability is an uncommon injury that is caused by high-energy traumas. Surgical treatment is used, in the majority of cases, to restore stability and enable early mobilization. Various stabilization techniques have been used in the treatment of spinopelvic instability, and lumbopelvic fixation (LPF) is currently the technique of choice due to its biomechanical superiority. One of its limitations is the fact that the technique does not directly address the lower sacral segment, permitting a residual kyphotic deformity. This deformity has been attributed to unsatisfactory outcomes, including late development of pelvic floor muscle defects and complications during childbirth. We report a case of a patient with spinopelvic instability due to sacral fracture, which was treated using a variation of the LPF technique, in which rods and screws originally developed for cervicothoracic fixation were adapted to correct sacral deformity in the sagittal plane. The upper sacral segment was reduced indirectly using hip extension and femoral traction manoeuvres, associated with distraction manoeuvres via rods. Bone reduction forceps were used to reduce the kyphotic deviation in the lower sacral fragment, enabling its fixation to the lumbopelvic rod and screws system. There were no complications of infection, suture dehiscence, or breakage of the implants, and at the end of the first year of follow-up, the sacral kyphosis was normal and radiographic consolidation was confirmed. Our technique provides a viable and promising alternative to traditional LPF, making it especially useful in fractures with accentuated deviations of the lower sacral fragment. Level of Evidence: 4.Type of study: Case series
Fractures of the sacrum with spinopelvic dissociation represents an infrequent but very severe injury, associated with high-energy trauma caused by traffic accidents, falls from a height and other major events. It is usually combined with severe concurrent injuries such as extensive soft tissue damage, haemorrhagic shock and the laceration of intra-abdominal cavity organs. Therefore, general management is very important in these patients. The current treatment for spinopelvic dissociation is surgical reduction and the fixation of fractures; usually, deformities require direct surgical reduction manoeuvres, either open or percutaneously. Nowadays, lumbopelvic fixation is considered to be biomechanically superior, and in more complex fractures it can be used alone or combined with iliosacrosal screws, interiliacus plates, transpedicular screws and other techniques. In general, complex fractures need vertical support and neutralization of shearing forces (neutralization and buttressing principles). Connecting the posterosuperior iliac screws to the lumbar rods can be a tricky manoeuvre, and care must be taken because although it is possible to apply connecting rods, on many occasions empty spaces are later filled by a haematoma which can provoke an infection. Still controversies exist on positioning, surgical access, intraoperative traction, neurological decompression, biomechanical construct, longitudinal length of fixation, screws length, quantity of weight bearing and hardware removal.
Background:
The purpose of this study was to determine the neurological outcome after transverse sacral fractures in patients with neurological impairment.
Methods:
A systematic review of the English, French, German, and Dutch literature was conducted. All study designs, including retrospective cohort studies and case reports, describing transverse sacral fractures were included. Two authors independently extracted the predefined data and scored the neurological impairment according to the Gibbons classification after the trauma and at the time of follow-up. The neurological outcomes were pooled according to the Gibbons classification.
Results:
No randomized controlled trials or prospective case series were found. A total of 139 articles were included, consisting of 81 case reports and 58 retrospective case series involving 521 patients. Regardless of the type of management, neurological recovery of at least 1 Gibbons category was reported in 62% of these patients. A comparison of the neurological outcome of nonoperatively treated patients and surgically treated patients showed similar neurological recovery rates. For the surgically treated patients, fixation of the fracture resulted in a better neurological improvement compared with an isolated decompression.
Conclusions:
This review could not provide evidence of improved neurological recovery after surgical treatment compared with nonoperative treatment. When surgical treatment was considered, there was a low level of evidence that fixation of the fracture results in better neurological improvement compared with isolated decompression.
Level of evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Sacral fractures are commonly associated with pelvic ring fractures due to high-energy mechanisms of injury. An understanding of the anatomic relation of the sacrum to the lumbar spine, pelvis, and surrounding neurovascular structures is critical in evaluating functional deficits that may be associated with sacral fractures. While displaced fractures can be easily diagnosed on high quality plain radiographs, nondisplaced or transverse fracture patterns may be difficult to diagnose without a computed tomography scan. Once identified, correct classification of a sacral fracture can facilitate ideal treatment strategies. Stable nondisplaced fractures are usually treated nonoperatively, while significantly displaced fractures require reduction and internal fixation. Surgical fixation techniques include percutaneously placed iliosacral screws, posterior sacral "tension band" fixation, and for certain fracture patterns osteosynthesis that incorporates the lower lumbar spine (lumbopelvic or triangular fixation). This article reviews the approach to sacral fracture diagnosis and management.
Thirteen patients with transverse fractures of the upper sacrum were studied to determine fracture anatomy, clinical presentation, and therapeutic approaches. The injury results from falls from a height and is usually associated with suicidal attempts by jumping. The position of the lumbar spine in lordosis or kyphosis at the time of impact determines which of three types of morbid anatomy will result. Because of associated polytrauma, fracture of the upper sacrum is often not recognized in the acute stage, and awareness of the possibility of such injury, especially in the presence of perineal neurologic deficit should result in securing good quality radiographic study, including tomograms. Surgical treatment is often required.
An unusual type of indirect isolated fracture of the upper sacrum is presented. The upper sacrum was markedly comminuted and nondisplaced relative to the lower fragment. There was a neurologic deficit present. On the basis of a review of the literature, a previous classification system and the actual fracture mechanism, this fracture is classified as a special type; type 4, or the neutral position fracture.
Sacral fractures, often undiagnosed and untreated, frequently result in neurologic symptoms and deficits to the lower extremities and urinary, rectal, and sexual dysfunctions. These same neurologic problems often remain the major chronic sequelae after the more obvious pelvic trauma lesion has healed. Specific treatments aimed at neurologic problems are available and may allow the patient functional recovery. This is illustrated by anatomic observations on the sacrum in 39 cadavers showing the relationship among sacral nerve roots within their foramina. These observations were valuable for a retrospective study of 236 consecutive patients with sacral fractures in a series of 776 patients with pelvic injuries. A new classification of sacral fractures evolved from this study and provided a better understanding of the mechanisms responsible for the associated neurologic symptoms. The classification is based on the direction, location, and level of sacral fractures. Three different zones were identified as having characteristic clinical presentations: Zone I, the region of the ala, was occasionally associated with partial damage to the fifth lumbar root. Zone II, the region of the sacral foramina, is frequently associated with sciatica but rarely with bladder dysfunction. Zone III, the region of the central sacral canal, is frequently associated with saddle anesthesia and loss of sphincter function. Routine pelvic roentgenograms were almost useless in identifying the pathologic process in sacral injuries with neurologic symptoms. Ferguson views, tomograms, and particularly computed tomography scans were crucial for understanding these injuries. Cystometrography was most helpful in positively identifying fractures causing neurogenic bladders. Cystometrograms should be ordered routinely in Zone III injuries. Preliminary observations suggest that surgical decompression permitted significantly better neurologic recovery than nonsurgical methods.
The sacral spine has received relatively little attention in the orthopedic and neurosurgical literature, in part because of the infrequency of developmental, degenerative, or neoplastic conditions of the sacrum requiring surgical intervention. This neglect is unwarranted in trauma, however, because sacral fracture and its associated neural deficit are both common and often complex problems. The sacrum and pelvis behave as a single functional unit; an understanding of the principles of sacropelvic stability has obvious relevance in planning the occasional resection of a sacral tumor and in dealing with the common problem of massive pelvic trauma. A classification of sacral fractures is reviewed along with the usual patterns of neurological involvement. Through analysis of an institutional series of cases, a specific attempt is made to correlate varying types of vertical sacral fractures with differing types of pelvic injury. The radiographic and physiological investigation of sacral fractures is reviewed, as are the various options for achieving the reduction, decompression, and stabilization of sacral fractures.
The sacrum is the mechanical hub of the axial skeleton, serving as the base for the spinal column and keystone for the pelvic ring. Both surgical and nonsurgical options are available to treat sacral spine fractures; however, because these fractures are relatively rare and heterogeneous in nature and because there is little evidence-based literature, choosing the optimal treatment is challenging. The timing of intervention and the choice of surgical technique need to be determined on an individual basis, with the goal of producing the best outcome for the patient.
Spinopelvic fixation techniques are evolving and now seem to be converging. Good S1 pedicle fixation is the initial key anchor point. The tricortical technique tests out as the best. Supplemental fixation options are available. The most efficacious seems to be iliac fixation, followed by two-level structural interbody support. Achieving appropriate global sagittal balance also lessens the likelihood of implant pullout and places the fusion mass under relatively more compressive forces than tension forces. Regardless of the method of fixation, the ultimate determinant of long-term implant survival is the achievement of adequate biologic fusion.
Background context:
Transverse sacral fractures (TSFs) are an uncommon type of sacral fractures. They are classified as zone III sacral fractures, but often the fracture line involves the three zones of Denis classification. A classification of TSF has been described previously but it only includes high TSF, different types of injuries as low TSF or special types of TSF are not included in this classification. Some authors advocate conservative treatment and others advocate surgical treatment for these fractures. Because TSF is an uncommon entity, spine surgeons have limited experience treating this kind of injury and consequently, a well-designed treatment protocol for these fractures does not exist.
Purpose:
To review current principles in the evaluation, diagnosis, and treatment of TSFs.
Study design/setting:
A literature review on TSFs.
Methods:
A MEDLINE search in the English language literature was performed from 1975 to 2006. To be included in the study, it was strictly necessary for every case to provide information about the neurological status, type of treatment, and outcome. Articles in which this information was not properly mentioned were eliminated.
Results:
The literature searching yielded 29 articles reporting 90 patients experiencing TSF, all of them were case reports or case series. High TSF are more frequent than low TSF and usually are caused by high-energy accidents. Ninety seven percent of patients presented some type of neurological impairment ranging from radiculopathy to bowel-bladder disturbance (BBD). Regarding the treatment, the outcome was reported using different criteria and for this reason is not possible to definitively conclude what treatment modality is the best for the treatment of TSF; however, the information obtained from every case suggest that patients treated surgically have better outcomes regarding stability and neurological status.
Conclusions:
Even though both are TSF, high and low TSF have many different characteristics, the only common characteristic they share is the high incidence of cauda equina disturbance. Evidence suggests that the neurological outcome depends mainly on the anatomic characteristics of nerve roots under the fracture and severity of fracture's displacement.
Transverse fracture of the upper sacrum. Suicidal jumper's fracture. Spine (Phila Pa
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- G Saillant
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Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture
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