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Diagnosis and Management of Sacral Spine Fractures


Alexander R. Vaccaro, David H. Kim, Darrel S. Brodke, Mitchel Harris, Jens Chapman, Thomas Schildhauer, M.L.
Chip Routt and Rick C. Sasso
J Bone Joint Surg Am. 86:166-175, 2004.

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Selected

The American Academy of Orthopaedic Surgeons


Printed with permission of the D AVID L. H ELFET
American Academy of EDITOR, VOL. 53
Orthopaedic Surgeons. This article,
as well as other lectures presented C OMMITTEE
at the Academy’s Annual Meeting,
VINCENT D. PELLEGRINI J R.
will be available in March 2004 in CHAIRMAN
Instructional Course Lectures,
Volume 53. The complete D AVID L. H ELFET
volume can be ordered online D ONALD C. FERLIC
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calling 800-626-6726 J. L AWRENCE M ARSH
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E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

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Diagnosis and Management


of Sacral Spine Fractures
BY ALEXANDER R. VACCARO, MD, DAVID H. KIM, MD, DARREL S. BRODKE, MD, MITCHEL HARRIS, MD,
JENS CHAPMAN, MD, THOMAS SCHILDHAUER, MD, M.L. CHIP ROUTT, MD, AND RICK C. SASSO, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Determining the optimal treatment of the complexities of load transfer from tic approach to sacral fractures should
sacral fractures is a challenge for spine the mobile lumbar spine to the hips be a goal.
surgeons and traumatologists alike. and the added variables of regional
Because of the relative rarity and heter- ligamentous and muscle support1. Be- Sacral Anatomy
ogeneous nature of sacral fractures, cause of the traumatic comorbidities The sacrum provides the foundation for
individual surgeons have limited ex- in patients with a sacral fracture, any lumbar as well as pelvic ring alignment.
posure to these injuries and studies of attempt to formulate standardized A combination of intact osseous and lig-
sacral fractures have been largely retro- treatment approaches is challenging, amentous components is necessary to
spective in nature and have involved if not impossible. provide a sound weight-bearing plat-
nonhomogeneous or small treatment In a large retrospective study of form as well as protection for the lum-
groups. Few scientifically based insights sacral fractures, Denis et al. reported bosacral (L4-S1) and sacral (S2-S4)
can be gathered from the current litera- that the chance of identifying a sacral plexuses and iliac vessels. Transmission
ture in this field. fracture was increased by the presence of load on the trunk is distributed by the
The sacrum is the mechanical of an associated neurological injury2. first sacral segment through the iliac
nucleus of the axial skeleton, serving as An existing sacral fracture was correctly wings to the acetabulum on either side1.
the base for the spinal column as well identified in 76% of patients presenting Strong posterior lumbosacral and lum-
as the keystone for the pelvic ring. De- with a neurological deficit but in only boiliac ligaments stabilize the osseous
spite its mechanical importance, the 51% of neurologically intact patients. components of this transition zone,
transitional location of the sacrum be- Unrecognized and inadequately which is characterized by noncon-
tween the spine and the pelvis has re- treated sacral fractures may lead to strained articulations. The sacrum is a
sulted in its being relatively neglected painful deformity and progressive loss kyphotic structure with a sagittal angu-
by both spine surgeons and traumatol- of neurological function3. Delayed sur- lation ranging from 0° to 90°. This con-
ogists and in both specialties having in- gery for posttraumatic sacral defor- tributes to the sacral inclination angle of
complete experience with treatment of mity is complex, and the results are the superior end plate of S1, which then
this spinal region. often less favorable than those of early determines the compensatory lordosis
Biomechanical testing of the surgery4. Therefore, determination of of the lumbar spine. The thin posterior
sacrum has proven difficult because of an integrated diagnostic and therapeu- soft-tissue coverage of the sacrum, con-
sisting of a thin layer of multifidus
muscle and the lumbosacral fascia, has
Look for these related articles in Instructional Course Lectures, Volume implications in terms of the ability of
53, which will be published by the American Academy of Orthopaedic this area to withstand blunt trauma and
Surgeons in March 2004: tolerate bulky implant systems.
The sacral spinal canal is capa-
• “Cervical Spine and Spinal Cord Injuries: Recognition and Treat- cious and provides more than adequate
ment,” by Frank J. Eismont, MD, Bradford L. Currier, and Robert A. space for the cauda equina. Of the ante-
McGuire, MD riorly exiting sacral roots, S1 has pro-
portionally the least foraminal exit area,

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occupying up to one-third of the fora- cremasteric reflexes5. Female patients foraminal disruption12.
men. The lower sacral roots have pro- should undergo a vaginal examination Computed tomography is the
gressively more relative space, with the so that an occult open pelvic fracture is preferred modality for diagnosing sus-
S4 root occupying only one-sixth of the not missed. pected or known posterior injury of the
available anterior foraminal area5. The Pelvic ring stability can be tested pelvic ring. A dedicated sacral com-
anterior rami of the S2 through S5 roots manually by gently applied internal and puted tomography scan with 2-mm or
contribute to sexual function as well as external rotation of the iliac wings8. thinner cuts as well as sagittal and coro-
bowel and bladder control by provid- Lower-extremity push-and-pull tests nal reformatted views offers superior
ing parasympathetic innervation to the with supplemental radiographic docu- visualization of a disrupted sacrum and
bladder and rectum. The sympathetic mentation of pelvic shifting have been is especially useful for complex sacral
ganglia of the inferior hypogastric described but are not commonly fractures10. Because of termination of
plexus extend from the anterolateral L5 performed9. In patients who can walk, the thecal sac at the S1-S2 interspace,
and S1 vertebral bodies caudally to the the presence of mechanically related computed tomography myelography is
anterior surface of the sacrum along the low-back or buttock pain may indicate of limited usefulness. Sacral magnetic
medial margin of the anterior foramina a sacral insufficiency fracture. resonance imaging may be helpful for
of S2, S3, and S45. The posterior rami of patients presenting with unexplained
the sacral roots consist of small sensory Imaging sacral neurological deficits after
fibers, with contributions to the cluneal The ATLS (Advanced Trauma Life Sup- trauma. In an elective setting, magnetic
nerves. port) protocol for imaging in the set- resonance imaging can reveal sacral
ting of a suspected sacral fracture stress fractures or provide visualization
Evaluation includes an anteroposterior radiograph of the lumbosacral plexus. Technetium
Physical Examination of the pelvis10. Because of the inclina- bone scans enhanced with single-pho-
Approximately 30% of sacral fractures tion angle of the sacrum, however, only ton emission computed tomography is
are identified late6. Delayed diagnosis of limited visualization is possible with an effective imaging modality for iden-
these injuries can have a negative im- this view. Pelvic inlet and outlet radio- tifying posttraumatic arthritis as well as
pact on long-term outcome and can be graphs are recommended as additional insufficiency fractures.
avoided by a targeted clinical evalua- studies to improve visualization of the
tion. Sacral injury should be suspected sacrum in any patient with a suspected Electrophysiological Assessment
in any patient reporting peripelvic pain. pelvic ring injury6. The sacral spinal ca- Patients who have a sacral fracture and
Inspection and palpation of the entire nal and a superior view of S1 are seen a neurological deficit or a cognitive im-
body is necessary following high-energy clearly on the pelvic inlet radiograph. pairment can be effectively evaluated
blunt trauma, especially in the presence The pelvic outlet radiograph can usu- with a variety of electrodiagnostic tests.
of an altered sensorium. Lacerations, ally provide true anteroposterior visual- Perineal somatosensory evoked poten-
bruising, tenderness, swelling, and ization of the sacrum. The Ferguson tials and anal sphincter electromyogra-
crepitus are clear signs of a potential view is a centrally coned-down modifi- phy are useful for assessing patients
underlying injury. More specific signs cation of a pelvic outlet view directed with a possible neurological deficit re-
suggesting possible sacral injury include perpendicular to the sacral inclination lated to sacral injury or as a monitoring
a posterior sacral osseous prominence to allow en face visualization of the en- tool during surgical intervention. Elec-
or a palpable subcutaneous fluid mass tire sacrum. The lateral sacrum view is a trodiagnostic evaluation can also be
consistent with lumbosacral fascial de- simple yet effective radiographic study used to differentiate upper motor neu-
gloving (Morel-Lavelle lesion)7. for screening and assessing sacral inju- ron lesions from spinal cord injury con-
Although rectal examination is ries, even in obese patients11. It should current with sacral trauma or for
a standard component of the evalua- be kept in mind that radiographic land- patients with an injury to the lower part
tion of a patient who has sustained marks may be obscured in a patient of the urinary tract, for whom neuro-
traumatic injury, patients with a sus- with osteopenia or lumbosacral dys- logical evaluation may be difficult5. Cys-
pected sacral fracture should also un- morphism, and the diagnosis may be tometrography performed with
dergo functional assessment of the delayed or missed altogether. sphincter electromyography and post-
lower sacral roots, including determi- Nork et al. identified several ra- voiding residual measurements can be
nation of spontaneous and maximum diographic indicators of potential sac- used as a follow-up test for patients
voluntary rectal sphincter contrac- ral fractures, including a fractured L5 with a neurogenic bladder. However,
tion, checking for the presence of light transverse process (found in 61% of pa- electromyography is not as useful in the
touch and pinprick sensation along tients with a sacral fracture), a paradox- acute setting, as abnormalities may take
the perianal concentric dermatomes ical pelvic inlet view found on supine several weeks to emerge.
of S2 through S5, and elicitation of anteroposterior radiographic projec-
specific reflexes including perianal tions (92% of patients), and a steplad- Classification
wink and the bulbocavernosus and der sign indicative of anterior sacral A perplexing number of classification

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tunately, the issue of defining stability


with respect to the pelvic ring remains
largely unresolved. Because of the pelvic
Fig. 1-A ring’s strong dependence on ligamen-
Figs. 1-A through 1-D Sys- tous support, any posterior ligamentous
tems for classification of sac- disruption of the pelvic ring is likely to
ral fractures. Fig. 1-A The be unstable. By convention, any sacral
three-zone system of Denis et or posterior pelvic fracture-displace-
al.2. Zone-I injuries are entirely ment of ≥1 cm is considered to be un-
lateral to the neuroforamina, stable. A three-stage system of stability
zone-II fractures involve the classification has been proposed for sac-
neuroforamina but do not in- ral injuries. With this system, stage A
volve the spinal canal, and indicates an osseoligamentous injury
zone-III injuries extend into the with retention of structural function;
spinal canal with primary or stage B, an occult osseoligamentous
associated fracture lines. disruption; and stage C, an obvious
complete osseoligamentous disruption.
Differentiation between stage-A and
B injuries can be very difficult and
systems have emerged to describe sac- cal deficit is a major determinant of a may require provocative tests, such as
ral injuries over the last decade (Figs. patient’s ultimate quality of life. Poten- weight-bearing and traction studies,
1-A through 1-D)8,13-15. A systematic tial neurological injuries in patients or repeated imaging over time. Descrip-
conceptual approach, rather than an with a sacral fracture include those in- tive systems for classification of pelvic-
extensive review of the various classifi- volving the cauda equina, the lum- sacral trauma have been put forth by
cation concepts, will be discussed. Five bosacral plexus, the sacral plexus, and several investigators including Tile8,
basic principles must be followed when the sympathetic and parasympathetic Denis et al.2, Roy-Camille et al.18, Strange-
assessing a sacral injury. chains. All neurological injuries can be Vognsen and Lebech19, and Isler20.
Presence of active bleeding: Sacral subclassified as complete or incomplete Systemic injury load: The cumula-
fractures may be associated with life- with the American Spinal Injury Asso- tive injury load or degree of force im-
threatening injuries to the iliac vessels, ciation (ASIA) classification system. pact sustained by the patient has
anterior perisacral venous plexus, or su- Pattern and stability of skeletal considerable short and long-term im-
perior gluteal artery. Determination of injury: Determination of structural plications for treatment and outcome.
hemodynamic stability is crucial. stability is a crucial component of the Certain patients or fractures may not be
Presence of an open fracture: The description of a sacral fracture. Unfor- amenable to surgical intervention. Also,
presence of an open sacral fracture sub-
stantially affects treatment and prog-
nosis. The majority of open sacral
fractures fall into the Type III-A cate-
gory according to the Gustilo-Anderson
system16. More substantial open inju-
ries include those with violation of the
rectal or vaginal vault or fracture con-
tamination from an accompanying uro-
genital injury. A variant of a true open
fracture is an extensive lumbosacral fas-
cial degloving injury similar to that de-
scribed in Morel-Lavelle syndrome14.
Technically, these injuries are closed,
but it is a substantial challenge to treat Fig. 1-B
them because of the severity of the soft- Subclassification of Denis zone-III fractures as suggested by Roy-Camille
tissue trauma. Grading of closed soft- et al.18 and modified by Strange-Vognsen and Lebech19 . From left to right:
tissue injuries has been well described Type-1 injuries are angulated but not translated, type-2 injuries are angu-
in the four-stage system of Tscherne17, lated and translated, type-3 injuries show complete translational dis-
and this system can be extrapolated to placement of the cephalad and caudad parts of the sacrum, and type-4
closed sacral soft-tissue injuries. injuries are segmentally comminuted as a result of axial impaction.
Neurological injury: A neurologi-

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and unstable zone-II injuries because


malunions in this area are associated
Fig. 1-C
with very poor functional outcomes.
Examples of complex sacral De-
Vertical shear injuries are considered to
be highly unstable zone-II fractures.
nis zone-III fractures2. The frac-
Any sacral fracture involving the
ture on the top left is frequently
spinal canal is classified as a zone-III in-
referred to as the “H” type, and
jury. This fracture subtype was encoun-
the one on the top right is the
tered the least frequently (in only 16%
sacral “U” type. The bottom row
of the patients in the study by Denis et
shows two of many other com- al.2) but was associated with the highest
plex fracture variations. On the prevalence and severity of neurological
left is a sacral “lambda” frac- injury, which affected 57% of the pa-
ture, and on the right is a sacral tients. Bowel and bladder control or
“T” fracture. sexual function was impaired in 76%
of the patients with a neurological in-
jury in this group.
Two additional factors to con-
sider are whether the injury is bilateral
and the axial level of the fracture. Pa-
tients with a transverse sacral fracture
a metabolically impaired patient with L4 and L5 nerve roots. involving the S1, S2, or S3 segment
multiple insufficiency fractures may not Zone-II fractures are the second tend to have a higher prevalence of
be amenable to surgical intervention. most common pattern, accounting for bladder dysfunction than do those with
These five basic principles of sac- 34% of the injuries in the study by Denis a more caudad sacral fracture affecting
ral fracture assessment provide the et al.2. These injuries consist of a vertical the S4 or S5 segment. It should be kept
treating physician with a sound funda- transforaminal fracture without involve- in mind that bilateral zone-I or II inju-
mental understanding of the nature of ment of the sacral spinal canal. An asso- ries are extremely uncommon and, on
the injury and facilitate communication ciated neurological injury is found in closer inspection, are usually associated
with other care providers. 28% of patients, and it most frequently with an unrecognized zone-III injury
The Denis three-zone classifica- affects the L5, S1, or S2 nerve root. It is and an obscure transverse fracture line.
tion system for sacral fractures was in- important to distinguish between stable The zone-III sacral fractures de-
troduced in 1988 and is based on
fracture anatomy (Fig. 1-A)2. Denis et
al. performed an eleven-year retrospec-
tive review of the cases of 236 patients
and determined that medial fracture Fig. 1-D

excursion was closely associated with Classification of injuries at the lum-


both injury mechanism and prevalence bosacral junction, as suggested by
of neurological injury. Due to its clarity Isler20. Type-A injuries are lateral to
and reproducibility, this remains the the L5-S1 facet joint and may affect
standard system for classification of pelvic ring stability but not lum-
sacral fractures. bosacral stability. Type-B injuries
Zone-I fractures are the most extend through the L5-S1 facet
common, accounting for 50% of the joint and are associated with a vari-
fractures in the series described by ety of displacements and neurologi-
Denis et al.2. Zone-I fractures mainly cal injuries. Type-C injuries violate
involve the sacral ala, with possible ex- the spinal canal, are invariably un-
tension into the sacroiliac joint. By defi- stable, and usually are complex.
nition, zone-I fractures occur lateral to
the sacral foramina. The fractures can
be subdivided into stable and unstable
injuries, according to the three-stage se-
verity system discussed above. Neuro-
logical injury occurs in approximately
6% of patients and typically involves the

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tion of the S1 vertebral body caused by


axial loading of the lumbar spine into
the cephalad part of the sacrum.

Injury at the Lumbosacral Junction


Injury at the lumbosacral junction is
an important, albeit incompletely un-
derstood, category of sacral injury. The
lumbosacral ligaments are quite strong,
so patients presenting with an injury in
this transitional zone have usually sus-
tained very high-energy trauma.
Like cervical spine injuries, lum-
bosacral injuries can be viewed conceptu-
ally as unilateral or bilateral dislocations,
with or without accompanying fractures.
Fig. 2-A
Displacement can vary from lumbosac-
Figs. 2-A, 2-B, and 2-C Sacroiliac fixation and foraminotomy. Fig. 2-A A pel- ral subluxation to complete lumbopelvic
vic computed tomography scan demonstrating a Denis zone-II transforami-
dissociation. Isler proposed a system for
nal sacral fracture in a twenty-four-year-old woman who was injured in a
assessing lumbosacral injury on the basis
of the location of the pelvic ring fracture
motor-vehicle collision. The patient was found to have a dense S1 radiculop-
relative to the L5-S1 facet joint (Fig. 1-
athy on the side of the fractured ala. The computed tomography scan shows
D)20. A vertical sacral fracture lateral to
a large cortical fragment obstructing the S1 foramen.
the L5-S1 facet joint is unlikely to have
an impact on lumbosacral stability but
scribed by Denis et al. have been subclas- tures are the least severe and demonstrate may affect pelvic ring stability. Fractures
sified by Roy-Camille et al.18, with further a simple flexion deformity of the sacrum. crossing through the L5-S1 facet joint can
modification by Strange-Vognsen and Type-2 injuries are partially translated as be differentiated as extra-articular frac-
Lebech19. With use of that system, injury well as hyperkyphotic. Type-3 injuries tures of the lumbosacral junction and ar-
severity, likelihood of neurological injury, display complete translation with no ticular dislocations with various stages
and therapeutic implications are directly fracture overlap, and type-4 injuries, of displacement of the L5 and S1 articu-
related to increasingly severe injury types as described by Strange-Vognsen and lar processes. Fractures crossing into the
(1 through 4) (Fig. 1-B). Type-1 frac- Lebech, consist of segmental comminu- neural arch medial to the L5-S1 joint are

Fig. 2-B Fig. 2-C


Fig. 2-B An attempt was made to achieve an indirect foraminal decompression in addition to accomplishing posterior stabilization of the pelvic ring
with early closed reduction and a percutaneously placed sacroiliac screw. There was no improvement of the S1 radiculopathy. Fig. 2-C After there
was no neurological improvement in the first forty-eight hours postoperatively, the decision was made to perform an early decompression of the S1
foramen. This was done under fluoroscopic guidance with a focal hemilaminotomy. Satisfactory decompression was confirmed on the postoperative
computed tomography scan.

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usually complex and inherently unstable, Options for pelvic reduction include ever treatment involves prolonged
necessitating stabilization. temporary skeletal traction, applica- recumbency, it is necessary to address
Spinal cord injuries have been tion of an anterior external fixator, the potential dangers of thromboembo-
classifed in a methodical fashion by the placement of a pelvic clamp, or use lism, pulmonary complications, and
American Spinal Injury Association of a wrap-around sheet. In the acute skin breakdown. Countermeasures may
partly on the basis of the original work posttraumatic setting, the goal is to include prophylactic anticoagulation
of Frankel5. This system, however, incom- achieve a noninvasive form of pelvic and pneumatic compression boots as
pletely addresses sacral injuries and the reduction and volume reduction and well as utilization of a spinal injury bed
greater variability of neural deficits aris- to minimize additional blood loss22. such as the Roto Rest bed (Kinetic Con-
ing from root injuries. Gibbons et al. cepts, San Antonio, Texas). Vigorous
designed a useful four-stage system spe- Nonoperative Management pulmonary toilet to prevent atelectasis
cifically to grade sacral neurological in- Nonoperative care consists mainly of ac- and pneumonia should also be insti-
juries21, but unfortunately this system has tivity modification aimed at preventing tuted. Repeat imaging studies should
not come into common usage. The stages further fracture displacement. This may be performed to verify that fracture-
of the system consist of 1 (no injury), 2 consist of prolonged bed rest in skeletal healing is proceeding with satisfactory
(paresthesias only), 3 (motor loss but traction, bed rest in a brace or cast with alignment. Progressive fracture dis-
bowel and bladder control intact), and 4 a unilateral or bilateral hip spica (i.e., placement, deterioration of neurologi-
(impaired bowel and/or bladder control). pantaloon spica), brace immobilization cal function, or persistent pain with
(with a thoracolumbar spinal orthosis attempts at mobilization may indicate
Treatment with a hip spica) with protected weight- failure of conservative treatment. As a
Early Management bearing, or early mobilization with pro- result of the high cost of labor-intensive
Early treatment of substantial unstable tected weight-bearing. care necessary for nonoperative man-
sacral injuries may include temporary The typical time frame for heal- agement, these strategies have largely
reduction of a displaced pelvic ring ing of a posterior pelvic ring fracture is fallen out of favor for the treatment of
fracture and interventional radiologi- two to four months. This allows for a patients with unstable injuries.
cal techniques such as angiographic transitional period of protected weight- Indications for nonoperative
embolization of bleeding pelvic vessels. bearing for one to two months8. When- management are vague and historically

Fig. 3-A Fig. 3-B


Figs. 3-A and 3-B Technique of iliolumbar fixation. Fig. 3-A Following lumbar pedicle screw fixation, iliac screws are placed
in a perpendicular trajectory parallel to the inclination angle of the outer table of the ilium. A suitable starting point is pre-
dictably located over the inferomedial aspect of the posterior superior iliac spinous process, with a trajectory leading 1 cm
above the iliac notch. The anterior target area lies in the region of the anterior inferior iliac spinous process. Visualization of
the outer iliac table and the sciatic notch as well as fluoroscopic guidance with a true lateral projection can be helpful tech-
nical aids. Fig. 3-B The final assembly, shown here with two iliac screws on either side, provides unparalleled stability.

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order to facilitate rehabilitation22. How-


ever, we are not aware of any meaning-
ful studies comparing the results of
operative and nonoperative treatment.

Surgical Decision-Making
Surgical intervention for patients with a
sacral fracture should incorporate clear
and realistically attainable goals, includ-
ing fracture stabilization and lumbosac-
ral realignment, optimization of the
chances for neurological recovery, ade-
quate débridement of open injuries and
compromised soft tissues, and minimi-
zation of additional morbidity.
Surgical options range from min-
imally invasive techniques to formal
Fig. 4-A open reduction and internal fixation.
Figs. 4-A through 4-D Lumbosacral fracture fixation in a forty-eight-year-old Techniques for neural decompression
woman who sustained multiple traumatic injuries. Fig. 4-A The patient was in- include laminotomy and foraminot-
jured in a hang gliding accident. The multiple injuries included a closed head omy, anterior bone disimpaction, and
injury, blunt torso and abdominal injuries, an open tibial fracture, and the De- lumbosacral plexus neurolysis. Ante-
nis zone-III, Roy-Camille type-2 sacral fracture shown here. The patient was rior sacral and pelvic stabilization tech-
found to have absent anal sphincter tone and to be areflexic. A computed axial niques involve various methods of
tomography scan confirmed severe posterior disruption of the pelvic ring with anterior stabilization of the pelvic ring
foraminal compression of the S2 and S3 segments. Pudendal somatosensory (e.g., application of a sacroiliac plate).
evoked potentials confirmed the presence of a severe sacral plexus injury. Posterior stabilization techniques in-
clude percutaneous sacroiliac screw fix-
have included nearly all sacral fracture objective evidence of neural compres- ation, bilateral sacroiliac screw fixation
patterns. Contraindications to nonop- sion, and extensive disruption of the with posterior tension-band plate fixa-
erative care are relative but include frac- posterior lumbosacral ligaments. Pa- tion, posterior alar plate fixation, and
tures with soft-tissue compromise, an tients with multiple injuries often bene- lumbopelvic segmental fixation.
incomplete neurological deficit with fit from timely surgical intervention in The timing of any surgical inter-

Fig. 4-B Fig. 4-C Fig. 4-D


After initial stabilization, posterior decompression and stabilization with lumbopelvic instrumentation was performed on the third day following the
injury. At the time of writing, the patient was able to walk without pain and had recovered normal voluntary bowel and bladder control, but she re-
ported diminished sexual function.

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vention should be chosen on the basis of Similarly, reconstruction of nerve roots surgical exposure. The vast majority of
treatment goals, the patient’s general with avulsion injuries is currently impos- sacral injuries can be effectively treated
medical status, and the invasiveness of sible. Traumatically transected roots are with posterior percutaneously based
the surgical procedure. Overly aggres- commonly associated with Denis zone- approaches. The role of external fixa-
sive early surgery can lead to unaccept- III injuries with Roy-Camille type-3 dis- tion, once a popular form of treatment
able intraoperative blood loss, soft-tissue placement. Avulsions of the lumbopelvic for a variety of pelvic fractures, is now
breakdown, and infection7. On the other plexus are associated with severely dis- limited to the emergent management
hand, delayed decompression of neural placed zone-II injuries, such as the so- of pelvic ring disruptions and to use as
elements beyond two weeks may ad- called vertical shear fracture. Surgery supplemental treatment devices for an-
versely affect chances for neurological should be considered if there is a reason- terior pelvic ring instability.
recovery2. Most minimally invasive pro- able chance of restoring even unilateral The need for anterior stabiliza-
cedures require early closed reduction lower sacral root function because such tion of the pelvic ring should be consid-
and are limited in terms of the amount function is sufficient for voluntary bowel ered before embarking on any posterior
of reduction that is attainable and the and bladder control24. lumbosacral procedure. Frequently, the
overall biomechanical stiffness of the An acceptable approach to early anterior pelvic ring injury can be re-
construct. Ultimately, when the treat- management of sacral injuries is an at- aligned and stabilized through limited
ment is being chosen, the advantages tempt at minimal reduction and stabili- measures such as anterior plate fixation,
and drawbacks of each approach should zation. The adequacy of reduction is then external fixation, or the use of retro-
be carefully weighed; a stereotyped ap- assessed with computed tomography grade pubic screws. This can provide
proach to all injuries should be avoided. combined with repeat neurological and protection for the pelvic ring during a
possibly electrodiagnostic examination procedure performed with the patient
Decompression Techniques to characterize persistent neurological prone and can aid in reduction of the
Neurological injuries from sacral frac- deficits. In the presence of satisfactory posterior part of the pelvic ring.
tures range from incomplete monoradic- skeletal stabilization but persistent neu- Posterior fixation ideally offers
ulopathies to a complete cauda equina roforaminal or spinal canal compromise, a high degree of mechanical construct
syndrome3. Sacral roots subjected to con- a focal limited decompression may be stiffness while producing a low implant
tusion, compression, or traction caused performed within the first two weeks af- profile that minimizes the risk of poste-
by angulation, translation, or direct com- ter injury, with use of a limited midline rior soft-tissue breakdown. Sacroiliac
pression have a theoretical chance of re- exposure and fluoroscopy-guided focal screws, initially described for injuries
covery. Neural recovery of transected or laminectomy6. of the sacroiliac joint, can be used for
avulsed sacral nerve roots is unlikely. An attempt should be made to re- stabilization of a variety of sacral frac-
Given an overall rate of neurologi- pair any dural tears that are encountered tures as well (Figs. 2-A, 2-B, and 2-C).
cal improvement of approximately 80% to minimize the chances of a pseudo- They can be placed, with the patient ei-
regardless of treatment, the indications meningocele developing. Patients pre- ther supine or prone, with use of con-
for and timing of surgical decompres- senting with a severely displaced fracture ventional c-arm imaging and through
sion in patients with neurological injuries that is unsuitable for closed reduction a percutaneous approach. The inser-
are somewhat controversial. From a neu- and percutaneous stabilization should be tion of sacroiliac screws with the guid-
rophysiological standpoint, decompres- considered for a comprehensive poste- ance of computed tomography imaging
sion of compromised neural elements is rior decompression and stabilization is of limited use: it is helpful only for
preferably performed early, within the procedure with use of the most appro- the treatment of displaced fractures in
first twenty-four to seventy-two hours priate stabilization methods available. a multiply injured patient. The safety
following injury5. This can be accom- of percutaneously placed sacroiliac
plished indirectly with fracture reduc- Surgical Stabilization Techniques screws has been established in several
tion or directly with a laminectomy. Early Stabilization of sacral fractures has large clinical series and has gained
surgical decompression may be associ- evolved from largely improvised use of considerable acceptance within the
ated with an increased risk of hemor- plates and hooks to the use of specifi- traumatology community6,9,12. Potential
rhage and wound-healing complications cally designed implant systems incorpo- drawbacks of this technique include
due to soft-tissue contusion and possibly rating cannulated long large-fragment limited biomechanical strength, reli-
to cerebrospinal fluid leak. Surgical de- screws or segmental lumboiliac rod- ance on closed reduction techniques
compression as an isolated procedure— and-screw fixation systems1. A major that may be inadequate, and lack of
i.e., without stabilization—is rarely in- goal of surgical intervention is to re- availability of a suitable image intensi-
dicated. Surgical decompression may store the stability of the lumbosacral fier. Injury to neural, vascular, and in-
be less useful in patients with transected articulation. Anterior approaches to testinal structures as a result of drill or
sacral roots. Huittinen found a 35% prev- the sacrum for decompression or inter- screw penetration has been described as
alence of root transection in a postmor- nal fixation have substantial approach- a rare complication. The risks of this
tem study of transverse sacral fractures23. related morbidity and provide limited surgical technique primarily consist of

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loss of fracture reduction and fixation cept of the Galveston technique but of two patients treated surgically. Simi-
in a malreduced position. Percutane- enhances it by allowing placement of larly, lower-extremity motor improve-
ous placement of sacroiliac screws may multiple large bicortical screws11. ment was found in four of six patients
be contraindicated in patients with Lumboiliac fixation allows com- treated nonoperatively compared with
anomalous transitional lumbosacral plete neurological decompression as three of four treated surgically.
anatomy or when closed fracture re- needed and can enhance the surgeon’s Denis et al. reported no improve-
duction cannot be accomplished9. Po- ability to perform an open reduction ment of bowel or bladder control in three
tential indications for percutaneous of a displaced sacral vertebral body. patients in whom a transverse sacral frac-
placement of sacroiliac screws include Supplemental internal fixation can be ture had been treated nonoperatively2. In
a Denis zone-I, II, or III sacral fracture, achieved with sacroiliac screws to main- contrast, all of five patients treated surgi-
which can be adequately reduced in a tain fracture reduction while the lum- cally had complete return of sphincter
closed fashion. Denis zone-III, Roy- boiliac fixation is applied. Because of control. Fountain et al. noted improve-
Camille type-2, 3, or 4 injuries are less the immediate stability conferred by ment of bowel and bladder control in five
amenable to this form of fixation as a lumboiliac fixation, most patients can patients treated surgically, whereas the
stand-alone device because of the in- walk with weight-bearing as tolerated one patient treated nonoperatively had
ability to reduce these injuries by closed without the use of a brace. spontaneous improvement26. Sabiston
means. Similarly, fixation of highly dis- and Wing generally recommended non-
placed zone-II fractures (vertical shear Results of Treatment operative care in a series of thirty-five
injuries) with this method is very chal- The results of the treatment of sacral patients with a sacral fracture, and they
lenging. Zone-II fractures with seg- fractures have been infrequently re- found no improvement of bowel and
mental comminution are susceptible ported and often poorly documented. bladder control in only one patient with
to overcompression and secondary fo- Aside from the retrospective multicenter a complete cauda equina syndrome who
raminal entrapment when an iliosacral study by Denis et al.2, most studies have was treated nonsurgically15.
compression screw is used. Such inju- been of small cohorts and have had con-
ries may be considered for fixation with siderable selection bias. The severity of Instrumentation Procedures
two static sacroiliac screws or for ili- the neurological injury frequently is not Nork et al. reported successful results
olumbar segmental fixation12. quantified or differentiated. Surgical of percutaneous sacroiliac screw fixation
Open reduction of the posterior techniques and timing of intervention in thirteen patients with a Denis zone-
aspect of the pelvic ring with plate fixa- have been highly variable or not re- III, Roy-Camille subtype-1 or 2 fracture
tion and screw insertion into the sacral ported. Investigators assessing the effi- and no substantial neurological deficit12.
ala, as described by Roy-Camille et al.18, cacy of neurological decompression in No deterioration of the sacral kyphosis
is an infrequently used strategy. The ap- patients with sacral fractures usually angle was found despite the fact that the
plication of vertically aligned plates on have not reported the severity or type posttraumatic deformity was stabilized
the posterior aspect of the sacral ala with of preoperative and postoperative neu- without aggressive attempts at reduc-
anteroposterior small-fragment screw rological injury. Outcomes measures tion. In one patient, it was necessary to
fixation is also of limited value because such as persistent pain and pelvic insta- revise the hardware because of disen-
of the frequent presence of comminu- bility rarely have been evaluated in a sys- gagement of a single iliosacral screw. Six
tion and osteopenia at the fracture site1,18. tematic fashion. patients presenting with L5 or S1 incom-
Use of a posterior iliac tension-band plete radiculopathy had a decrease in the
plate as a supplemental internal fixation Decompression Surgery symptoms without the need for neural
method with sacroiliac screw fixation Establishing the benefits of decompres- decompression. On the basis of their ex-
can facilitate open fracture reduction sion over a nonoperative approach in perience, the authors recommended in-
and enhance biomechanical stiffness25. neurologically impaired patients is dif- sertion of bilateral midline-crossing
However, it requires a posterior two- ficult. Neurological improvement rates sacroiliac screws when the technique is
incision approach, which has been of up to 80% are frequently quoted, re- used to treat a zone-III “H” or “U” frac-
associated with an increased rate of gardless of the type of operative or non- ture configuration.
wound-healing complications. operative management. Using a cadaveric model, Schild-
From a biomechanical perspec- In a retrospective study of forty- hauer et al. demonstrated that segmen-
tive, the most stable method of lum- four patients, Gibbons et al. reported tal lumbopelvic fixation provided
bosacral fixation involves the use of neurological improvement in eleven of substantially better stiffness than did a
lower lumbar pedicle screw fixation fifteen patients treated nonoperatively dual sacroiliac screw construct11. They
and iliac screw fixation with longitudi- compared with seven of eight patients reported clinically successful results of
nal and transverse rod connections to managed surgically21. Four of six pa- lumbopelvic fixation in their series of
facilitate fracture reduction (Figs. 3-A tients with loss of bowel and bladder thirty-four patients with a vertically un-
through 4-D). The technique of iliac control had improvement after nonop- stable zone-I or II fracture. Ninety-one
screw placement follows the basic con- erative treatment compared with two percent of the patients were found to

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THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG DIAG NOSIS AND MANAGEMENT OF
VO L U M E 86-A · N U M B E R 1 · J A N U A R Y 2004 S A C R A L S P I N E F R A C T U RE S

have fulfilled the authors’ standards for not been resolved conclusively. The tim- Orthopaedic Services, Harborview Medical
a stable fracture union. They reported a ing of intervention and the optimal sur- Center, 325 North Avenue, Seattle, WA 98104
9% rate of complications, which con- gical techniques need to be determined
Thomas Schildhauer, MD
sisted of wound-healing problems and on an individual basis with the potential Chirurgische Klinik und Poliklïnïk, BG-
a 3% prevalence of iatrogenic radicu- benefits of early neural decompression, Kliniken Bergmannsheil, Ruhr-Universität
lopathy. With use of the same concept skeletal stabilization, and patient mobili- Bochum, Bürkle-de-la-Camp-Platz 1, Bo-
but a different implant configuration, zation weighed against the risks of sur- chum D-47789, Germany
Abumi et al. treated seven patients with gery, such as blood loss, infection, and
a vertically and rotationally displaced anesthesia-related complications. Rick C. Sasso, MD
zone-I or II pelvic ring injury with bi- Indiana Spine Group, 8402 Harcourt Road,
Suite 400, Indianapolis, IN 46260-2074
lateral S1 screw fixation and a transverse
rod connection attached to a Galveston- Alexander R. Vaccaro, MD
Rothman Institute, 925 Chestnut Street, The authors did not receive grants or outside
type rod extension into the ilium on the funding in support of their research or prepa-
Philadelphia, PA 19107. E-mail address:
injured side27. Satisfactory healing was alexvaccaro3@aol.com ration of this manuscript. They did not receive
reported in six of the seven patients. payments or other benefits or a commitment
Complications included one deep David H. Kim, MD or agreement to provide such benefits from a
wound infection and one unresolved The Boston Spine Group, 125 Parker Hill commercial entity. No commercial entity paid
Avenue, Boston, MA 02120 or directed, or agreed to pay or direct, any
neurological deficit.
benefits to any research fund, foundation,
Darrel S. Brodke, MD educational institution, or other charitable or
Overview University of Utah, 30 North 1900 East, 3B165, nonprofit organization with which the authors
Assessment and treatment of thora- Salt Lake City, UT 84132 are affiliated or associated.
columbar and sacral fractures has im-
proved considerably as a result of Mitchel Harris, MD Printed with permission of the American
advances in general trauma management Department of Orthopaedic Surgery, Wake Academy of Orthopaedic Surgeons. This
Forest University Baptist Medical Center, article, as well as other lectures presented at the
and diagnostic modalities. Surgical tech-
Medical Center Boulevard, Winston-Salem, Academy’s Annual Meeting, will be available in
niques have evolved substantially over the NC 27157-1070 March 2004 in Instructional Course Lectures,
past ten years as well. However, several Volume 53. The complete volume can be or-
basic issues, such as the appropriate roles Jens Chapman, MD dered online at www.aaos.org, or by calling
of operative and nonoperative care, have M.L. Chip Routt, MD 800-626-6726 (8 A.M.-5 P.M., Central time).

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