Delayed Recognition of Lumbosacral Fracture Dislocations in the Multitrauma Patient: The Triad of Transverse Process Fractures, Unilateral Renal Contusion and Lumbosacral Fracture Dislocation

Traumatic lumbosacral instability: part 1 - proposing a definition and identifying underlying injury patterns

Traumatic lumbosacral instability (TLSI) generally refers to a traumatic disruption of the lumbopelvic junction. The ambiguous use of this term has contributed to confusion and limited understanding of injuries that can impact lumbosacral stability. As of now, TLSI lacks a clear definition, and the underlying injury patterns remain inadequately characterized. Therefore, the objectives of the first part of this two-part series are: (1) to establish a precise definition of TLSI, (2) to identify and systematically characterize the injury patterns underlying TLSI, and (3) to outline principles for diagnosing and classifying these underlying conditions.

Traumatic Lumbosacral Dislocation: Current Concepts in Diagnosis and Management

Traumatic lumbosacral dislocation is a rare, high-energy mechanism injury characterized by displacement of the fifth lumbar vertebra in relation to the sacrum. Due to the violent trauma typically associated with this lesion, there are often severe, coexisting injuries. High-quality radiographic studies, in addition to appropriate utilization of CT scan and MRI, are essential for proper evaluation and diagnosis. Although reports in the literature include nonoperative and operative management, most authors advocate for surgical treatment with open reduction and decompression with instrumentation and fusion. Despite advances in early diagnosis and management, this injury type is associated with significant morbidity and mortality, and long-term patient outcomes remain unclear.

SACRECTOMY ASSOCIATED WITH VERTEBRECTOMY: A NEW TECHNIQUE USING DOWEL GRAFTS FROM CADAVERS

Objective:

The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver.

Study design:

Report of a case series with description of a new surgical technique.

Methods:

The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used.

Results:

In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively).

Conclusion:

The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.

A Levering Technique Using Small Parallel Rods for Open Reduction of High-Grade Thoracolumbar Dislocation

STUDY DESIGN

Technical report.

OBJECTIVE

Dorsolumbar vertebral dislocations, with or without associated fractures, occur secondary to very high velocity trauma. The reduction procedures and techniques, which may be adopted in these situations, have been multifariously discussed in the literature. Our objective was to assess the outcome of a novel reduction maneuver, using parallel rods which we have employed in reduction of high-grade thoracolumbar fractures to achieve precise sagittal balance as well as accurate vertebral alignment with minimal soft tissue damage.

METHODS

The study included a total of 11 cases of thoracolumbar dislocations, who had presented to our emergency spine services following high-velocity trauma. After appropriate systemic stabilization and necessary investigations, all patients were surgically treated using the described technique.

RESULTS

There were no surgical complications at 2-year follow-up. Radiographs showed good reduction and maintained sagittal balance.

CONCLUSION

We believe that this technique is an excellent means of achieving safer, easier, and accurate reduction for restoration of sagittal/coronal balance and alignment in high-grade thoracolumbar dislocations. It is easily reproducible and predictable.

Unilateral lumbosacral dislocation: case report and a comprehensive review

Lumbosacral fracture-dislocation is a rare occurrence. There are more than 73 cases reported in the English literature. We report on the imaging findings and surgical treatment in a patient suffered of unilateral traumatic L5-S1 dislocation associated with severe disruption of the posterior ligamentous complex. The patient underwent open reduction and stabilization of L4-S1 vertebrae with posterior instrumentation system. Open reduction and internal fixation was mandatory as post-traumatic ligamentous insufficiency would lead to abnormal motion. Operative treatment managed to produce a solid arthrodesis and restore stability of the lumbosacral junction. Follow-up revealed excellent results. This study reports a rare injury of the lumbosacral junction, and the literature concerning this unusual condition is extensively reviewed.

Open Reduction without Fusion of Bilateral Jumped Lumbosacral Facet Dislocation Associated with Symphysis Pubis Separation and Cauda Equina Syndrome: Case Report

This paper reports a rare case of a lumbosacral dislocation associated with symphysis pubis separation and cauda equina syndrome. A 39-year-old male who diagnosed traumatic lumbosacral dislocation underwent an open reduction without fusion. After an open reduction and internal fixation of a symphysis pubis separation, a missed lumbosacral dislocation was diagnosed and an open reduction was performed without fusion. Due to the symphysis pubis separation, the patient was not allowed weight bearing for 3 months, which then began from wheel chair ambulation. At the 6-month follow up evaluation, there was no back pain but the patient reported mild S1 nerve root sensory symptoms. Lumbosacral dislocation is common in high energy polytrauma patients and can be misdiagnosed. However, prompt reduction without fusion is a good alternative treatment.

Lumbosacral dislocation: a review of the literature and current aspects of management

Lumbosacral fracture dislocation is a very rare lesion and was first described by Watson-Jones in 1940. Two anatomical classifications are described in the literature, all other reports are case presentations. This fracture type is characterised by an antero- or retrolisthesis or a lateral translation of the 5th lumbar vertebra in relation to the sacrum. Biomechanics are discussed controversially. Most patients suffer from a high energy trauma with concomitant severe injuries. There is a high rate of additional neurological deficits. Fractures of the transverse process are thought to be sentinel fractures. MRI and CT scans are essential to detect the whole extent of the lesion. Circumferential fusion is recommended by several authors to regain stability at the lumbosacral junction.

The use of an expandable cage for corpectomy reconstruction of vertebral body tumors through a posterior extracavitary approach: a multicenter consecutive case series of prospectively followed patients

BACKGROUND CONTEXT

Posterior decompressions in the form of laminectomies for vertebral body tumors have poor outcomes. Surgical management typically requires anterior decompression and reconstruction; however, these procedures can be associated with significant morbidity and mortality.

PURPOSE

To evaluate the feasibility of anterior spinal column reconstruction using an expandable cage through a posterior approach.

STUDY DESIGN/SETTING

Multicenter consecutive case series of 21 prospectively followed patients.

PATIENT SAMPLE

Twenty-one patients with vertebral body tumors treated with anterior and posterior resection and reconstruction from a single posterior approach were followed prospectively.

OUTCOME MEASURES

Pre- and postoperative neurologic status, number of levels instrumented and fused, length of surgery, length of stay after surgery, and complications related directly or indirectly to surgery were analyzed. In addition, pre- and postoperative radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans were evaluated for involvement of the vertebral body and associated posterior elements. Particular attention was paid to the presence of either unilateral or bilateral pedicle and/or middle column involvement.

METHODS

Patients were placed in a prone position on a rotating radiolucent table. Corpectomy was performed from an extracavitary approach, and anterior column reconstruction was completed with an expandable cage. The posterior tension band and spinal fusion was completed with segmental pedicle screw fixation and performed through the same posterior exposure. No patient required a separate anterior procedure.

RESULTS

Patients' average age was 60.3 years (range, 17-78); there were 12 women and 9 men. Eighteen underwent single-level corpectomies (11 thoracic and 7 lumbar), and 3 underwent two-level corpectomies (T4-T5, T11-T12, and T12-L1). Average estimated blood loss (EBL) and length of surgery per level were 1,360 cc (range, 200-2,500) and 5.3 hours (range, 2.7-8.6), respectively. Average postoperative stay was 4.7 days. Nine patients had at least one partial motor grade improvement. One patient had postoperative left lower extremity weakness after surgical decompression and reconstruction secondary to iatrogenic nerve root traction but remained ambulatory. No chest tubes or postoperative bracing was required. At the most recent follow-up, six patients were alive at an average of 16.1 months (range, 3-33). For the 15 patients who died, the average life span after surgery was 6.8 months (range, 1-16). In addition to the iatrogenic nerve root injury, one cage required repositioning on postoperative Day 2 and one cage demonstrated radiographic evidence of settling but did not require surgical intervention; there were no deep venous thromboses (DVTs), pneumothoraces, pneumonias, ileus, or other complications, with a total complication rate of 14.3%.

CONCLUSIONS

This is the largest study that specifically examines the use of an expandable cage through a posterior extracavitary approach for reconstruction after vertebral body tumor resection. The use of an expandable cage combined with an extracavitary approach is feasible and allows the surgeon to address both the anterior and posterior columns through a single incision. Although technically challenging, both one- and two-level corpectomies in the thoracic and/or lumbar spine can be performed with this technique. Furthermore, insertion of the expandable cage in the collapsed position and then expansion in situ after implantation allowed for all lumbar reconstructions to be completed without sacrificing any of the lumbar nerve roots. Our 14.3% complication rate is similar to those reported in anterior-alone and circumferential spinal procedures.

Traumatic Anterior Lumbosacral Dislocation Caused by Hyperextension Mechanism in Preexisting L5 Spondylolysis

Of many reports referring to injury mechanism in anterior lumbosacral dislocation, there were none concerning hyperextension mechanism. We report a case of a 46-year-old man with preexisting L5 spondylolysis sustaining traumatic complete anterior lumbosacral dislocation. The operative findings, together with the radiologic findings, strongly suggested that the dislocation occurred by hyperextension mechanism. Open reduction was done by applying force of distraction with flexion using a rod and screw system, followed by the internal fixation from the L3 to S1 vertebrae and the postero-superior iliac spine. The lumbosacral dislocation was reduced to 77%. At the follow-up at 5 years after surgery, bony union was obtained and the patient could move with a wheelchair although the neurologic deficit in lower extremities observed preoperatively did not recover. Preexisting L5 spondylolysis was considered to increase the potential for anterior lumbosacral dislocation by additional force of compression with hyperextension. Posterior instrumentation using a rod and screw system was considered a useful method for reduction, decompression, stabilization, and fusion.

A novel "four-rod technique" for lumbo-pelvic reconstruction: theory and technical considerations

STUDY DESIGN

Surgical technique with case example.

OBJECTIVE

To report on a novel technique that allows for the placement of 4 separate longitudinal rods across the lumbo-pelvic junction.

SUMMARY OF BACKGROUND DATA

Despite advances in surgical techniques and instrumentation, lumbo-pelvic fixation remains a significant challenge. Fusions to the pelvis create long lever arms and generate high forces across the lumbosacral junction, resulting in high rates of screw pullout and implant fracture. In the attempt to achieve better bony fixation, techniques described include the use of bone cement, hydroxyapatite, and expandable screws. Although this process has decreased the incidence of screw pullout, it has not addressed the problem of rod fracture at the lumbo-pelvic junction.

METHOD

There are 4 separate longitudinal rods placed across the lumbo-pelvic junction that couples proximal lumbar screw anchors to 4 separate pelvic fixation points. Proximal lumbar fixation anchors are based on alternating Roy-Camille "straight ahead" screws and Magerl "lateral to medial converging" pedicle screws. There are 4 distal pelvic fixation anchors used based on 1 pair of Galveston-like screws and 1 pair of proximal iliac wing screws.

RESULTS

Early results of both ex vivo and in vivo reconstruction show that careful insertion of the lumbar and pelvic screws allows for divergent placement of the pedicle screw heads in a manner that 2 longitudinal rods can be placed per side, resulting in a total of 4 longitudinal rods across the lumbo-pelvic junction. Selection of cross-links in various combinations allows for additional axial and torsional stability, depending on the desired reconstruction.

CONCLUSION

Longer follow-up is necessary, and biomechanical and finite element studies are needed to show long-term efficacy of this technique, however, early results indicate that such a construct is feasible. Furthermore, depending on the general medical condition of the patient, immediate postoperative weight bearing is possible and reasonable.