Over the course of acute hospitalization, iliac decubiti developed and necessitated surgical débridement and closure. Hardware removal was performed eight months after surgical stabilization, once radiographs and a computerized tomographic scan of the pelvis suggested stable healing of the sacral and L5 fractures.
At the time of the most recent follow-up examination, six years after the injury, the patient was able to walk without an assistive device. He had no motor deficits in either lower extremity but had some paresthesias in the left lower extremity. He continued to have bowel and bladder dysfunction, but with some improvement. The range of motion of the lumbar spine was estimated to be 50° in flexion, 25° in extension, and 10° on lateral bending to each side. Overall, the patient was satisfied with the outcome and had returned to sedentary work with his previous employer.
While there have been a number of case series on fracture-dislocations involving the lumbosacral3-5,7,13-15 and sacroiliac joints9,16-18, there have been only a few case reports on traumatic spondylopelvic dissociation1,10-12. Nork et al. described the largest series of such debilitating injuries in their review of thirteen U-shaped sacral fractures that had been treated with iliosacral screw fixation9. However, such fractures differ slightly from traumatic spondylopelvic dissociations1,3,10,14. Traumatic spondylopelvic dissociation results in mechanical dissociation of the pelvis from the spine as the result of a highly comminuted sacral fracture with severe instability in the cephalad direction. This extremely high-energy fracture pattern is associated with extensive soft-tissue damage, hemorrhage, and orthopaedic and visceral injury. It is presumed that reports on the treatment of traumatic spondylopelvic dissociation are rare because of a high associated mortality rate1. However, advancements in the emergency management system as well as improvements in trauma transport and resuscitation have resulted in the need to develop treatment strategies for these rare injuries.
The lack of sites for sacral fixation is the primary challenge when treating the gross instability associated with traumatic spondylopelvic dissociation17,19. Previous investigators have used a combination of pedicle screws, sacroiliac screws, plates, percutaneous fixation, and Harrington rods with varying degrees of success1,2,9,18. The technique that we described is a modification of Galveston iliac fixation. Originally, the Galveston technique was accomplished by inserting angled rods into the iliac wings20,21. Our modification of this technique allowed spanning fixation from the lumbar spine directly to each ilium with the use of screws and rods. Placing two iliac screws per ilium, instead of one, and connecting them both to the distal rods allows for a greater degree of stability and an improved ability to mobilize the patient. In both of our patients, all hardware remained well fixed until the time of removal.
The mechanism of injury in our two patients was a direct blow to the posterior part of the sacrum. In both cases, the skin overlying the sacral region remained intact but was extremely contused. The surgical approach that we used avoids direct exposure of the comminuted sacrum as well as additional injury to the traumatized soft tissues19,22. As noted in other reports, traumatic spondylopelvic dissociation is likely to be associated with neurologic injury1. The rationale for our approach to the treatment of the neurologic injury was provided in the description of the case of the first patient (Case 1). Whether sacral nerve root exploration would have benefited these patients is unknown, but surgical exploration remains a consideration. We believe that treatment in this regard must be tailored to the individual patient and remains a matter of judgment.
Restoration of spondylopelvic alignment at the time of surgical stabilization is important. The assessment of coronal alignment with use of intraoperative radiographic imaging is relatively straightforward. The assessment of sagittal alignment is more difficult and therefore requires more consideration. The surgeon is essentially trying to restore the lumbosacral angle or the sacral inclination. If the vertical plane is considered to be the normal sagittal plumb line for the spine23, normal sacral inclination is approximately 45°23. The sagittal relationship of the spine to the sacrum and the ilium should be reviewed preoperatively in order to avoid difficulty in assessing it intraoperatively. Difficulty may arise from the loss of visual clues secondary to the sacral comminution. We recommend that sagittal alignment be assessed with use of fluoroscopy at the time of patient positioning. This alignment should then be reconfirmed before fixation of the hardware. The two-point iliac fixation creates excellent rotational stability for maintaining this alignment24.
In an attempt to preserve lumbar motion, we took measures to avoid facet injury and chose not to fuse the lumbar spine. The rationale for this approach was to compensate for any spondylopelvic malalignment and to minimize future disc degeneration cephalad to the fused segments in these young patients. Both patients had preservation of some lumbar motion, but it remained limited.
These multiply traumatized patients exhibited substantial catabolic weight loss despite what was considered at the time to be an adequate nutritional resuscitation2,7,15. As noted previously, the combination of tissue damage, fracture, and decubiti places these patients at a very high risk for infection and underscores the need for aggressive nutritional resuscitation. A manifestation of the weight loss, which was a direct consideration in these patients, was skin breakdown overlying the iliac screws. These screws, which were recessed at the time of surgery, became more prominent secondary to weight loss, and ulceration at the sites of the screws necessitated surgical treatment. This problem may have been avoided if more aggressive preventative measures had been instituted before the breakdown.
In summary, traumatic spondylopelvic dissociation is a rare high-energy injury that requires surgical stabilization. A modification of the Galveston technique provides stable fixation while sparing the traumatized sacral area. ▪
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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