Traumatic Spondylopelvic Dissociation: A Report of Two Cases

Vresilovic, Edward J. MD, PhD; Mehta, Samir MD; Placide, Rick MD, PT; Milam, R. Alden IV MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.D.01925
Case Reports
Author Information

1 Drexel University School of Biomedical Engineering, 3141 Chestnut Street, Philadelphia, PA 19104-2875. E-mail address: edward.j.vresilovic@drexel.edu

2 Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104. E-mail address: samir.mehta@uphs.upenn.edu

3 West End Orthopaedic Clinic, 9210 Arboretum Parkway, Suite 260, Richmond, VA 23236

4 Charlotte Spine Center, Charlotte Orthopaedic Specialists, 2001 Randolph Road, Charlotte, NC 28207

Article Outline

Traumatic spondylopelvic dissociation is an extremely rare injury resulting in mechanical dissociation of the pelvis from the spine1. Similar mechanical dysfunction can occur in association with lumbosacral fracture-dislocation or bilateral sacroiliac joint dislocation2-9. However, traumatic spondylopelvic dissociation is a distinct injury pattern, characterized by a transverse sacral fracture in conjunction with bilateral sacroiliac fracture-dislocation, that requires a unique approach to overall patient management and surgical stabilization1,10-12. Options for the surgical treatment of spondylopelvic dissociation are limited as the sacrum may not provide structural support or stability for internal fixation. Our patients were informed that data concerning the cases would be submitted for publication.

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Case Reports

CASE 1. A nineteen-year-old woman who was wearing a helmet while riding as a passenger on a motorcycle was ejected at high speed, struck a tree, and subsequently was run over by an eighteen-wheel tractor-trailer. She initially presented to an outside hospital with a Glasgow Coma Score of 15 but was unable to move either lower extremity. She was intubated because of respiratory distress, and a chest tube was inserted bilaterally for the treatment of pneumothorax. A diagnostic peritoneal lavage was positive, and the patient underwent exploratory laparotomy. She had multiple musculoskeletal injuries, including spondylopelvic dissociation with highly comminuted sacral fractures that had both vertical and transverse components (Fig. 1-A), a closed fracture of the proximal part of the right femoral shaft, a comminuted fracture of the left acetabulum, open midshaft fractures of the left tibia and fibula, left metacarpal fractures, and degloving injuries of both feet. The open fractures of the left tibia and fibula were irrigated and débrided in the operating room and then were stabilized with external fixation. A traction pin was placed in the distal part of each femur. The patient then underwent bilateral internal iliac artery embolization. Acute respiratory distress syndrome developed on the day of the injury. Because of increasing intra-abdominal pressure and concern about an abdominal compartment syndrome, the patient was returned to the operating room for abdominal decompression.

On the first day after the injury, the patient was transferred to our tertiary-care academic hospital for further management. At the time of arrival, she continued to have substantial pulmonary difficulties that prevented a return to the operating room. On the sixth day of hospitalization, the patient had improved enough to undergo adjustment of the external fixator in the left tibia, repeat irrigation and débridement of the left tibia and foot, and wound closures. A bedside tracheostomy was performed on the tenth day.

The patient's condition improved over the next several days, and, on the sixteenth day after the injury, she underwent stabilization of the spondylopelvic dissociation. Because of the neurologic deficits in the lower extremity, immediate exploration of the nerve roots within the sacral fracture was considered. However, given the extensive trauma to the soft tissues in the sacral area and the high likelihood of disruption of the lower sacral roots, a decision was made to defer exploration of the neural elements. The treatment plan was to restore alignment and to stabilize the spondylopelvic dissociation with internal fixation while leaving the sacral fracture and the tissues overlying the traumatized sacral region undisturbed. The reason for avoiding further disruption of the sacral soft tissue was so that the sacral skin could be closely monitored and potentially used as an operative site in the event of a nonunion of the sacrum. Additionally, in an attempt to preserve lumbar spine motion, the lumbar segment was not fused.

To accomplish these goals, the spinous processes and laminae at the L3, L4, and L5 levels were exposed through a limited midline incision, and the posterior superior iliac spine was exposed bilaterally through two small, separate incisions. Pedicle screws (ISOLA instrumentation; DePuy Acromed, Raynham, Massachusetts) were placed bilaterally at L3, L4, and L5, with avoidance of the facet joints. Two iliac bolts were placed in each posterior superior iliac spine to create Galveston-like iliac fixation. An attempt was made to recess these bolts as much as possible. The iliac bolts and the pedicle screws were interconnected with I-rods. These I-rods were bent to restore sacral inclination with the eyelets positioned to accommodate the distal iliac bolts. A slotted connector was added to each I-rod for attachment of the proximal iliac bolt at each posterior superior iliac spine, and the I-rods were tunneled from the iliac incisions below the fascia into the lumbar wound. Slotted connectors for the pedicle screws were then added to the rod in the lumbar wound. All screws and bolts were then attached and tightened to secure the hardware, and the rods were interconnected with multiple transverse connectors (Figs. 1-B and 1-C).

On the eighteenth hospital day, the fracture of the right femur was treated with internal fixation with use of an intramedullary rod. The fracture of the left acetabulum was treated nonoperatively with traction. The patient remained in the intensive-care unit for forty-five days. Over the course of that time, she lost 35 lb (15.9 kg) (20% of her body weight) despite efforts to keep her in an anabolic state. She began to move all four extremities, although she still had bilateral lower extremity deficits in the distributions of the L4, L5, and S1 nerve roots. An iliac decubitus ulcer with wound dehiscence began to develop approximately one month postoperatively. It was successfully treated with wet-to-dry dressing changes. By six weeks, the patient had been weaned from the ventilator. She required supportive acute hospitalization for two months and was then discharged to an acute rehabilitation unit. The spinal hardware was removed electively seven months postoperatively, after plain radiographs and a computerized tomographic scan of the pelvis suggested stable healing of the sacral fractures.

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At the time of the most recent follow-up examination, five years and two months after the injury, the patient was able to walk without an assistive device. The left-sided neurologic deficits had resolved, and the patient had no obvious motor deficiencies; however, she continued to have right-sided sensory deficits in the distributions of the L4, L5, and S1 nerve roots as well as bowel and bladder dysfunction. The range of motion of the lumbar spine was estimated to be 55° in flexion (measured by having the patient bend forward with her knees straight), 20° in extension (measured by having the patient bend backward over the examiner's hand when placed over the posterior superior iliac spine), and 15° on lateral bending (measured by having the patient lean to each side after stabilization of the iliac crest). Overall, the patient was satisfied with the outcome, and she had returned to school.

CASE 2. A twenty-one-year-old man who worked as a radio tower installer fell approximately 100 ft (30.5 m) before landing on the roof of a building. At the time of presentation to our institution, he had an initial Glasgow Coma Score of 15 and was rapidly intubated in the trauma bay before undergoing a thorough neurologic examination. A chest tube was inserted bilaterally for the treatment of pneumothorax. The patient had multiple musculoskeletal injuries, including spondylopelvic dissociation (Fig. 2-A), a highly comminuted sacral fracture with vertical and transverse components, an L5 burst fracture, a bilateral intra-articular distal radial fracture, a bilateral scaphoid fracture, a fracture-dislocation of the right elbow with a fracture of the radial head and a tear of the medial collateral ligament, closed fractures of the right tibia and fibula, Grade-IIIB open fractures of the left tibia and fibula, closed fractures of the right calcaneus and talus, Grade-IIIB open fractures of the left calcaneus and cuboid, and a dislocation of the left talonavicular joint.

The patient underwent embolization of the right internal iliac artery and then was taken to the operating room for multiple orthopaedic procedures: irrigation and débridement and external fixation of the open fracture of the left tibia, irrigation and débridement of the open fracture of the left calcaneus, closed reduction of the dislocation of the left talonavicular joint, intramedullary rodding of the closed fracture of the right tibia, splinting of the wrist fractures, and closed reduction of the fracture-dislocation of the right elbow. The patient remained intubated. On the third day after the injury, the patient underwent open reduction and internal fixation of both scaphoid fractures, both intra-articular distal radial fractures, and the right radial head fracture. The patient was then weaned from the ventilator and extubated. After extubation, a detailed neurologic examination revealed motor and sensory deficits in the distribution of the L3, L4, and L5 nerve roots in the right lower extremity and complete paralysis of the left lower extremity.

On the eighth day after the injury, the patient underwent stabilization of the spondylopelvic dissociation. The technique was identical to that used for the previous patient (Case 1), except that the lumbar fixation included L2 instead of L5 because of the L5 burst fracture (Figs. 2-B and 2-C). Once again, the region overlying the traumatized sacral region was left undisturbed and no attempt at fusion was made.

On the fourteenth day after the injury, the patient underwent open reduction and internal fixation of the right calcaneal fracture along with primary subtalar fusion, open reduction and internal fixation of the right talar fracture, closed reduction and pinning of the right navicular fracture, closed reduction and pinning of the left talonavicular joint, and irrigation and débridement of the open left calcaneal fracture. He required supportive acute hospitalization for one month and was then discharged to an acute rehabilitation unit. During the period of acute hospitalization, the patient lost 20 lb (9.1 kg) (12% of his body weight).

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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.

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Discussion

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

1. , France JC, Glover JM, Kaylor KL. Traumatic spondylopelvic dissociation. A case report and literature review. Spine. 1996;21: 1814-9.
2. , Buchvald P, Suchomel P, Lukas R. [Traumatic spondylolisthesis of L5-S1]. Acta Chir Orthop Traumatol Cech. 2003;70: 121-5. Czech.
3. , Rayo A, Rodriguez de Oya R, Berjano P, Garate E. Acute traumatic lumbosacral dislocation treated by open reduction internal fixation and fusion. Spine. 2003;28: E51-3.
4. , Williams RC. Fracture-dislocation of the lumbosacral spine. Report of a case and review of the literature. Clin Orthop. 1984;186: 205-11.
5. , Govender S, Preston MH. Fracture-dislocation of the lumbosacral spine. S Afr Med J. 1992;82: 486-7.
6. , Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumper's fracture. Spine. 1985;10: 838-45.
7. , Bago J. Traumatic lumbosacral dislocation. Spine. 2000;25: 756-9.
8. , Shuster J, Asher MA, McClarty SJ. Traumatic L5-S1 spondylolisthesis. South Med J. 1999;92: 316-20.
9. , Jones CB, Harding SP, Mirza SK, Routt ML Jr. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma. 2001;15: 238-46.
10. , Hansen ST Jr. Bilateral fracture-dislocation of the sacrum. A case report. J Bone Joint Surg Am. 1984;66: 1297-9.
11. , Fleetcroft JP. Bilateral fracture-dislocation of the sacrum. Injury. 1989;20: 301-3.
12. , Dahners LE, Renner JB, Baker CC. Fracture-dislocation of the lumbosacral spine: case report and review of the literature. J Trauma. 1992;33: 779-84.
13. , Wright NM, Yundt KD, Lauryssen C. Adjacent fracture-dislocations of the lumbosacral spine: case report. Neurosurgery. 1999;44: 1134-7.
14. , Oner FC, Dhert WJ, Verbout AJ. Traumatic lumbosacral dislocation: case report. Spine. 2001;26: 1942-4.
15. . Traumatic lumbosacral dislocation. A case report and review of the literature. Orthopedics. 1987;10: 1271-4.
16. , Rey del Castillo J, Marco-Martinez F, Gimeno MD, Lopez-Duran L, Martinez J. Bilateral sacroiliac dislocation with intrapelvic intrusion of the lumbosacral spine. A case report. Int Orthop. 1994;18: 177-9. Erratum in: Int Orthop. 1994;18:251.
17. , Jacobs RR. Irreducible sacroiliac dislocation of the pelvic ring with caudal displacement. A case report. Clin Orthop. 1988;237: 216-8.
18. Jr, Zwally HJ 2nd, Burgess AR. Innominosacral dissociation: mechanism of injury as a predictor of resuscitation requirements, morbidity, and mortality. J Orthop Trauma. 1997;11: 82-8.
19. , Jennings A, Smith M. Current management of U-shaped sacral fractures or spino-pelvic dissociation. Injury. 2002;33: 123-6.
20. Jr, Ferguson RL. The Galveston technique for L rod instrumentation of the scoliotic spine. Spine. 1982;7: 276-84.
21. Jr, Ferguson RL. The Galveston technique of pelvic fixation with L-rod instrumentation of the spine. Spine. 1984;9: 388-94.
22. , Romfh JH. Closure of large traumatic lumbosacral defects. Neurosurgery. 1982;11: 234-8.
23. , Winter RB. Terminology and measurement of spondylolisthesis. J Bone Joint Surg Am. 1983;65: 768-72.
24. , Kilicoglu O. S1 pediculoiliac screw fixation in instabilities of the sacroiliac complex: biomechanical study and report of two cases. J Orthop Trauma. 2003;17: 262-70.
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