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Nikjou DA, Taggart CM, Lettieri SC, Collins MR, McCabe OT, Rousseau LA, Feiz-Erfan I. Laminectomy for acute transverse sacral fractures with compression of the cauda equina: A neurosurgical perspective. World Neurosurg X 2024; 23:100374. [PMID: 38584879 PMCID: PMC10997834 DOI: 10.1016/j.wnsx.2024.100374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/28/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Optimal management of transverse sacral fractures (TSF) remains inconclusive. These injuries may present with neurological deficits including cauda equina syndrome. We present our series of laminectomy for acute TSF with cauda equina compression. Methods This was a retrospective chart review of all patients that underwent sacral laminectomy for treatment of cauda equina compression in acute TSF at our institution between 2007 through 2023. Results A total of 9 patients (5 male and 4 female) underwent sacral laminectomy to decompress the cauda equina in the setting of acute high impact trauma. Surgeries were done early within a mean time of 5.9 days. All but one patient had symptomatic cauda equina syndrome. In one instance surgery was applied due to significant canal stenosis present on imaging in a patient with diminished mental status not allowing proper neurological examination. Torn sacral nerve roots were repaired directly when possible. All patients regained their neurological function related to the sacral cauda equina on follow up. The rate of surgical site infection (SSI) was 33%. Conclusion Acute early sacral laminectomy and nerve root repair as needed was effective in recovering bowel and bladder function in patients after high impact trauma and TSF with cauda equina compression. A high SSI rate may be reduced by delaying surgery past 1 week from trauma, but little data exists at this time for clear recommendations.
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Affiliation(s)
- Devin A. Nikjou
- Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Arizona State University, School of Biological and Health Systems Engineering, Tempe, AZ, USA
| | - Chani M. Taggart
- Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Division of Trauma, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Salvatore C. Lettieri
- Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Division of Plastic Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Division of Plastic Surgery, Mayo Clinic, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Michael R. Collins
- Department of Radiology, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Owen T. McCabe
- Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Division of Trauma, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Layne A. Rousseau
- Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Division of Urology, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
| | - Iman Feiz-Erfan
- Division of Neurosurgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Department of Surgery, Valleywise Health Medical Center, Phoenix, AZ, USA
- Creighton University, School of Medicine Phoenix, Phoenix, AZ, USA
- University of Arizona, College of Medicine Phoenix, Phoenix, AZ, USA
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Aprato A, Branca Vergano L, Casiraghi A, Liuzza F, Mezzadri U, Balagna A, Prandoni L, Rohayem M, Sacchi L, Smakaj A, Arduini M, Are A, Battiato C, Berlusconi M, Bove F, Cattaneo S, Cavanna M, Chiodini F, Commessatti M, Addevico F, Erasmo R, Ferreli A, Galante C, Giorgi PD, Lamponi F, Moghnie A, Oransky M, Panella A, Pascarella R, Santolini F, Schiro GR, Stella M, Zoccola K, Massé A. Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures. J Orthop Traumatol 2023; 24:46. [PMID: 37665518 PMCID: PMC10477162 DOI: 10.1186/s10195-023-00726-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment. MATERIALS AND METHODS The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment. RESULTS Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated. CONCLUSIONS This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients. LEVEL OF EVIDENCE IV. TRIAL REGISTRATION not applicable (consensus paper).
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Affiliation(s)
- Alessandro Aprato
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy.
| | | | | | | | - Umberto Mezzadri
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | - Alberto Balagna
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
| | | | | | | | | | | | | | | | | | - Federico Bove
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | | | | | | | | | | | - Rocco Erasmo
- Ospedale Civile Santo Spirito di Pescara, Pescara, Italy
| | | | | | | | | | | | - Michel Oransky
- Università degli studi di Roma, ASST degli spedali Civili di Brescia, Brescia, Italy
| | | | | | | | | | | | | | - Alessandro Massé
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
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3
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Barber LA, Katsuura Y, Qureshi S. Sacral Fractures: A Review. HSS J 2023; 19:234-246. [PMID: 37065102 PMCID: PMC10090841 DOI: 10.1177/15563316221129607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 08/05/2022] [Indexed: 04/18/2023]
Abstract
At the cornerstone of the pelvis and spine, the sacrum may be fractured in patients of all ages. Sacral fractures range from high-energy injuries, with mortality rates of up to 18%, to low-energy insufficiency fractures. The intricate geometry of the sacrum, the breadth of morphotypes, and the presence of congenital anomalies all can complicate the treatment of these fractures. Agreement on the surgical indications for these injuries is limited. This narrative review aims to update orthopedic surgeons on the clinical evaluation and the non-surgical and surgical management of these fractures.
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Affiliation(s)
| | | | - Sheeraz Qureshi
- Emory Spine Center, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Hospital
for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
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4
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Morris CA, Moo Young JP, Savakus JC, Obey MR, Pereira DE, Hills JM, McKane A, Babcock SN, Miller AN, Stephens BF, Mitchell PM. Neurologic injury after spinopelvic dissociation: Incidence, outcome, and predictors. Injury 2023; 54:615-619. [PMID: 36371318 DOI: 10.1016/j.injury.2022.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Traumatic spinopelvic dissociation is a rare injury pattern resulting in discontinuity between the spine and bony pelvis. This injury is associated with a known risk of neurologic compromise which can impact the clinical outcome of these patients. We sought to determine incidence and characteristics of neurologic injury, outcomes following treatment, and predictive factors for neurologic recovery. METHODS We reviewed the clinical documentation and imaging of 270 patients with spinopelvic dissociation from three Level-1 trauma centers treated over a 20-year period. From this cohort, 137 patients fulfilled inclusion criteria with appropriate follow-up. Details surrounding patient presentation, incidence of neurologic injury, and outcome variables were collected for each injury. Neurologic injuries were categorized using the Gibbons criteria. Multivariate analysis was performed to assess for patient and injury factors predictive of neurologic injury and recovery. RESULTS The overall incidence of neurologic injury in spinopelvic dissociation injuries was 33% (45/137), with bowel and/or bladder dysfunction (n=16) being the most common presentation. Complete neurologic recovery was seen in 26 cases (58%) and two patients (4%) improved at least one Gibbon stage in clinical follow-up. The most common long-term neurologic sequela at final follow-up was radiculopathy (n=12, 9%). Increased kyphosis was found to be associated with neurologic injury (p=0.002), while location of transverse limb and Roy-Camille type were not predictive of neurologic injury (p=0.31 and p=0.07, respectively). There were no factors found to be predictive of neurologic recovery in this cohort. CONCLUSION Neurologic injury is commonly seen in patients with spinopelvic dissociation and complete neurologic recovery was seen in the majority of patients at final follow-up. When present, long term neurologic dysfunction is most commonly characterized by radiculopathy. While increasing kyphosis was shown to be associated with neurologic injury, no patient or injury factors were predictive of neurologic recovery.
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Affiliation(s)
- Cade A Morris
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Justin P Moo Young
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jonathan C Savakus
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Mitchel R Obey
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States
| | - Daniel E Pereira
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States
| | - Jeffrey M Hills
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ava McKane
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Sharon N Babcock
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, United States
| | - Byron F Stephens
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Phillip M Mitchell
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, United States.
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Kweh BTS, Tee JW, Oner FC, Schnake KJ, Vialle EN, Kanziora F, Rajasekaran S, Dvorak M, Chapman JR, Benneker LM, Schroeder G, Vaccaro AR. Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic review. J Neurosurg Spine 2022; 37:914-926. [PMID: 35907199 DOI: 10.3171/2022.5.spine211468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems. METHODS A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems. RESULTS A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable "U-type" fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date. CONCLUSIONS The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries.
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Affiliation(s)
- Barry Ting Sheen Kweh
- 1National Trauma Research Institute, Melbourne.,2Department of Neurosurgery, The Alfred Hospital, Melbourne.,3Department of Neurosurgery, Royal Melbourne Hospital, Parkville
| | - Jin W Tee
- 1National Trauma Research Institute, Melbourne.,2Department of Neurosurgery, The Alfred Hospital, Melbourne.,4Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - F Cumhur Oner
- 5Department of Orthopaedics, University Medical Center Utrecht, The Netherlands
| | - Klaus J Schnake
- 6Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen.,7Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Germany
| | | | - Frank Kanziora
- 9Spinal Surgery and Neurotraumatology Centre, BG Trauma Clinic Frankfurt, Frankfurt am Main, Germany
| | | | - Marcel Dvorak
- 11Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jens R Chapman
- 12Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington
| | | | - Gregory Schroeder
- 14The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R Vaccaro
- 14The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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6
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Abstract
CT is often performed as part of a whole-body protocol in the setting of polytrauma and is the standard of care for diagnosing and characterizing sacral fractures. These fractures are not uncommon, occurring in conjunction with pelvic ring disruption in approximately 40%-50% of patients. Knowledge of basic functional anatomy and fracture biomechanics is important in understanding sacral fracture patterns, which only rarely result from direct impact. More often, sacral fractures result from an indirect mechanism with fracture lines that propagate along relative lines of weakness, leading to predictable fracture patterns. Each fracture pattern has implications with respect to neurologic injury, spinopelvic stability, management, and potential complications. The authors explore the Denis, Roy-Camille, Isler, Robles, Sabiston-Wing, and shape-based classification systems for sacral fractures. These form the basis of the subsequently discussed unified AOSpine sacral fracture classification, a consensus system developed by spine and orthopedic surgeons as a means of improving and standardizing communication. The AOSpine sacral fracture classification also includes clinical designations for neurologic status and patient-specific modifiers. When a patient is unexaminable owing to obtundation or sedation, CT is an invaluable indirect marker of nerve compression or traction injury. It also plays an important role in visualizing and characterizing the type and extent of any associated soft-tissue injuries that may warrant a delay in surgery or an alternative operative approach. ©RSNA, 2022.
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Affiliation(s)
- David Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| | - Elana B Smith
- From the Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
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Li J, Yu XK, Tian W, Dong XM, Guo L, Li XF. The clinical value of using magnetic resonance contrast-enhanced three-dimensional nerve view in the diagnosis and management of sacral fracture accompanied by sacral plexus injury. Technol Health Care 2022; 30:1407-1415. [PMID: 35661030 DOI: 10.3233/thc-213543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The treatment of sacral fractures accompanied by nerve injury is complex and often leads to an unsatisfactory prognosis and poor quality of life in patients. OBJECTIVE The present study aimed to investigate the clinical value of using 3.0T magnetic resonance contrast-enhanced three-dimensional (MR CE-3D) nerve view magnetic resonance neurography (MRN) in the diagnosis and management of a sacral fracture accompanied by a sacral plexus injury. METHODS Thirty-two patients with a sacral fracture accompanied by a sacral plexus injury, including 24 cases of Denis spinal trauma type II and 8 cases of type III, were enrolled in the study. All patients had symptoms or signs of lumbosacral nerve injury, and an MRN examination was performed to clarify the location and severity of the sacral nerve injury. Segmental localization of the sacral plexus was done to indicate the site of the injury as being intra-spinal (IS), intra-foraminal (IF), or extra-foraminal (EF), and the severity of the nerve injury was determined as being mild, moderate, or severe. Surgical nerve exploration was then conducted in six patients with severe nerve injury. The location and severity of the nerve injury were recorded using intra-operative direct vision, and the results were statistically compared with the MRN examination results. RESULTS MRN showed that 81 segments had mild sacral plexus injuries (8 segments of IS, 20 segments of IF, 53 segments of EF), 78 segments had moderate sacral plexus injuries (8 segments of IS, 37 segments of IF, and 33 segments of EF), and 19 segments had severe sacral plexus injuries (7 segments of IS, 9 segments of IF, and 3 segments of EF). The six patients who underwent surgery had the following intra-operative direct vision results: 3 segments of moderate injury (IF) and 20 segments of severe injury (7 segments of IS, 10 segments of IF, 3 segments of EF). There was no statistically significant difference in the results between the intra-operative direct vision and those of the MRN examination (p> 0.05). CONCLUSION MR CE-3D nerve view can clearly and accurately demonstrate the location and severity of sacral nerve injury accompanied by a sacral fracture, and has the potential for being the first choice of examination method for this kind of injury, which would be of important clinical value.
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Affiliation(s)
- Jian Li
- Department of Radiology, Tianjin Hospital, Tianjin, China.,Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Xiao-Kun Yu
- Department of Radiology, The Fifth Centre Hospital of Tianjin City, Tianjin, China.,Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Wei Tian
- Department of Traumatic Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Xiao-Man Dong
- Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Lin Guo
- Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Xiao-Feng Li
- Department of Radiology, Tianjin Hospital, Tianjin, China
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Müller F, Füchtmeier B. A systematic review of the transiliac internal fixator (TIFI) for posterior pelvic injuries. SICOT J 2021; 7:40. [PMID: 34309508 PMCID: PMC8312281 DOI: 10.1051/sicotj/2021037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/04/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To summarize the literature on transiliac internal fixator (TIFI) indications and outcomes for treating posterior pelvic ring injuries. METHODS We searched databases for original publications in journals. Biomechanical and clinical studies using a TIFI for posterior pelvic ring injuries were considered for inclusion. The dates of publications that were included ranged from January 2000 until December 2020. RESULTS A total of 13 articles were reviewed, including eight clinical studies and five biomechanical tests. We found only case series and no multicenter or randomized study. The clinical studies contained data for a total of 186 cases, including indications, treatments, complications, and outcomes, with a minimum follow-up time of 12 months. All studies reported superior results according to operation time, blood loss, complication, dislocation, and union. One biomechanical test evaluated inferior results. CONCLUSIONS The TIFI is a user-friendly and safe device to treat posterior pelvic injuries. It can also be used for acute, high-impact injuries, and fragility fractures. Nevertheless, there is no evidence concerning which types of pelvic fractures are most beneficial. Therefore, further biomechanical and clinical studies are necessary to resolve this question.
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Affiliation(s)
- Franz Müller
- Clinic for Trauma, Orthopaedics and Sports Medicine, Hospital Barmherzige Brüder, Prüfeninger Str. 86, 93049 Regensburg, Germany
| | - Bernd Füchtmeier
- Clinic for Trauma, Orthopaedics and Sports Medicine, Hospital Barmherzige Brüder, Prüfeninger Str. 86, 93049 Regensburg, Germany
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9
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[Closed reduction and minimally invasive fixation of a sacral avulsion fracture : Minimal invasiveness with maximum stability]. Unfallchirurg 2021; 125:492-496. [PMID: 34160638 DOI: 10.1007/s00113-021-01035-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
Surgical stabilization of high-energy sacral avulsion fractures with spinopelvic dissociation places high demands on the surgeon. The goal is to achieve maximum stability while minimizing invasiveness. The present case of a dislocated U‑type fracture in a 25-year-old motocross rider exemplifies how a reduction with the targeted application of closed reduction techniques through hyperextension of the hip joints and lordosis in the lumbosacral hinge and through a standardized procedure in intraoperative fluoroscopic imaging, a minimally invasive stabilization by means of transsacral screw fixation and spinopelvic fixation of lumbar vertebra 5 to the ilium in the sense of a bilateral triangular stabilization is possible without compromising the achieved stability of the osteosynthesis. The limitations of the described approach are also pointed out.
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10
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LoRusso S. Disorders of the Cauda Equina. Continuum (Minneap Minn) 2021; 27:205-224. [PMID: 33522743 DOI: 10.1212/con.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Cauda equina dysfunction (often referred to as cauda equina syndrome) is caused by a diverse group of disorders that affect the lumbosacral nerve roots. It is important to recognize dysfunction of the cauda equina quickly to minimize diagnostic delay and lasting neurologic symptoms. This article describes cauda equina anatomy and the clinical features, differential diagnosis, and management of cauda equina disorders. RECENT FINDINGS The diagnosis of disorders of the cauda equina continues to be a challenge. If a compressive etiology is seen, urgent neurosurgical intervention is recommended. However, many people with clinical features of cauda equina dysfunction will have negative diagnostic studies. If the MRI is negative, it is important to understand the diagnostic evaluation and differential diagnosis so that less common etiologies are not missed. SUMMARY Cauda equina dysfunction most often occurs due to lumbosacral disk herniation. Nondiskogenic causes include vascular, infectious, inflammatory, traumatic, and neoplastic etiologies. Urgent evaluation and surgical intervention are recommended in most cases of compressive cauda equina syndrome. Other types of treatment may also be indicated depending on the etiology.
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11
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Schubert I, Höch A, Pöppelmeier O, Josten C, Strohm PC. U-Frakturen des Os sacrum – Wie therapiert man richtig? Unfallchirurg 2020; 123:896-903. [DOI: 10.1007/s00113-020-00842-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Ipsilateral S2 nerve root transfer to pudendal nerve for restoration of external anal and urethral sphincter function: an anatomical study. Sci Rep 2019; 9:13993. [PMID: 31570751 PMCID: PMC6768882 DOI: 10.1038/s41598-019-50484-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/13/2019] [Indexed: 11/13/2022] Open
Abstract
Patients suffer bilateral sacral plexus injuries experience severe problems with incontinence. We performed a cadaveric study to explore the anatomical feasibility of transferring ipsilateral S2 nerve root combined with a sural nerve graft to pudendal nerve for restoration of external anal and urethral sphincter function. The sacral nerve roots and pudendal nerve roots on the right side were exposed in 10 cadavers. The length from S2 nerve root origin to pudendal nerve at inferior border of piriformis was measured. The sural nerve was used as nerve graft. The diameters and nerve cross-sectional areas of S2 nerve root, pudendal nerve and sural nerve were measured and calculated, so as the number of myelinated axons of three nerves on each cadaver specimen. The length from S2 nerve root to pudendal nerve was 10.69 ± 1.67 cm. The cross-sectional areas of the three nerves were 8.57 ± 3.03 mm2 for S2, 7.02 ± 2.04 mm2 for pudendal nerve and 6.33 ± 1.61 mm2 for sural nerve. The pudendal nerve contained approximately the same number of axons (5708 ± 1143) as the sural nerve (5607 ± 1305), which was a bit less than that of the S2 nerve root (6005 ± 1479). The S2 nerve root in combination with a sural nerve graft is surgically feasible to transfer to the pudendal nerve for return of external urethral and anal sphincter function, and may be suitable for clinical application in patients suffering from incontinence following sacral plexus injuries.
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13
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Li P, Qiu D, Shi H, Song W, Wang C, Qiu Z, Zhao C, Zhou D. Isolated Decompression for Transverse Sacral Fractures with Cauda Equina Syndrome. Med Sci Monit 2019; 25:3583-3590. [PMID: 31089068 PMCID: PMC6532556 DOI: 10.12659/msm.916483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical outcomes of isolated decompression for patients with transverse sacral fractures and cauda equina syndrome, which have been rarely reported before. MATERIAL AND METHODS Twelve neurological impaired patients with transverse sacral fracture from January 2010 to March 2017 treated in our institution were evaluated. All patients went through isolated decompression and were followed for a minimum of 12 months. Fracture causes, classifications, associated injury, radiologic results, clinical outcomes using the Majeed index, and neurological outcomes using the Gibbons criteria were evaluated. RESULTS Motor vehicle accidents and falling injuries were the major causes of trauma. The average time from trauma to surgery was 89.8 days. Eleven patients underwent laminectomy with no more than 3 segments resected and 1 patient had S1-S4 excised. Three patients with fracture involving the lumbopelvic joint had L5 laminectomy. All patients achieved bony union, with 7 patients (63.6%) showing satisfactory pelvic outcome. Average Gibbons scores improved from 2.8 to 1.9 at 18-month average follow-up, but most patients were left with residual pain. No surgical-related complications were seen in any patients. CONCLUSIONS Isolated decompression can be considered for patients who present a stable sacrum with non-displaced fracture or an old fracture that shows fracture healing. Favorable pelvic outcomes and neurological recovery, along with acceptable stability, can be acquired.
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Affiliation(s)
- Pengyu Li
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
| | - Daodi Qiu
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
| | - Hongbiao Shi
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
| | - Wenhao Song
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
| | - Chunhui Wang
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
| | - Zhen Qiu
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
| | - Chuang Zhao
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
| | - Dongsheng Zhou
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China (mainland)
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