Complications associated with surgical stabilization of high-grade sacral fracture dislocations with spino-pelvic instability

Abstract

Study design: Retrospective evaluation of 19 consecutive patients with sacral fracture dislocations and cauda equina syndrome.

Objective: To review the safety and patient impact of early surgical decompression, and rigid segmental stabilization in patients with high-grade sacral fracture dislocations.

Summary of background data: The ideal treatment for patients presenting with fracture dislocations of the sacrum resulting from high-energy mechanisms remains unknown. Previous studies consisted of multicenter case reviews that showed satisfactory outcomes with either nonoperative or a variety of surgical methods. However, over the last 20 years, no consistent treatment algorithm for these severe injuries has emerged. The advent of rigid, low-profile segmental fixation of the lumbar spine to the pelvic ring has offered a solution to many of the surgical challenges. This study evaluates the rate of complications of this method. It is intended to serve as a foundation for further evaluation and development of this treatment strategy, and as a basis for future comparison studies.

Methods: Patients were treated with a formally established algorithm, including resuscitation, and clinical assessment with detailed neurologic assessment and radiographic workup with pelvic computerized tomography and reformatted views. Electrophysiologic testing was conducted to confirm the presence of sacral plexus injuries in patients who were unable to be examined. Patients received neural element decompression and open reduction with segmental internal fixation through a midline posterior approach by connecting lower lumbar pedicle screws to long iliac screws when the patient's general medical condition allowed for surgical intervention. A formal sacroiliac arthrodesis was not performed. For the purposes of this study, patients were assessed specifically for the following adverse events: (1) infection, (2) wound healing, (3) neurologic deterioration following surgical treatment, (4) postoperative loss of sacral fracture reduction, (5) instrumentation failure, (6) axial lumbopelvic pain requiring further treatment, and (7) unplanned secondary surgery.

Results: There were 19 patients with an average age of 32 years treated according to this algorithm. Fracture reduction was successfully maintained in all patients. During the index surgical intervention, 14/19 patients (74%) had had either a traumatic dural tear or nerve root avulsion. Major complications involved fracture of the connecting rods in 6/19 patients (31%) and wound healing disturbances in 5/19 (26%). There were no lasting complications such as chronic osteomyelitis noted. In patients followed over a 1-year period, the visual analog score, referable to the sacral injury, averaged 5.5 on a scale of 0-10.

Conclusions: Rigid segmental lumbopelvic stabilization allowed for reliable fracture reduction of the lumbosacral spine and posterior pelvic ring, permitting early mobilization without external immobilizaton and neurologic improvement in a large number of patients. Complications were primarily related to infection, wound healing, and asymptomatic rod breakage, and were without long-term sequelae.