2011 Annual Meeting

Instructional Course
Lecture Handout

Course Number: 252

Course Title: Thoracolumbar Fracture: Evaluation and Management from ER to Rehab
Location: San Diego Convention Center, Room 4
Date & Start Time: 16-Feb-2011 01:30 PM
INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:
Carlo Bellabarba, MD - 2 (Synthes);5 (Stryker; Synthes); Submitted on: 09/21/2010 and last confirmed as
accurate on 10/16/2010.
Marcel F Dvorak, MD - 1 (Medtronic Sofamor Danek);2 (Medtronic Sofamor Danek; Synthes);3B (Medtronic
Sofamor Danek);5 (Medtronic Sofamor Danek; DePuy, A Johnson & Johnson Company; Synthes; Arcus);6 (DePuy,
A Johnson & Johnson Company; Medtronic Sofamor Danek; Synthes);7 (Thieme); Submitted on: 09/29/2010.
John C France, MD - 6 (Medtronic Sofamor Danek); Submitted on: 09/13/2010.
Mitchel B Harris, MD - (n) Submitted on: 05/25/2010 and last confirmed as accurate on 09/12/2010.
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2011 AAOS Annual Meeting

ICL 252 - Thoracolumbar Fracture: Evaluation and Management from ER to
Rehab
Moderator: Mitchel B. Harris, MD
Order of Presentations:
Mitchel Harris, M.D. FACS
Emergency Room Evaluation of the Trauma Patient R/O Spinal Injury
Evaluation and Early Management of the Spin Injured Patient
Marcel Dvorak, MD, FRCSC
Non-operative Management of Thoracolumbar Injuries
John C. France M.D.
Thoracolumbar Fractures Anterior versus Posterior Surgical Options
Carlo Bellabarba, M.D
Sacral Fractures with Lumbosacral/Lumbopelvic Instability

EMERGENCY ROOM EVALUATION OF THE TRAUMA PATIENT

R/O SPINAL INJURY
EVALUATION AND EARLY MANAGEMENT OF THE SPINE INJURED
PATIENT
Mitchel Harris, M.D. FACS
Partners Orthopaedic Trauma Service
Brigham and Womens Hospital
Associate Professor
Harvard Medical School
Dept. of Orthopaedic Surgery
I.

ATLS: ADVANCED TRAUMA LIFE SUPPORT

Advanced Trauma Life Support teaches a systemic, concise approach to the early
care of the trauma patient. The ATLS Program provides a safe, reliable method
for immediate management of the injured patient and the basic knowledge
necessary to address life then limb threatening injuries. All trauma patients are
presumed to have sustained a spinal column injuryuntil proven otherwise.
1. Primary Survey
A. Airway Management
1. Intubation: method to protect airway from obstruction after trauma
a. Blood
b. Tongue, teeth
c. Laryngeal trauma
d. Facial trauma: 7-24% association with cervical spine
injuries (J Trauma 93; 34:549-553; J Trauma85; 90-93)
2. Tracheostomy: in line intubation; chin lift, jaw thrust
B. Breathing
1. Tension/Open Pneumothorax
2. Hemothorax
3. High energy chest trauma increases suspicion for thoracic spine
injury
a. Sternal fractures: Fourth column
b. Floating/Flail chest
4. Supplemental O2 administration in presence of SCI
C. Circulation
1. Heart rate
2. Blood pressure, urine output
3. Hypotension rule out hemorrhage first; crystalloid resuscitation

a. if unresponsive: early admin of O negative blood

b. Hypotension (90 mm Hg) + bradycardia (<50 BPM) =
neurogenic shock. Vasopressors + atropine will support
Circulatory collapse, and limit threat for further SCI.
Goal: BP > 100 mm Hg.

D. Cervical Spine immobilization in the field

1. Adults: Field collar and backboard
2. Kids: pediatric trauma board with recessed head spot
a. Pediatric cranium disproportionately large compared to
trunk neck forced into flexion.
b. Forehead taped to backboard with sandbags at sides
2. Secondary Survey
Complete clinical assessment from head to tail. Begins after hemodynamic
stability is achieved or during active resuscitation. Principle Goal:
Identification of additional injuries that may require urgent/emergent
intervention as well as lesser injuries.
A. Patients actively able to participate in evaluation
B. Patients able to participate but distracted from associated
injuries
C. Patients unable to actively participate in evaluation
1. Closed head injury
2. Intubated and sedated
3. Alcohol, drugs, pharmaceuticals
3. Secondary Survey With Respect to the Spine
A. Credible Exam: findings determine necessity of radiographs
B. Compromised Exam: pharmacologically induced or other full
spine evaluation
1. Log-rolling not as safe as we believe
( J Trauma 87; 27:525-31; J Trauma 2004; 57: 609-611)
2. Observe: abrasions, ecchymosis, open injuries
3. Palpate
a. Tenderness
b. Step-offs/Diastasis
c. Soft tissue bogginess
4. Full sensori-motor examination (see diagram)

5. Peri-anal/perineal exam
6. Spinal shock = spinal cord concussion
a. Bulbo cavernosus reflex
b. Conus injury

4. Steroids (Spine 2001; 26(24): S39-46)

A. Routine use of steroids in patients with acute SCIs is not
supported by the literature
B. Polytrauma patients may be more susceptible to complications
associated with the administration of high doses of steroids
1. Wound infections
2. Pulmonary complications: pneumonia, emboli
3. Sepsis
II.

RADIOGRAPHIC EVALUATION OF THE SPINE IN THE EMERGENCY

ROOM
1. Isolated Spinal Injury
A. Plain films if low energy; region specific
B. MDCT with reconstructive views
C. MRI
1. Neurological injury
2. Unexplainable clinical exam after MDCT
3. Pre-op assessment of soft tissue component of injury:
ligaments, disc, spinal cord
2. Spine Injury in Presence of Polytrauma
A. CT scan of Head/C-spine/Chest/Abd/Pelvis
1. Recon views for initial spinal screening
2. Dedicated MDCT for spinal pathology if initial CT inadequate
for full assessment
3. Dedicated MDCT for pre-op planning
B. MRI: Only if patient sufficiently stable
1. Neurological injury
2. Unexplainable clinical exam

3. Pre-op assessment of soft tissue component of injury:

ligaments, disc, spinal cord

III.

SPINAL ASSESSMENT
1. Biomechanical Stability: Definition: subject to much debate
A. 2-column: Holdsworth
B. 3-column: Louis, Denis< McAfee
C. Mechanistic classification: Magerl/ AO
i. Flexion --- predominant compression ( anterior column) injury
spectrum
ii. Distraction --- predominant extension ( posterior disruption)
injury spectrum
iii. Multi-directional instabilityno residual stability
D. Posterior ligamentous complex (PLC) integrity of high
importance to stability theories ( Spine 94 James)
i. MRI assessment of PLC
1. Spine 2000; 25: 2079-2084
2. Radiology 95; 194: 49-54 Black Stripe
3. Spine J 06; 6: 524-528
2. Neurology: #1 Driving factor to operative intervention
A. Intact neurology
i. Regardless of canal compromise: You cant be better than
neurologically intact
ii. Rare occasion of subacute neurological deterioration
B. Incomplete SCI/ Conus Injury
i. Tendency to want to create an environment for neurological
improvement through decompression
ii. Only animal studies document direct relationship between
length of time and severity of compression with respect to
neurological improvement
iii. Isolated Conus lesion demonstrates better improvement with
anterior decompression.
C. Complete SCI:
i. Biomechanical stability: no need for spinal procedure
ii. Unstable biomechanically: restore stability and avoid bracing
which can limit mobilization and lead to pressure sores in the
insensate.
3. Combined neurological and mechanical instability

Non-operative Management of
Thoracolumbar Injuries
Marcel Dvorak, MD, FRCSC
Professor of Orthopaedics
University of British Columbia
Vancouver General Hospital
Introduction:
Thoracolumbar burst fractures account for approximately fifteen percent of all
thoracolumbar spine injuries. Burst fractures occur as a result of an axial load which
produces comminution of the involved vertebral body with associated retropulsion of
bone into the spinal canal, hence the term burst fracture. Despite being a common
fracture, there is significant variability in treatment recommendations bridging the
spectrum from anterior vertebrectomy and reconstruction to mobilization without
external bracing. This controversy exists partly in response to ambiguity regarding the
definition of mechanical stability and the indications for operative treatment of these
fractures.
Stability of Thoraco-lumbar Fractures:
Generally, thoracolumbar burst fractures can be categorized as being clinically stable or
unstable from a mechanical or neurologic perspective. Denis proposed that injury to
middle vertebral column in addition to the anterior column is the hallmark of vertebral
instability. Contrary to the assertions of Denis, James et al found that the posterior
column is the most important contributor to spinal stability. They used staged
osteotomies to compromise the integrity of the anterior, then middle, and finally the
posterior columns of L1. The disruption of the anterior column alone, led to a significant
increase in angulation and translation of the T12-L2 motion segment when compared to
the intact spine. Further disruption of the middle column did not substantially change the
flexibility. Whereas, when the posterior ligaments were severed, there was a significant
increase in angulation over that observed when just the anterior and middle columns were
disrupted.
It is apparent from biomechanical studies, as well as clinical studies of Oner and others,
that both the vertebral body injury and the posterior element injuries contribute in
different ways to the resultant degree of stability or stiffness of the injured spine segment.
The challenge is to somehow quantify the degree of disruption of these various
anatomical structures and thus express their relative contribution to the overall stability of
the injured spine.

Stability as defined by Radiographs

Clinicians rely on radiographic parameters, such as kyphosis, vertebral comminution, and
loss of vertebral height, when determining fracture stability and the indications for nonoperative or surgical treatment. The loss of anterior unit height, which is the anterior
vertebral height plus the disc spaces above and below, has a strong correlation with
flexion-extension motion and axial stability. The deformation ratio; defined as the ratio
of the greatest sagittal vertebral diameter to the average of the anterior vertebral height
and posterior vertebral height correlates strongly with stability.
Neurologic Injury and Spinal Canal Occlusion
Neurologic deficit is associated with up to 50% of thoracolumbar burst fractures.
Dynamic canal encroachment at the moment of fracture differs from the static
encroachment measured after the injury has occurred. There is no significant correlation
between the occurrence or the extent of neurologic injury with the degree of spinal canal
occlusion measured by axial CT.
Comparative Surgical vs. Non-Operative Studies
There are a number of comparative studies looking at surgery vs non-surgical care for
thoracolumbar fractures without neurological deficit.
Wood, in a prospective trial found a statistically significant difference in function and
disability favouring non-operative treatment; however, significant methodological issues
reduce the impact of this conclusion. Shen found that correction of kyphosis was
achieved better through surgery. However, the degree of kyphosis was found to progress
regardless of treatment and final kyphosis did not correlate with pain or function, a theme
consistent throughout the literature. Shen suggested an improved outcome in the surgical
patients at 6 months but no difference at one year.
Siebenga, in a well designed and appropriately powered prospective study suggested that
surgery leads to improved outcomes, less pain and disability and improved return to
work.
Neurological deterioration in this population is rare. Surgery exposes patients to a greater
risk of both complication and possible future surgery.
Burst fractures of the thoracolumbar junction are common. There exists a wealth of
published studies concerning thoracolumbar burst fractures; however their
methodological quality is uniformly poor. At present, the available evidence to justify
the additional risks of surgery is minimal. Fisher has shown that use of a thoracolumbar
orthosis does not improve outcome when compared to mobilization without an orthosis.

It is possible that surgery is the treatment of choice for burst fractures at the
thoracolumbar junction without neurological deficit. Surgery theoretically may result in
earlier mobilization, and hospital discharge, less initial pain and faster return to work, an
issue of considerable economic relevance.
Although final sagittal alignment is better maintained in patients who have undergone
surgery, vertebral alignment does not seem to correlate with HRQoL outcomes. Until
further evidence becomes available, the clinician should consider these facts when
making treatment decisions in cases of this common injury.

References:
1) Hashimoto T, Kaneda K, Abumi K. Relationship between traumatic spinal canal
stenosis and neurologic deficits in thoracolumbar burst fractures. Spine 1988;
13(11):1268-1272.
2) Limb D, Shaw DL, Dickson RA. Neurological injury in thoracolumbar burst fractures.
J Bone Joint Surg Br 1995;77(5):774-777.
3) Mehta JS, Reed MR, McVie JL, Sanderson PL. Weight-Bearing Radiographs in
Thoracolumbar Fractures : Do They Influence Management ? Spine 29(5) : 564567.
4) Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, Vernon JD,
Walsh JJ. The value of postural reduction in the initial management of closed injuries
of the spine with paraplegia and tetraplegia. Paraplegia 1969;7(3):179-192.
5) Davies WE, Morris JH, Hill V : An analysis of conservative (non-surgical)
management of thoracolumbar fractures and fracture-dislocations with neural damage.
J Bone Joint Surg Am 1980;62:1324-1328.
6) Burke DC, Murray DD: The management of thoracic and thoracolumbar injuries of
the spine with neurological involvement. J Bone Joint Surg Br 1976;58:72-78.
7) Kinoshita H, Nagata Y, Ueda H, Kishi K. Conservative treatment of burst fractures
of the thoracolumbar and lumbar spine. Paraplegia 1993;31(1):58-67.
8) Hartman MB, Chrin AM, Rechtine GR. Non-operative treatment of thoracolumbar
fractures. Paraplegia 1995;33(2):73-76.
9) Rivlin AS, Tator CH. Objective clinical assessment of motor function after
experimental spinal cord injury in the rat. J Neurosurg 1977;47(4):577-581.
10) Rivlin AS, Tator CH. Effect of duration of acute spinal cord compression in a new
acute cord injury model in the rat. Surg Neurol 1978;10(1):38-43.
11) Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental
spinal cord compression injury. J Neurosurg 1980; 53(6):749-755.
12) Delamarter RB, Sherman J, Carr JB : Pathophysiology of spinal cord injury :
Recovery after immediate and delayed compression. J Bone Joint Surg Am
1995 ;77 :1042-1049.
13) Carlson GD, Minato Y, Okada A, Gorden CD, Warden KE, Barbeau JM, Biro CL,
Bahnuik E, Bohlman HH, Lamanna JC. Early time-dependent decompression for
spinal cord injury : vascular mechanisms of recovery. J Neurotrauma 1997;
14(12):951-962.

14) Holdsworth F: Fractures, dislocations and fracture-dislocations of the spine. J Bone

Joint Surg Am 1970;52:1534-1551.
15) James KS, Wenger KH, Schlegel JD, et al : Biomechanical evaluation fo the stability
of thoracolumbar burst fractures. Spine 1994;19:1731-1740.
16) Denis F: The three column spine and its significance in the classification of acute
thoracolumbar spinal injuries. Spine 1983;8:817-831.
17) Panjabi MM, Goel VK, Takata K. Physiologic strains in the lumbar spinal ligaments. An in
vitro biomechanical study. 1981 Volvo Award in Biomechanics. Spine 1982;7(3):192-203.
18) Panjabi MM, Oxland TR, Lin RM, McGowen TW : Thoracolumbar burst fracture:
A biomechanical investigation of its multidirectional flexibility. Spine 1994;19:578585.
19) Gertzbein SD: Scoliosis Research Society: Multicenter spine fracture study. Spine
1992;17:528-540.
20) Weinstein JN, Collalto P, Lehmann TR: Thoracolumbar burst fractures treated
conservatively: A long-term follow-up. Spine 1988;13:33-38.
21) Mumford J, Weinstein J, Spratt K, Goel V. Thoracolumbar burst fractures. The
Clinical efficacy and outcome of nonoperative management. Spine 1993; 18(8):955970.
22) Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH.
Functional outcome of thoracolumbar burst fractures managed with hyperextension
casting or bracing and early mobilization. Spine 1996; 21(18):2170-2175.
23) Shen WJ, Shen YS: Non-surgical treatment of three-column thoracolumbar junction
burst fractures without neurologic deficit. Spine 1999;24:412-415.
24) Kraemer WJ, Schemitsch EH, Lever J, McBroom RJ, McKee MD, Waddell JP.
Functional outcome of thoracolumbar burst fractures without neurological deficit. J
Orthop Trauma 1996 ; 10(8) :541-544.
25) Rechtine G, Cahill D, Chrin A. Treatment of thoracolumbar trauma : comparison of
complications of operative versus nonoperative treatment. J Spinal Disord
1999 ;12(5) :406-409.
26) Wood K, Butterman G, Mehbod A, Garvey T, Jhanjee R, Sechriest V: Operative
compared with nonoperative treatment of a thoracolumbar burst fracture without
neurological deficit. J Bone Joint Surg 2003;85-A:773-781.
27) Cantor JB, Lebwohl NH, Garvey T, Eismont FJ: Non-operative management of
stable thoracolumbar burst fractures with early ambulation and bracing. Spine
1993;18:971-976.
28) Siebenga, J, Leferink V, Segers M, et al: Treatment of Traumatic Thoracolumbar
Spine Fractures: A Multicenter Prospective Randomized Study of Operative Versus
Nonsurgical Treatment. Spine. 31(25):2881-2890, December 1, 2006.

Thoracolumbar Fractures
Anterior versus Posterior Surgical Options
John C France M.D.
Professor of Orthopaedic Surgery
West Virginia University
Determining Factors
1. Fracture Dependent
Ability to correct deformity (alignment) of fracture
Need or & ability to decompress neural elements
Ability to control fracture (stabilize)
Fracture level (e.g. Low lumbar)
Multiples levels
Fracture pattern
Compression
Burst
Flexion distraction
Extension
Fracture dislocation
Ankylosing spondylitis
Determining Factors
2. Surgeon/ Facility Dependent
Familiarity with approaches
Ancillary support (ICU & vascular, thoracic, or trauma surgeons)
Available equipment
Better to do what you do best
Determining Factors
3. Patient Dependent
Additional injuries
Medical Comorbidities
Osteoporosis
Body habitus
Desires of patient
Fracture Patterns
Generalities
Compression fracture
Stability & alignment only issues
Easily achieved posteriorly, short segment
Flexion distraction injuries

Neuro decompression may be simple realignment (disc herniation?)

Posterior tension band disrupted therefore restore posteriorly
Extension fractures
Associated with rigid spines
Long lever arms
Require multilevel fixation
Multiple level fixation better posteriorly
Fracture dislocations
High degree of instability, requires rigid fixation
(Traditionally posterior, some support anterior)
Sasso, RC et al J.Spinal Disord Tech 2005
May benefit from direct removal of bone from canal vs. indirect by
realignment
Burst fractures
Anterior or posterior options
Concept of anterior column support
Neuro deficit plays role
Level of fracture plays a role
Low lumbar vs. thoracolumbar
Most Controversial: Ant or Post

Surgical Decision Making

Anterior
Direct anterior decompression
Anterior support
Short segment
More involved
Posterior
Indirect decompression
Stronger construct
Include additional levels
More familiar
Anterior Versus Posterior Treatment of Stable Thoracolumbar Burst Fractures
Without Neurologic Deficit A Prospective, Randomized Study
K. B. Wood, MD, D. Bohn, MD, and A. Mehbod, MD
J Spinal Disord Tech 2005; 1 8(suppl 1):S 1 5-S23
43 enrolled, 38 completed a minimum of 2-year followup
18 posterior 20 anterior
Hospital stay and operating time were similar
Blood loss was higher in the group treated anteriorly; transfusion equal
There were 17 "complications" including instrumentation removal for pain in
patients treated posteriorly, 3 minor complications in 3 patients treated anteriorly.
Patient-related functional outcomes were similar for the two groups.

Decompression
If patient has deficit
Posterior

Ligamentotaxis

Posterior

Anterior

Ligamentotaxis with
posterolateral
decompression

Direct anterior
decompression

Limits of Posterior Decompression

Rotated fragment,
Create addition instability by bone removal
Diminish surface area for fusion
Bleeding
Verification

Decompression
Anterior
Direct visualization
Reconstruct with anterior column support through defect
Posterior
Indirect, more difficult to verify complete
Add to instability and decrease surface area for fusion mass
Both can be bloody
How much decompression necessary?

Stability
Axial load injuries
Burst or flexion-compression
Anterior column support: Load sharing concept
McCormack T, Karaikovic E, Gaines RW
Spine 1994 19:1741-1744

Special Circumstances
Osteoporosis
Posterior
Include extra levels
Percutaneous Fixation
Boney Chance
Multi-trauma
Summary
Spine trauma Surgeon should be familiar with both anterior & posterior
approaches
Can usually use surgeon preferred direction
Some circumstances clearly favor one direction need to recognize these

SACRAL FRACTURES Bellabarba

Sacral Fractures with Lumbosacral/Lumbopelvic

Instability
Carlo Bellabarba, M.D
Associate Professor
Department of Orthopaedics
University of Washington School of Medicine
Harborview Medical Center
Seattle,Washington
Harborview Medical Center
325 Ninth Ave., Seattle, WA 98104
Tel.: (206) 731-3466
Fax: (206) 731-3266
cbella@u.washington.edu

1.

Introduction
- Sacrum: cross-shaped (Latin), bony structure at intersection of two anatomic
entities, spine and pelvis.
- Treatment of sacral fractures ideally combines the experience of spine surgeons
perspective of neuroanatomy/physiology and spinal stability with a perspective
on alignment as well as the traumatologists insight in patient resuscitation and
pelvic ring stability.

2.
Anatomic Overview
Osseous structures:
- 5 fused segments (number of sacral segments subject to variation with
transitional lumbosacral vertebrae)
- Caudally decreasing vertebral body and spinal canal size
- Kyphotically aligned
- Sacral kyphosis varies: 45 to 60 o (range: 10 o to more than 90 o)

SACRAL FRACTURES Bellabarba

- 4 ventral and dorsal sacral neuroforamina
- Structural integrity of the sacrum depends on surrounding ligamentous structures
Neural anatomy:
- Lumbosacral plexus (L4 S1)
- Sacral plexus (S2 S4)
- L5 root shoulders the sacral ala
- Passage space of sacral nerve roots in ventral foramina is proportionally
narrowest at S1 and relatively most capacious at S4 (S1 and S2 roots: 25 35 %
of the ventral sacral foraminal space occupied by roots, S3 and S4, occupy 10
16 % of ventral foraminal space
- Caudal end of dural sac at S2 segment
- Sacral root function can be affected by direct injury, sacral angulation, translation
and direct compression in spinal canal or ventral foramina.
3. Patient Evaluation
Basics:
- Sacral fractures are easily missed!
- Low energy mechanism: insufficiency fractures with metabolic or neoplastic
disease
- High-energy injury mechanisms: MVC, MCC, falls, jumps > 10 feet height.
- Follow ATLS protocol for high-energy mechanism trauma patients
Examination focus:
- Circumferential inspection and palpation of torso
- Bruising and ballottable subcutaneous fluid collections
- Pelvic /sacral trauma requires rectal and vaginal (where applicable) examination
to assess for occult open pelvic ring fracture
- Anal sphincter function reflects sacral root function
- Components:
- spontaneous sphincter tone
- reflex function
- perianal, buttock and posterior thigh sensation
- best-effort voluntary anal sphincter contraction
- L5 and S1 assessment important in sacral fractures, including traction signs
Radiographic evaluation
- Pelvis AP view
- Pelvic inlet and outlet views
- (Ferguson view: true sacral AP)
- Sacrum lateral
- Pelvis CT scan with any suspicion of pelvic ring or sacral fracture
- Sacral CT scan with sagittally and coronally reformatted views for complex
sacral fracture
- MRI rarely necessary for acute trauma
- MRI neurography for unclear posttraumatic sacral radiculopathy
Electrodiagnostics
- Perineal SEPs
- Anal sphincter EMG (both also for intraoperative monitoring)
- Cystomyography and post-void residuals for follow-up on neurogenic bladder
Timing:
Collate various factors such as:
- systemic injury load
- soft tissue injury
- initial neurologic injury or evolution thereof
- fracture displacement
- ligamentous versus bony disruption

SACRAL FRACTURES Bellabarba

4.
-

Classification
Stable versus unstable
Three basic categories of pelvic region injuries:
- Pelvic ring fractures (Tile, Letournel, AO/ASIF)
- Lumbo-sacral junction disruption (Isler) Sacral fractures: Denis
- Roy-Camille sub-classification system for transverse Denis Zone III fractures.

Category

Pelvic Ring

Lumbo
sacral
junction

Sacrum

Tile
Letournel
AO/ASIF

Isler

Denis
Roy-Camille
(Subclassificatio
n of Denis Zone
III)
Descriptive
alphabet pattern

Prevalent
Injury Zone

Classification system

Pelvic ring injury Category B: Lumbo-sacral junction trauma:

- Dislocation versus fracture dislocation
- Unilateral versus bilateral
Classification of Isler differentiates location of a sacral fracture relative to L5 - S1 stability.
1.
Fracture lateral to the L5 S1 facet joint: lumbo-sacral stability not impaired
2.
Injuries crossing through the L5- S1 facet joint
a)
extra-articular fractures of the lumbo-sacral junction
b)
articular dislocations with various stages of displacement of the L5 and S1 articular
processes.
3.
Fractures crossing into the neural arch medial to the L5-S1 joint are usually complex
and inherently unstable in nature.

SACRAL FRACTURES Bellabarba

Pelvic ring injury Category C: Sacral fractures:
Descriptive letter system: H, U, T or lambda fracture pattern
Not standardized but helpful for communication

.
Three-Zone system (Denis 1988)
This system correlates with incidence and type as well as frequency of neurologic injury
- Zone I injury: Alar fracture, injury lateral to sacral neuroforamina. L-5 root injury
- Zone II injury: Transforaminal fracture
- Zone III injury: Any sacral fracture extending into the spinal canal

Sublassification of Denis Zone III sacral fractures by Roy-Camille modified by StrangeVognsen

- Type 1: simple flexion deformity of the sacrum
- Type 2: flexion and translational deformity
- Type 3: complete translation of the upper to the lower sacral elements
- Type 4 (Strange-Vognsen): Segmentally comminuted S1 vertebral body

5.

Treatment

Goals:
-

Optimize chances for patient survival

Assure pelvic ring and lumbosacral stability
Protecting neural structures or optimizing their recovery potential in the presence of deficits.

Nonoperative management
- Options:
- Activity modification
- Bed-rest

SACRAL FRACTURES Bellabarba

-

Brace or cast immobilization with unilateral or bilateral hip spica extensions

Recumbent skeletal traction
Duration: 8 to 12 weeks

Decompression Techniques
Posterior: central spinal canal or neuroforaminal decompression
Indication: reduction of the size of the first or second sacral foramen by 50 per cent in conjunction with
sciatica-type symptoms
Technique: midline exposure with hemilaminotomy/ laminectomy emanating from the L5/S1 laminar
interspace preferable to a parasagittal approach to avoid soft tissue compromise.
Bilateral parasagittal approaches , such as necessary for bilateral transiliac iliac platings, such be if at all
possible, avoided due to high soft tissue breakdown rate.
Anterior: ilioinguinal or low transperitoneal exposure
Indications: patients with lumbosacral plexopathy who require prealar neurolysis of decompression (rare)
Decompression techniques:
- Direct (fragment removal, laminectomy etc.)
- Indirect (fracture reduction, ventral disimpaction, sacral kyphectomy)
Surgical Stabilization Techniques
- Assess anterior fixation needs first
- Posterior pelvic ring stabilization
- Transiliac threaded compression rods (largely outdated)
- Iliac tension band plates (requires bilateral parasagittal approaches)
- Sacral alar plating (small fragment plates inserted into ala lateral to posterior
neuroforamina) limited usefulness due to frequent comminution and limited
biomechanical stiffness
- Open or percutaneous sacro-iliac screw fixation (for a wide variety of mildly and
moderately displaced sacral fractures)
- Galveston-type lumbo-iliac fixation techniques (for complex sacral H and U type
fractures); newer systems allow for segmental screw fixation to ileum instead of rod
placement.
- Segmental lumbo-screw screw/rod fixation for lumbo-sacral dislocation
6. References:
1. Bellabarba C, Schildhauer TA, Vaccaro AR, Chapman JR: Complications associated with
Surgical Stabilization of High-Grade Sacral Fracture-Dislocations with Spino-Pelvic
Instability. Spine 31(11S):S80-88, 2006.
2. Chapman JR, Schildhauer TA, Bellabarba C, Nork SE, Mirza SK: Treatment of Sacral
Fractures with Neurologic Injuries. Top Spinal Cord Inj Rehabil, 8(2): 59-78, 2002.
3. Denis F, Davis S, Comfort T. Sacral fractures: An important problem. Retrospective analysis
of 236 cases. Clin Orthop 1988;227:67-81.
4. Isler B. Lumbosacral lesions associated with pelvic ring injuries. J Orthop Trauma
1990;4:1-6.
5. Josten C, Schildhauer TA, Muhr G: Therapy of unstable sacrum fractures in pelvic ring.
Results of osteosynthesis with early mobilization] Chirurg. 1994 Nov;65(11):970-5. German.

SACRAL FRACTURES Bellabarba

6. Nork SE, Jones CB, Harding SP et al. Percutaneous stabilization of U-shaped sacral
fractures using iliosacral screws: Technique and early results. J Orthop Trauma 2001;15:23846.
7. Oransky M, Gasparini G: Associated lumbosacral junction injuries (LSJIs) in pelvic
fractures. J Orthop Trauma. 1997 Oct;11(7):509-12.
8. Phelan ST, Jones DA, Bishay M. Conservative management of transverse fractures of the
sacrum with neurological features: A report of four cases. J Bone Joint Surg [Br] 1991;73:96971.
9. Roy-Camille R, Saillant G, Gagna G, et al. Transverse fracture of the upper sacrum: Suicidal
jumpers fracture. Spine 1985;10:838-45.
10. Savolaine ER, Ebraheim NA, Rusin JJ, et al. Limitations of radiography and computed
tomography in the diagnosis of transverse sacral fracture from a high fall. A case report. Clin
Orthop 1991;272:122-126.
11. Schildhauer TA, Ledoux WR, Chapman JR, et al. Triangular osteosynthesis and iliosacral
screw fixation for unstable sacral fractures: A cadaveric and biomechanical evaluation under
cyclic loads. J Orthop Trauma 2003;17:22-31.
12. Schildhauer TA, McCulloch P, Chapman JR, et al. Anatomic and radiographic
considerations for placement of transiliac screws in lumbopelvic fixations. J Spinal Disord
Tech 2002;15:199-205.
13. Schildhauer TA, Josten CH, Muhr G. Triangular osteosynthesis of vertically unstable
sacrum fractures: A new concept allowing early weight bearing. J Orthop Trauma
1998;12:307-14.
14. Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt MLC, Chapman JR:
Decompression and Lumbopelvic Fixation for High Grade Sacral Fracture-Dislocations with
Spino-Pelvic Dissociation, J Orthop Trauma 20:447-457, 2006.
15. Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum. J
Orthop Trauma 1991;5:200-3.
16. Strange-Vognsen HH, Kiaer T, Tondevold E: The Cotrel-Dubousset instrumentation for
unstable sacral fractures. Report of 3 patients. Acta Orthop Scand. 1994 Apr;65(2):219-20.