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Alan M. Levine, M.D.

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35
Fractures of the Sacrum Fractures of the Sacrum

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Alan M. Levine, M.D.

Treatment of injuries to the sacrum requires consideration of a number of additional factors beyond those relevant to injuries of the thoracic and thoracolumbar spine. These factors are related to the anatomic complexity of the sacrum, difculty with xation to the sacrum, and the relatively large forces necessary to achieve and maintain reduction and increased normal mobility of the lumbosacral junction. Additionally, sacral fractures encompass a wide variety of entities that range in severity from a simple buckle fracture of the sacral ala to a severely comminuted fracture associated with major injury to the pelvis. The spectrum is also broad when the causes of the injury are considered along with the epidemiology of the affected individuals. These fractures may be the result of highenergy trauma such as motor vehicle and motorcycle accidents or suicide attempts involving younger individuals, as well as insufciency fractures and low-energy falls involving older persons. Throughout the 1970s and 1980s, the lack of satisfactory techniques for reduction and stabilization of injuries in the sacrum frequently resulted in less than optimal treatment results and led some authors to espouse nonoperative techniques as a better alternative.14, 25, 27 Occasional reports, however, suggested that an operative approach yielded better anatomic results and perhaps even better functional outcomes.44, 68 Even with the more widely accepted use of pedicle screw xation in the lumbar spine and various methods of sacral xation in North America, some early, poorly conceptualized operative approaches to fractures in this region also led to early failure.4, 5, 40, 77 These results caused some surgeons to accept chronic pain and the failure to return to preinjury occupation as the norm in this very young group of patients. The lumbosacral junction in particular must resist a number of large forces, but it must also permit a signicant amount of motion. It has therefore been difcult to obtain anatomic reduction and reconstruction of the lumbar spine and sacrum until the most recent advances in instrumentation. This difculty has led many authors to suggest either limited procedures and goals or benign neglect as the

methods of treatment of sacral injuries. In addition, in the sacrum, failure to recognize the nature of the injuries and their severity has resulted in a lack of organized treatment schemes. The normal kyphotic sagittal conguration of the sacrum and the many overlying structures have made imaging difcult, even with the use of standard twodimensional computed tomography (CT). Fixation to the bone of the sacrum has been even more problematic. These numerous features and problems distinguish fractures of the sacrum from the more abundant and common fractures at the thoracolumbar junction. More accurate diagnostic imaging studies, as well as advances in instrumentation techniques, should now allow us to treat sacral injuries with the same degree of accuracy and competence as more proximal spinal injuries. To this end, however, we must have a clear understanding of the anatomic and functional differences that distinguish the sacrum from the remainder of the more proximal areas of the spine. Treatment goals for spine trauma in general are (1) anatomic reduction of the injury, (2) rigid xation of the fracture, and when necessary, (3) decompression of the neural elements. For treatment of the sacral spine, we must add the considerations of (4) maintenance of sagittal alignment and (5) prevention of frequent complications (e.g., loss of sacral xation, failure to attain decompression and reduction, and pseudarthrosis). As the characteristics of the sacrum are reviewed, it will become evident that techniques that were discussed in the previous section for the treatment of cervical, thoracic, thoracolumbar, and lumbar spine injuries are not applicable to the treatment of sacral injuries.

ETIOLOGY AND EPIDEMIOLOGY

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Sacral fractures can be subdivided into several major categories based on etiology. The most common etiology of sacral fractures is high-energy trauma resulting in major pelvic disruption, which has a high incidence of associated
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sacral fractures. Pohlemann and associates62 found that 28% of patients with pelvic ring injuries had sacral fractures (377 sacral fractures/1350 pelvic fractures), and Denis and colleagues reported a 30% incidence (236 sacral/776 pelvic).18 Most of these fractures are vertical in orientation and may be either unilateral or bilateral; in addition, they may occasionally have a transverse component. Isolated sacral fractures are much more uncommon and represent approximately 5% to 10% of all traumatic injuries that occur as a result of high-energy accidents. Most of the isolated fractures are transverse and result from direct trauma such as a fall from a height.74 The nal type of sacral fracture is an insufciency fracture, which occurs either spontaneously or after a trivial episode of trauma.72 Most patients in whom insufciency fractures of the sacrum develop have predisposing factors such as osteopenia, chronic steroid use, or pelvic irradiation.52, 72 The actual incidence of this type of fracture is unknown because recognition and diagnosis have not been frequently emphasized. Although more than 500 cases have been reported in the literature,24, 38 the incidence is considerably higher because insufciency fractures are an unrecognized cause of back pain in elderly female patients.15, 33

ANATOMIC FEATURES

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The sacrum forms both the terminal portion of the spine and the central portion of the pelvis. Its ve fused vertebrae give rise to an overall kyphotic sagittal alignment that inuences the alignment of the mobile spine above it. The normal kyphosis of the thoracic spine falls within a range of 15 to 49,86 whereas normal lumbar lordosis is generally thought to be less than 60. These values are in part determined by the slope of the sacral base, which averages approximately 45 from the horizontal. This angle is critical in determining the amount of shear force76 to which the lumbosacral junction is subjected. Anatomic differences in the structure of the lumbar vertebrae and sacrum inuence therapeutic decisions and make attachment of xation devices necessarily different from that for proximal levels in the thoracic and lumbar spine. The sacroiliac joint, which joins the sacrum to the rest of the pelvis, includes the lateral portions of S1, S2, and part of S3, with the more caudal portions of the sacrum remaining free. The stability of the sacroiliac joint is maintained by strong ligamentous attachments such as the anterior and posterior sacroiliac ligaments, the sacrotuberous ligaments, and the sacrotransverse ligaments. The strength of this ligamentous complex helps determine the location of fractures of the sacrum, with transverse fractures commonly occurring at the midportion of S3 at the end of the sacroiliac attachment. Similarly, vertical fractures occur through the ala rather than through the joint as a result of the strength of the sacroiliac joint in resisting disruption. With caudal descent in the lumbar spine, the overall dimensions of the canal enlarge, whereas the area occupied by the neural elements decreases. The cord in the thoracic region measures approximately 86.5 mm2 and is housed within a canal that is generally 17.2 16.8 mm2. Thus, in

the thoracic region, the cord occupies about 50% of the canal area. In the thoracolumbar region, the conus broadens, as does the canal. The spinal cord usually terminates at approximately L1. In the lumbar region, the canal is typically large (23.4 17.4 mm2).21, 64 Here, the roots of the cauda equina are the only contents. In the sacrum, however, the diameter of the canal again begins to narrow and atten. In addition, with the normal, slightly kyphotic angle at the midpoint of the sacrum (S2S3), the roots are tethered in a relatively xed location. This tethering of the roots allows less exibility in placing any xation devices within the canal in the sacrum. The sacral roots are responsible for urinary continence, micturition, fecal continence, defecation, and sexual function. After emanating from the conus medullaris, the sacral roots traverse the canal of the lumbar spine in a relatively posterior location and exit through the ventral and dorsal foramina. Fractures through the sacral ala can also result in an L5 root injury as demonstrated by Denis and associates.18 This root exits the foramen and traverses over the top of the sacral ala such that displacement of the alar fracture can cause injury to the root. Denis and co-workers also evaluated the frequency of injury to individual sacral roots and found that root injury at the ventral foramen was less likely at S3 and S4 than at S1 and S2 because of a signicant difference in the root-to-foramen ratio in the two areas. Because innervation of bowel and bladder function is by bilateral sacral roots, injury to one side does not disrupt sphincter function whereas bilateral injury does.34 With the increasing emphasis on innovative methods of xation for injuries in the low lumbar spine and sacrum, an understanding of the pertinent anatomic dimensions takes on new signicance. Previously, with hook xation or sublaminar wiring to the posterior elements, the only important consideration was the posterior topographic anatomy. However, the dimensions, position, and orientation of the pedicles, as well as the shape of the vertebral body, are likewise critical. The initial anatomic description of pedicle morphology with respect to pedicle screw xation was presented by Saillant70 in 1976 and conrmed by two later studies from North America.41, 87 The critical features are the sagittal and transverse width of the pedicles, pedicle length, pedicle angle, and chord length (depth to the anterior cortex along a xed orientation). Understanding the three-dimensional anatomy of the various sacral levels, as well as the position of the neurovascular structures applied to the anterior surface of the sacrum, is critical to the conceptualization of adequate and safe xation to the sacrum. The anatomic constraints of the sacrum are quite severe, with its overall sagittal contour being gradually kyphotic at about 25 with the apex at S3. The sacral laminae are extremely thin and might be absent in some areas. At their maximal thickness, the sacral alae are between 40 and 45 mm. The area of maximal bone thickness is in the vestigial pedicle of each sacral segment, and this area rapidly decreases in size with progression to the distal segments. At S3 or S4, the maximal thickness may only be 20 mm. The anatomic structures that may be encountered at the level of the S1 body are the internal iliac vein, the lumbosacral plexus, and the sacroiliac joint. A safe zone about 2 cm wide and bordered by the sacral

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promontory medially and the iliac vein laterally is present and invariably entered with orientation of a screw along the S1 pedicle.50 Screws can be directed only medially at the S1 level because the critical neurovascular structures will then lie lateral to the sacral promontory. Screws placed laterally at either 30 or 45 are aimed at a smaller lateral safe zone. The more lateral orientation provides for a longer screw length of 44 mm.50 The S1 level is the only segment that will allow simultaneous screw placement in the lateral and medial directions. Screw placement should be bicortical for maximal purchase. At the S2 level, the only vulnerable structure is the sigmoid colon on the left side. Penetration through the cortex by more than 1 cm is usually necessary for injury. At the S2 level, the thickness of the sacral bone has decreased signicantly compared with that at the S1 level, and thus, the holding power of the bone in an axis parallel to placement of S1 would be signicantly less. To compensate for these deciencies, orientation of xation devices proximally and laterally will signicantly increase the length of screw purchase and therefore pull-out strength. Variations in the amount of cancellous and cortical bone mass in different regions of the sacrum signicantly affect xation possibilities and the risks associated with xation. Because of increased bone mass, sacrum xation is more secure in the ala or vertebral bodies than in the very thin posterior laminar structures. Anatomic considerations are different for vertical sacral alar fractures that require xation. Iliosacral xation is dependent on visualizing the anterior border of the ala on the inlet view, which can be difcult. As a result of the concavity of the ala, it is easy to misdirect screws anterior to the ala and jeopardize neurovascular structures. The starting point for percutaneous iliosacral screws is based on landmarks on the lateral aspect of the ilium. Preoperative planning based on CT allows accurate assessment of the anatomic relationships. The use of image intensication for screw guidance requires accurate identication of the anterior and superior aspects of the sacrum to avoid exiting the ala anteriorly and then reentering it more medially. As a result of the contour of the body, passage of screws is safer at S1 than at S2, and use of S2 should be reserved only for patients with severe comminution of the S1 ala.

SACRAL INJURY PATTERNS

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Facet Fractures and Dislocations

Facet injuries to the lumbar spine occur infrequently. Levine and colleagues noted that bilateral facet dislocations below L1L2 represent only 10% of the total cases,45 and those at the lumbosacral junction are even less common. The important feature of this type of exiondistraction injury is that it is mainly a soft tissue injury that results in complete disruption of the posterior ligamentous complex, as well as the intravertebral disc. The bony architecture of the facets may remain intact in many cases, but they are totally juxtaposed and dislocated. The minor compression of the anterior portion of the inferior body is merely a result of the severe ligamentous injury and does not contribute to the overall instability of the injury. The

posterior walls of the vertebral bodies remain intact, and canal compromise results from translation of one intact vertebral ring in relation to the adjacent ring. This injury must be differentiated from a facet fracture, which is a different injury mechanically and consists of comminution of the facets and sometimes also the laminae, pars interarticularis, and vertebral body. The severe translation observed with facet dislocations may lead to partial or complete cauda equine syndrome. This severe translation is a result of posterior ligamentous disruption combined with severe disc disruption. Denis17 suggested that complete posterior disruption is insufcient to account for the degree of exion instability seen in this injury. Only incompetence of the posterior longitudinal ligament, anulus brosus, and disc could produce such a degree of translational instability. The anterior longitudinal ligament is often stripped from the anterior portion of the inferior body but remains intact. A number of authors37, 46, 48, 84 have suggested that this might be a exion-distraction injury with the axis of rotation posterior to the anterior longitudinal ligament. Radiographs of facet fractures and dislocations at the lumbosacral junction are usually diagnostic. They demonstrate an intact posterior wall at L5 with signicant translation, lesser degrees of anterior compression, and loss of disc height (Fig. 351). Anteroposterior (AP) radiographs of the lumbar spine often reveal dislocation of the facets. CT conrms the pathology and demonstrates an empty facet sign,56 as well as the severity of canal compromise on sagittal reconstructions.29 Although unilateral facet dislocations and fracturedislocations are rare in the thoracic or lumbar spine, unilateral facet injuries have been reported to occur to a disproportionate degree at the lumbosacral junction.11, 13, 16, 19, 36, 42, 53, 71, 88 For unilateral facet dislocations to occur, a combination of exion-rotation and distraction is required. Facet fracture-dislocations can occur when the extent of distraction is not sufcient to allow the inferior facet to clear the superior facet. An element of shear is present in both unilateral and bilateral facet fracture-dislocations. It is of note that in the more recent literature, a number of case reports have documented the combination of a unilateral lumbosacral facet dislocation and an associated sacral fracture.13, 20, 35, 81 Recognition of these unusual high-energy injuries is predominantly due to improved imaging of the sacrum. The combination of a facet dislocation and a sacral fracture, especially if comminuted, can complicate xation at the lumbosacral junction. The implications for postreduction stability are signicantly different for a true facet dislocation (intact facets) and a fracture-dislocation. Unilateral dislocations or fracture-dislocations differ from bilateral dislocations in that on the AP view, a signicant rotatory component can be seen in the former. In addition, in unilateral dislocations and fracturedislocations, avulsion of the transverse processes may be seen.

Sacral Fractures
Until recently, fractures of the sacrum were combined with fractures of the pelvis,28 although they were rst men-

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FIGURE 351. Unilateral facet dislocations in the lumbar spine are exceedingly rare and have a rotational abnormality that is often diagnostic. A, On a lateral radiograph, rotational malalignment is indicated by the step-off between the posterior walls of L5 and S1 (dotted lines). B, Anteroposterior radiograph demonstrating asymmetry of the disc space, as well as a suggestion of widening of the facet at L5 and S1 (arrow). C, Computed tomographic scan demonstrating a dislocated facet with the inferior articular process of L5 lying anterior to the superior articular process of S1 (arrow). (AC, From Kramer, K.M.; Levine, A.M. J Bone Joint Surg Am 71:12581261, 1989.)

tioned by Malgaine in 1847. Bonin7 was one of the rst to attempt to characterize these injuries. He identied six different types of sacral fracture from a review of 44 pelvic injuries, 45% of which were also associated with sacral fractures. He also provided a discussion of the mechanisms of injury, as well as the occurrence of neurologic decit. Although a number of reports have been published,9, 10, 22, 23, 26, 49, 63, 85 less than 5% of all sacral fractures occur as isolated injuries. As mentioned previously, in addition to the association with pelvic fractures, the combination of lumbosacral dislocation with facet injury and sacral fracture is a relatively common pattern.13, 35, 81 Similarly, a more recent study3 identied 17 patients with concomitant noncontiguous thoracolumbar and sacral fractures. The implications are signicant in that ve of the sacral fractures were missed initially, thus resulting in the possibility of continued or additional injury to the distal roots. Two reports18, 73 attempted to classify sacral fractures by manageable criteria so that they could be correlated with the fracture pattern, neurologic decit, and treatment options. Sacral fractures can be caused by direct trauma to the sacrum, but most result from indirect forces acting on the pelvis or lumbar spine. Sacral fractures are usually classied according to the direction of the fracture line; thus, fractures can be vertical, transverse, or oblique (Fig. 352). Most sacral injuries, however, are vertical. After reviewing the literature and their own series, these fractures were classied in a useful fashion by Schmidek and colleagues73 into indirect and direct patterns. Indirect patterns of vertical fractures include (1) lateral mass fracture, (2) juxta-articular fracture, (3) cleaving fracture, and (4) avulsion fracture (Fig. 353). In addition, they included high transverse as

the nal type of indirect mechanism and considered gunshot wounds and low transverse fractures to be direct mechanisms of injury. Sabiston and Wing suggested a simpler three-part classication69 (Figure 354). Denis and associates18 classied 236 sacral fractures into zones based on both clinical and anatomic cadaveric studies of the sacrum. The three zones that they thought had clinical signicance were zone 1, which was the sacral ala up to the lateral border of the neural foramen; zone 2, which was the neural foramen; and zone 3, which included the central portion of the sacrum and the canal (Fig. 355). In this series, 118 patients had fractures in zone 1, 5.9% of whom had neurologic decits. These injuries were frequently fractures caused by lateral compression of the pelvis, vertical shear fractures, or sacrotuberous avulsions.18 The next group was zone 2, or foraminal fractures. These fractures involved one or more foramina, and the fracture line exited through the sacral canal without involvement of the central neural canal. This type of fracture was found in 81 of 236 patients, and 28.4% of these patients had some neurologic ndings. Zone 2 injuries often resulted from vertical shear fractures. The nal group of patients had zone 3, or central sacral canal involvement. These injuries were seen less frequently, in only 21 of 236 patients, but had a high rate of neurologic decit (56.7%). This group included some patients who had a transverse component of the fracture. Oblique fractures most often combine some element of a transverse fracture with that of a vertical fracture. In addition, an oblique fracture is the type that may involve both the sacrum and the lumbosacral junction. Thus, an oblique component ends proximally in a fracture at the base of the S1 facet or goes directly through the facet joint.

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As a result, the level and complexity of the instability are increased. Transverse fractures of the sacrum occur less frequently than vertical fractures7, 25, 68 and account for approximately 4.5% to 10% of each series. They most commonly result from high-energy injuries, such as falling from a height onto the lower extremities. As characterized by Roy-Camille and co-workers68 from their own series of 13 patients and extensive cadaveric studies, these fractures are generally high transverse fractures (S1 or S2) with anterior bending (kyphosis) between the superior and the inferior fragments and verticalization of the distal fragment. They are frequently associated with bilateral alar fractures and fractures of the L5 transverse process. Displacement and tilting of the fragments can be related to the relative exion or extension of the hips at the moment of impact. Direct blows to the sacrum can result in low transverse fractures (S3 or S4) by levering on the distal segments below the point of xation by the sacroiliac joints. Three distinct types of fractures were identied. Type I was a exion injury without signicant deformity, type II was a exion injury with posterior displacement of the cephalad frag-

ment, and type III was caused by extension with anterior displacement of the cephalad fragment. Depending on displacement, these transverse fractures can be associated with rectal perforation or cerebrospinal uid leakage. They are frequently associated with neurologic decits, including bowel and bladder dysfunction and perineal numbness. No motor weakness is usually detected. These fractures are, therefore, the most easily missed and have the gravest implications for signicant neurologic decit. Generally found in the S2S3 region, they may be responsible for complete loss of bowel and bladder function. The diagnosis is usually very difcult on plain radiographs and may also be missed on CT because the fracture is parallel to the axial cuts and thus may not be well visualized even with two-dimensional reconstruction. Interestingly, the most predictable method of visualization for this particular type of sacral fracture seems to be magnetic resonance imaging (MRI) (see Fig. 356). Recognition plus description of the patterns observed in sacral insufciency fractures is a relatively recent occurrence that is in large part due to the use of MRI. Because the fractures are visualized infrequently on plain

FIGURE 352. Fractures of the sacrum can be classied in a number of different ways. One of the most common is that of the direction of the fracture line within the sacrum. Therefore, fractures can be vertical (A), oblique (B), or transverse (C). These fractures can occur at any level in the sacrum. Vertical fractures may occur in the alae or through the foramina. Similarly, oblique fractures may occur at any location. Transverse fractures are less common and are found more frequently at the apex of the sacral kyphosis between S2 and S3, but they may also occur as a high transverse fracture at S1 or S2.

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B Oblique A Vertical
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C Transverse

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FIGURE 353. Schmidek and colleagues classied vertical fractures into four fracture patterns, including lateral mass fractures (A), juxta-articular fractures (B), cleaving fractures (C), and avulsion fractures (D). (AD, Redrawn from Schmidek, H.H.; et al. Neurosurgery 15:735746, 1984.)

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radiographs, the observer must often depend on areas of edema and compaction observed on MRI to nd all the fracture lines. A number of different patterns are seen, including a single vertical line parallel to the sacroiliac joint,12, 32 but the most commonly described pattern is the H or Honda sign.8, 58 Peh and coauthors58 described a series of 21 patients with insufciency fractures of the sacrum, 9 of whom had the H conguration. Four patients had high bilateral sacral fractures without the bar, and four had unilateral sacral ala fractures. Two had bilateral fractures with a partial transverse element, and one each had a unilateral ala fracture with a transverse component. The nal patient had only a transverse component. Classication of these injuries may require a combination of bone scintigraphy, CT, and MRI.

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height or ejection from a motor vehicle or motorcycle have the potential for either a pelvic ring fracture combined with a sacral injury or an isolated sacral fracture. Physical examination should include palpation of the entire spinal column, pelvis, and sacrum, as well as visual inspection for ecchymosis or bruising. As part of the routine physical examination, the perineum and especially the anus should be assessed for normal sensation and tone. In patients with signicant trauma to the urethra or the rectum, rectal perforation may be present. Rectal perforation may also occur in association with a transverse fracture of the sacrum without any other injury to the pelvis, depending on the direction of displacement of the sacral fracture. Assessment of an elderly patient with low back or sacral pain should also include a very careful evaluation of the sacral region. A clinical history of previous irradiation, signicant osteopenia resulting from a drug effect, or senile osteoporosis should also be elicited.15, 33, 52, 82 Neurologic complications of insufciency fractures are rare,38 but a careful history of bowel and bladder function should be obtained. Such a history may be confusing, especially if the patient has been taking narcotics for the pain and now has constipation secondary to the pain medication obscuring changes in bowel function. In view of the low yield of plain

EVALUATION

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz After resuscitation and general evaluation of a trauma victim, it is very important to ascertain the details of the accident from either the patient or the rescue personnel. High-energy decelerating injuries such as falls from a

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radiographs in these patients, a technetium-labeled bone scan should be performed early in the course of the patients symptoms.

Neurologic Decit
1 2 3

Sacral injuries may be associated with neurologic decit, depending on the type of injury and the direction of the fracture line. Patients with vertical fractures involving the sacral roots on just one side can have normal bowel and bladder function and only subtle sensory decits, unless the S1 root is involved. Transverse fractures of the sacrum with translation, however, are accompanied by neurologic decit in almost all patients. Zone 1 vertical alar fractures are associated with neurologic decit in 5.9% of patients, and the decit usually involves only the sciatic nerve or the L5 root and is generally minor. Zone 2 sacral fractures are associated with neurologic decit in approximately 28.4%

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FIGURE 355. Denis and associates classied 236 fractures of the sacrum into zones. Zone 1 was the region of the ala, and fractures in this area occurred in 118 patients, 5.9% of whom had neurologic decits. Zone 2 was the foraminal region, where the fracture line involved one or more foramina and exited without involvement of the central neural canal. This group comprised 81 patients, 28.4% of whom had neurologic ndings. The nal group of patients had zone 3 injuries, or central canal involvement. This pattern was seen in only 21 patients, but they had an extremely high rate of neurologic decit (56.7%). (Redrawn from Denis, F et al. Clin Orthop 227:6781, 1988.) .;

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FIGURE 354. Sabiston and Wings classication of sacral fractures had three main types. Type A included vertical fractures, type B consisted of transverse fractures below the level of the sacroiliac joint, and type C fractures were transverse at the level of the sacroiliac joint with vertical components. (Redrawn from Sabiston, C.P.; Wing, P.C. J Trauma 26:11131115, 1986.)

of patients, a small proportion of whom have bowel and bladder involvement. The remainder have sciatica associated with L5, S1, or S2. The L5 root can be associated with a displaced vertical shear fracture and fracture of the transverse process of L5, a combination that has been termed the traumatic far-out syndrome.18 This injury is most frequently associated with footdrop. Zone 3 fractures involve the central sacral canal and are associated with neurologic decit in at least 50% of patients. Most of these patients have bowel, bladder, and sexual dysfunction. The remainder of patients with injury at this level have L5 or S1 ndings. With neurologic injury from S2 to S5, impairment of bowel and bladder function can occur, but patients might not have functional incontinence with preservation of at least one of the two S2 and S3 roots. Bilateral root disruption invariably leads to severe decits. Cystometry performed in conjunction with sphincter electromyography can be useful in correlating ndings from clinical examination. With all sacral fractures, however, a complete investigation should be carried out because it is often difcult to ascertain whether the root involvement is a result of the pelvic fracture or the associated sacral fracture. Neurologic complications of insufciency fractures are exceedingly rare. In the few reported cases, the onset of neurologic decit was delayed in relation to the onset of

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fracture symptoms.38, 60 Urinary retention, as well as numbing and tingling of the feet, has been reported. The mechanism of onset of neurologic symptoms associated with this entity is unclear in that the onset is not always associated with displacement. Surgery is not generally required because resolution of the neurologic symptoms seems to occur spontaneously with resolution of the back symptoms. However, MRI is recommended for patients who do have a decit; surgery for decompression is reserved for those with severe compression and displacement; and nonoperative treatment is given to the majority.38

Radiologic Evaluation
Radiographic diagnosis of sacral injuries is in general quite difcult. Plain AP and even lateral radiographs of either the pelvis or sacrum are often not helpful in visualizing fractures of the sacrum. Detail is often overlaid by soft tissue shadows and bowel gas, and in addition, the lumbar lordosis and kyphotic sagittal contour of the sacrum make the fracture lines oblique to the plane of the radiograph (Fig. 356). The Ferguson view is the best view of the upper portion of the sacrum and can demonstrate foraminal involvement. Lateral radiographs can help

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FIGURE 356. A 19-year-old woman was involved in a motor vehicle accident and sustained a transverse sacral fracture. The fracture was not visualized well on either the initial lateral (A) or the initial anteroposterior (AP) (B) radiographs and was thus not recognized at rst. The lateral x-ray only shows a slight break in the round sagittal contour (arrow). On the AP view only the vertical component of the fracture is visible. Although the patient had loss of both bowel and bladder function, this also was not initially appreciated. When the neural decit was recognized, a CT scan was obtained. C, The axial view shows only the vertical component of the fracture, not the transverse. D, Midsagittal reconstruction does not demonstrate clearly the conguration of the fracture.

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FIGURE 356 Continued. E,The MRI, however, showed an angulated fracture in the S2 region. The fracture was in kyphosis with the superior fragment displaced posterior to the inferior fragment. The patient underwent operative reduction and decompression with plate xation as shown on lateral (F) and AP (G) views. The double screw xation in S1 stabilized the proximal fragment, with the cephalad screw directed medially and the next screw directed laterally. The patient regained bowel and partial bladder function and return of perineal sensation.

diagnose transverse fractures of the sacrum. Denis and co-workers reported that up to 50% of patients in their series who were neurologically intact had a delay in diagnosis of the sacral fracture. Such delay still occasionally occurs even in patients with neurologic decit. Plain radiographs show only 30% of sacral fractures in most series. Even with careful retrospective study, only another 35% of these injuries can be detected. Thus, clinical suspicion coupled with the mechanism of injury should trigger the use of ancillary studies for both acute traumatic injury and insufciency fractures. CT has become the standard for evaluation of both pelvic and sacral frac-

tures18, 39, 82 (Fig. 357). It provides better visualization of especially difcult fractures lateral to the sacral ala.51 Transverse sacral fractures are difcult to delineate because they are parallel to the coronal plane of the primary CT scan and require sagittal reconstruction for demonstration. In addition, MRI can be helpful in delineating both the areas of neural compression in the sacrum and displacement of the fracture fragments. Whereas myelography was used previously to evaluate patients with neurologic decit, MRI is now the study of choice for acute sacral injuries with decit. MRI not only assesses the area of compression but also gives clear images of the displace-

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ment because the information is gathered primarily in both the axial and sagittal planes without reformatting (see Fig. 356). Evaluation of an elderly patient with a suspected insufciency fracture of the sacrum is more complicated. In this instance, the use of plain radiographs is generally unrewarding but should not be overlooked because they are helpful in ruling out other lumbosacral pathology. A technetium bone scan is the initial study and can be of help in these patients (Fig. 358). It will generally show activity in one of the patterns previously described, soon after the onset of symptoms.31, 33, 52, 58 Standard imaging for a bone scan is an anterior and posterior projection, with the posterior view being more effective in demonstrating activity in these fractures. However, activity in the sacrum can sometimes be obscured by residual activity in the bladder, so an outlet view can be helpful in those circumstances. Although a bone scan is highly sensitive, it is not specic, and accurate conrmation of the fracture along with delineation of the pattern is more optimally achieved with CT. Proper alignment of the gantry and thin cuts (2 mm) allowing for reconstruction are critical to obtain the maximal amount of data from the study. Routine CT of the pelvis does not permit diagnostic resolution of this problem. Vertical fractures are viewed as a combination of the fracture line and sclerosis. The transverse component, when it exists, is best seen on a reconstruction. Additionally, other helpful changes are evident on CT besides the fracture lines and sclerosis in older fractures. A vacuum phenomenon can sometimes be appreciated both within the sacroiliac joint and within the fracture site (intraosseous).59, 75 MRI can be used either as a screening tool in a symptomatic patient or to dene the fracture. It is often helpful in a patient with previous irradiation to help rule out recurrence. MRI can both visualize and dene the fracture with a single study. The fracture lines are dened as bands of decreased signal intensity on T1-weighted images, whereas on T2weighted and STIR (short tau inversion recovery) images, the lines can be seen as areas of edema around the ala or

body of the sacrum. Some authors believe that MRI is sensitive but nonspecic and suggest conrmation with CT, but recently it has been shown that the nding of uid within the fracture seems to be helpful in conrming the diagnosis.60

MANAGEMENT Indications

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz

Various systems have been devised in an attempt to classify spinal injuries according to both mechanism and degree of instability. In addition, a number of denitions have been proposedfor example, stable versus unstable. A generic denition of spinal stability includes fracture patterns that are not likely to change position with physiologic loads and will therefore not cause additional neurologic decit or increasing deformity. Although many systems that are applicable to lumbar spine injuries have been proposed, no pragmatic system has been devised that clearly groups the injuries so that treatment approaches can be differentiated. In general terms, surgical indications for sacral injuries are the following: (1) the presence of detectable motion at the fracture site that cannot be controlled by nonoperative methods (instability), (2) neurologic decit, or (3) severe disruption of axial or sagittal spinal alignment. With a large canal-toneural element ratio, signicant translation or angulation must take place to cause a neural injury. Because vertical sacral fractures usually occur in combination with other pelvic ring fractures, considerations of instability and treatment are discussed with the remainder of pelvic fractures. Transverse fractures of the sacrum are generally of two types. A greenstick type, which increases sacral kyphosis without translational deformity, is generally stable (Fig. 359). Proximal transverse fractures of the sacrum with neurologic decit are often accompanied by gross translational instability for which no nonoperative solution is available.

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Presentation

FIGURE 357. A 24-year-old woman sustained pelvic trauma in a motor vehicle accident. A, An anteroposterior radiograph of her pelvis demonstrates a fracture of her right pubis and ischium with an indistinct fracture through the sacrum. B, Computed tomography clearly shows the fracture line (arrows) traversing the neural foramina; thus, it is classied as a zone 2 fracture. This patient had radicular decits in the S2 and S3 distributions.

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Presentation

FIGURE 358. This 87-year-old man was working in his garden and began to have severe low back pain without a history of trauma. A, A plain anteroposterior (AP) radiograph of his pelvis was unremarkable, but the intensity of his pain continued to escalate. A bone scan showed increased activity in the S1 joints on the AP view (B) and a Honda sign on the posteroanterior view (C). Axial CT images (D, E) showed the fracture line (D, arrow) with coronal reconstruction (E) most effectively demonstrating the fracture pattern. MRI also helped to dene the problem.

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Presentation

FIGURE 359. This patient fell from a height and landed on his buttocks. A, A lateral radiograph shows an increase in kyphosis and comminution of the anterior cortex (arrow). B, On an anteroposterior view, the fracture line was seen to occur at the level of the termination of the sacroiliac joint and its attachment to the sacrum (arrows). C, A computed tomographic scan shows minimal comminution with fracturing of only the anterior cortex (arrow).

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CHAPTER 35 Fractures of the Sacrum

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The second criterion that constitutes an indication for treatment is neurologic decit. Considerable controversy has arisen concerning the benets of operative treatment of spinal injury with respect to neurologic recovery for cord-level injuries. In the small group of patients with high transverse sacral fractures, kyphosis, and neurologic decit, reduction of deformity, laminectomy, and decompression of the involved roots are indicated and often provide return of neural function,25, 68 although one very small series (four patients) suggests that an unspecied group can regain some function with nonoperative treatment.61 Other neurologic injuries that accompany fractures of the sacrum are less likely to respond to direct operative intervention. A signicant portion of these injuries are root avulsions, and the remainder are neurapraxias, which frequently respond to conservative treatment. The next indication for treatment is severe sagittal- or coronal-plane deformity. Most fractures of the sacrum result in kyphotic deformities and may be accompanied by translational and rotational abnormalities. Because maintenance of normal sagittal alignment is critical for the normal weight-bearing axis of the body and therefore for optimal function of the paraspinous musculature, restoration to normal is a criterion for treatment of many fractures in the spine but to date has not been applied to the sacrum. However, this statement has not been fully veried because most of these injuries occur in relatively young individuals and the follow-up in most operative and nonoperative series is still relatively short. In the absence of neurologic decit, clinically stable fractures that do not have signicant associated kyphosis can be optimally treated nonoperatively. Thus, in summary, fractures and dislocations involving the lumbosacral junction that result in neurologic decit, instability, or deformity need to have operative treatment. This group includes oblique sacral fractures that destroy the stability of the lumbosacral articulation on either side. Reestablishment of pelvic stability when the sacral fracture is combined with a more signicant pelvic injury is a critical goal of treatment and can be accomplished either operatively or nonoperatively. Finally, transverse sacral fractures that are either traumatic or insufciency in type and cause marked root compression and decit, especially with severe fracture site angulation or translation, also require surgical intervention. The paramount consideration for operative versus nonoperative treatment of traumatic sacral injuries is the presence or absence and the type of neurologic decit. Patients with vertical fractures or some patients with oblique fractures who have an isolated root decit are treated on the basis of the instability of the injury and not the decit. Transverse fractures or some oblique fractures with loss of bowel and bladder function are treated with an attempt to recover these functions. Although nonoperative treatment can be considered in the latter circumstance,61 other studies have suggested that decompression either indirectly by realignment or directly by removing the compression fragment yields better results. Gibbons and colleagues,30 in a series of 23 patients with neurologic decits from sacral fractures, showed that 88%

regained some function with operative treatment whereas only 20% regained any function with nonoperative treatment.

Treatment Options
A number of treatment measures can be used for the management of sacral fractures and generally involve either nonoperative or operative treatment. Nonoperative treatment consists mainly of bedrest or postural reduction, or both, in combination with external immobilization by a cast or orthosis. With the possible exception of pelvic and sacral fractures, the role of traction or external xation is limited. Operative intervention can involve various procedures, including reduction, stabilization, and fusion of spinal fractures from a posterior approach,1 with or without indirect or direct decompression of neural elements from a posterior or posterolateral approach.2 Patients with intact neurologic function and minimally displaced or angulated fractures (zone 1 or 2 in combination with a stable pelvic fracture) may require only a short period of bedrest followed by early mobilization with or without an orthosis (see Fig. 357). Weight bearing is progressively increased, depending on the fracture pattern and displacement. Occasionally, an external xator is necessary for the anterior portion of the ring, whereas the interdigitation of the fragments may provide sufcient stability posteriorly. Most insufciency fractures of the sacrum can be treated nonoperatively, even those accompanied by neurologic decit (see Fig. 358). The necessity of using bedrest as the initial portion of the treatment has, however, been a matter of debate. In fact, the use of bedrest initially does not preclude the subsequent development of a neurologic decit.38 However, many reports have advocated the use of bedrest31, 38, 54, 57, 58, 83 despite the many complications associated with a period of bedrest in the elderly, including increased osteopenia, deep venous thrombosis, decreased muscle strength, and cardiac, gastrointestinal, and genitourinary complications.6 Currently, however, no evidence is available in the literature to advocate one methodology over another. No published series has suggested that patients managed with bedrest have an unacceptable rate of complications; in addition, however, no evidence has indicated that the time to healing and relief of symptoms is shorter when an initial period of bedrest is used before progressive ambulation is initiated. Most studies demonstrate a prolonged period of symptoms lasting at least 3 months and often as long as 9 months before complete relief of symptoms and return to full function.15, 31, 33, 58 Those with a previous history of irradiation may require an even longer period before resolution of symptoms, in some cases up to and exceeding 1 year.52 Few reported patients had adverse outcomes; however, the duration of disability and symptoms was prolonged. Even those with neurologic symptoms who were treated nonoperatively had reasonable functional outcomes.38 For vertically unstable fractures in zone 1, the displacement should be initially reduced with the use of skeletal

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traction, followed by anterior or posterior xation (or a combination of both). Fixation can be achieved with the use of anterior plating of the symphysis and posterior techniques such as posterior iliosacral plating, sacral bars, and tension band plates across the ilium. More recently, the use of iliosacral screws placed percutaneously has allowed stable xation with less extensive surgery.55, 65, 66, 79, 80 The method for that technique is well described in Chapter 36 and will not be repeated here. Satisfactory outcomes are dependent on achieving reduction of the sacral fracture before initiating the procedure and on obtaining adequate visualization of the sacrum with image intensication to ascertain that the screws remain within the sacrum.65, 66 For patients with either isolated transverse or oblique fractures with or without involvement of the L5/S1 articulation, either bilateral plating43, 68 or other techniques78 can be considered. These measures should not be considered for minimally displaced fractures.

Surgical Techniques for Specic Types of Injuries

FIXATION DEVICES Beginning with the work of Louis47 and Roy-Camille and associates,67 systems of spinal plates xed with pedicle screws have been used for fractures. Their use is most appropriate for xation of both the lumbosacral junction and the sacrum. Especially for the sacrum, they not only provide a mode of xation for sequential screws but, by proper bending of the plating, can also control displacement and angulation. The strength of these plates lies in the fact that they can achieve rigid xation of the spine with limited length of instrumentation. Roy-Camille plates for the lumbar spine allow two pedicle screws to be placed at each level, which is especially important at S1. For localized xation only at the lumbosacral junction, the use of a screw/rod construct is optimal. Screws are placed into the pedicle of L5, and after reduction of the dislocation or fracture-dislocation, the rods can be attached to screws directed either medially in S1 or laterally into the ala. Their utility is somewhat diminished if xation needs to be carried to S2 to stabilize an oblique fracture line because the construct has a higher prole and somewhat less versatility than plate xation on the sacrum proper. LUMBOSACRAL FACET INJURIES AND DISLOCATIONS The patient should be placed in the prone position with the table exed at the level of the hips to allow easy reduction of the dislocation. After the dislocation is reduced, the table is extended to lock the reduction before beginning stabilization. A posterior incision is made from the midportion of the spinous process of L4 down to the level of S2. Care is taken during dissection to avoid disruption of the L4/L5 interspinous ligament or the facet capsules of the same level. Careful dissection of the L5/S1

facets is performed to ascertain whether any fracture lines have occurred through the articular processes or through the base of the S1 articular process and obliquely into the sacrum. If no fracture lines are present, reduction can be accomplished by applying distraction through towel clips placed on the spinous processes of L5 and S1 to disengage them (see Fig. 351). If reduction cannot be readily accomplished, additional ex is added to the table. Once the articular processes are disengaged, those of L5 are pulled posteriorly and inferiorly to lock them into the appropriate position. Usually, they do not completely engage until the table is switched from exion to slight extension. It is inadvisable to resect the tips of the articular processes to perform the reduction maneuver because such resection compromises the stability of the nal reduction. If it is difcult to achieve complete reduction or hold it because the spinous processes tend to spread apart, an interspinous wire can be placed temporarily to maintain the reduction until the nal instrumentation is placed. Care should be taken to not attempt to compress the interspace with either the wire or the nal construct because of the potential for compression of the disc, which can result in nerve root impingement. After reduction is achieved, the posterior aspect of the disc should be palpated to ensure that disc herniation and root impingement have not occurred. If such is the case, discectomy should be performed at this point after the initial reduction. After the interspace is checked, pedicle screws should then be placed in routine fashion in L5 and S1. Medial placement of the screws at S1 is somewhat easier with this injury, and the nal position of the hardware should be in only slight compression, just enough to maintain the reduction. Fusion is done with iliac crest graft. In patients with fractures through the tips of the articular processes, the fragments should be removed before attempting to achieve the reduction. The nal reduction may not be as rotationally stable and may require wire xation before placing the nal construct. If a fracture line goes through the base of an articular process and then obliquely into the sacrum, the articular processes of that side may not have even been juxtaposed by the translation achieved by displacement. Therefore, reduction may be accomplished on the affected side simply by translating the fractured fragment posteriorly. This technique does not allow for stable reduction before the application of instrumentation. In this instance, a plate construct should be used as described later, with one screw in L5 and two in S1 and the plate extended as far distally as necessary to fully stabilize the oblique nature of the fragment. SACRAL FRACTURES Surgical treatment of sacral injuries has only recently been shown to provide signicant benet to the patient. Previously, surgical treatment was usually restricted to sacral laminectomies and decompression. Only rarely was an indication for reduction of any sacral deformities noted because no adequate methods of sacral stabilization existed. However, more recently it has been appreciated

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Presentation

FIGURE 3510. The patient, a 30-year-old man, fell from a height of 35 ft, landed on both feet, and fell backward onto his buttocks; he sustained multiple injuries to both feet and an oblique sacral fracture with a complete neural injury at the S2 level. A, An anteroposterior radiograph did not clearly demonstrate the oblique nature of the fracture line (dashed line) with extension into the L5S1 articulation on one side. B, A lateral view shows the increase in kyphosis apparent at the fracture site (arrow). C, An axial computed tomographic scan clearly shows the oblique nature of the fracture line as it courses through the oor of the canal into the neural foramen and the ventral surface of the sacrum. D, The nature of the displacement is better seen on magnetic resonance imaging, with the proximal fragment displaced anteriorly and the distal fragment posteriorly. The fracture traversed the base of the S1 facet on the right and therefore required plating to the L5 pedicle (E, F) to achieve reduction and stabilization.

that transverse fractures with severe kyphosis might be improved by manipulation and stabilization to prevent skin compromise in thin individuals and afford decompression to compromised sacral roots. Vigorous manipulation of the fragments can carry the risk of rectal perforation and should be considered with great caution. Patients with transverse fractures of the sacrum and neurologic decit undeniably benet from surgical decompression and stabilization.3, 68, 78 Compression of the sacral roots may be due to combined causes. Most transverse fractures angulate into increased kyphosis and may indeed translate (Fig. 3510). Thus, the sacral roots may be tented over the exaggerated kyphosis. Certainly, sacral laminectomy fails to decompress the roots because the kyphosis still remains. In addition, if decompression is achieved by removing or tamping the apex of the kyphosis down without stabilization, the impingement can recur with additional translation (see Fig. 3510). Thus, in that instance, reduction of the distal fragment to

the proximal fragment is accomplished, followed by plate stabilization and subsequent removal of any unreduced fragments. If the fracture is more impacted and comminuted and not as angulated, compression of the roots is generally due to retropulsion of fragments into the canal. In that instance, reduction is not necessary because the impacted fragments should not be disturbed. Stabilization in situ should be performed and decompression then accomplished. The technique for reduction and stabilization of an angulated transverse fracture of the sacrum is reasonably straightforward (Fig. 3511). Most transverse fractures occur between S1 and S3. A radiolucent operating table is necessary for screw placement. For a transverse fracture or even one with an oblique component, the patient is placed on the operating table in the prone position with the hips and knees slightly exed. A longitudinal incision is used for exposure from the L5 spinous process (sparing the L5S1 facet capsule) to the S4 level if there is no

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Presentation

C
FIGURE 3511. Technique of reduction and plate xation of transverse sacral fractures. A transverse fracture line in the sacrum usually occurs at the region of the second or third dorsal foramen. A, A lateral view of the model demonstrates kyphosis of the fracture, as well as translational deformity. Most transverse sacral fractures occur in the most kyphotic area of the sacrum, S2S3. After an appropriate workup to delineate the direction of the fracture and the area of maximal sacral root compression, the patient is placed in the prone position with the hips exed 45. The incision runs from the inferior tip of the L4 spinous process to the region of S4. Although the sacrum is approached through a midline incision and the posterior aspect is stripped subperiosteally, exposure is often insufcient. Detaching the inferior-most attachment of the paraspinal musculature from the sacrum at S3S4 can broaden the exposure. B, The rst step in reduction is to expose the complete fracture line and then perform a laminectomy approximately 2.5 cm in length and centered on the fracture line to clearly visualize the neural elements. It should be carried far enough laterally to extend out into the dorsal foramen. C, After the nerve roots are clearly delineated, the fracture line is opened on both sides of the sacrum, rst with a small curette and then with a small Cobb elevator inserted gently in each side to pry apart the impacted fracture. By using the elevators to gently lever the fracture, the kyphosis and translation can be at least partially reduced (D).

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L5
Presentation

FIGURE 3511 Continued. If the proximal fragment is posteriorly displaced (E), the instrument should be placed under the ventral surface of the distal fragment. Separation of the fracture fragments and at least partial reduction are critical before plate xation is begun. A 3.5- or 4.5-mm pelvic reconstruction plate is selected on the basis of hole spacing and the size of the sacrum. If anatomic positioning is achieved manually, the plate is contoured to directly match the contour of the posterior aspect of the sacrum; if the position is less than anatomic, the plate is slightly undercontoured. If the fracture is more oblique and shortened, a temporary screw can be placed in both the proximal and distal fragments and a distraction tool applied to achieve length while the nal plate is being positioned. F, With the exception of the S1 segment, plate placement and screw starting points lie on a line along the dorsal foramen with the screw directed laterally into the residual pedicle. Two screws are placed at S1, the more proximal screw directed laterally from the dimple at the base of the S1 facet. Illustration continued on following page

involvement of the L5S1 facet on either side. If the fracture is more oblique, exposure to the L4 level is necessary to include the L5 pedicle in the instrumentation. Removing the distal attachment of the paraspinous musculature subperiosteally from the posterior aspect of the sacrum at its terminal position at S3 to S4 can facilitate exposure of the posterior aspect of the sacrum. A sacral laminectomy is performed from S1 to S4 to expose the sacral roots (see Fig. 3511), with dissection continued laterally to fully delineate the transverse fracture. The laminectomy is initiated at the proximal end of the sacrum, where the canal is larger, and directed distally until the fracture line is encountered. The decompression is extended laterally to identify the takeoff of the ventral roots and the bone of the vestigial pedicles. Although complete decompression is not necessary at this point, the fracture line may be entered with a curette laterally and the sacral canal partially undercut to remove the bone at the apical point of the kyphosis and prevent impingement of the roots after reduction (see Fig. 3511). The fracture is disimpacted by opening the fracture line with Cobb elevators gently placed on both sides of the fracture or by using a distraction device temporarily placed proximal

and distal to the fracture to distract it. If the proximal fragment lies posteriorly, the Cobb elevator can be gently placed within the fracture lines laterally anterior to the ventral surface of the distal fragment to lever it posteriorly and correct the kyphosis. If the fracture is easily reduced by levering it with the Cobb elevators, the spine is prepared for xation. In cases in which the fracture line passes through the canal at an oblique angle (20 to 40), the sacrum may become foreshortened by sliding obliquely. Length can be regained by using a pelvic reduction clamp placed on two unicortical screws. If the fracture does not involve the L5S1 articulation, screw placement is begun in the area of the pedicles at each level from S1 to S4. The most proximal screw at the medial border of the S1 facet is directed 30 medially into the body of S1. The next screw just proximal to the rst dorsal foramen is directed laterally at about 40 into the sacral ala. This technique allows two screws to be placed in S1, and a screw is then placed in each subsequent pedicle running parallel to the sacroiliac joint. At a point midway between each dorsal foramen and in a line just medial to the level of the foramen, a 2-mm drill bit is angled laterally between 30 and 45, and a hole is drilled

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through both cortices. Each hole is depth gauged and tapped for the use of a cancellous screw. A malleable titanium or stainless steel plate (pelvic reconstruction plate) of correct length (about 40 mm in S1 and decreasing sequentially to 20 mm at S4) is then selected and its holes spaced to accommodate the predrilled holes when the sacral fracture is in the reduced position. The fracture is reduced by gentle leverage with the Cobb elevators, and both plates are placed simultaneously. Care should be taken to not use the plates to achieve fracture reduction!! All screws are placed on both sides and tightened down sequentially (see Fig. 3511). In patients with comminution, screws may be placed in the sacroiliac joint and posterior of the ilium or extended up to the L5 pedicle for more proximal involvement or for involvement of the L5S1 articulation. At this point, if compression of the ventral surface of the roots is still occurring after reduction of the angular deformity, excavation lateral to the canal at the level of the fracture should be performed. Such excavation allows the bone to be removed with a pituitary rongeur from under the canal. The bone should not be tamped down but, instead, removed to ascertain that the decompression is complete. Bone grafting of the

fracture is not necessary in the body of the sacrum; however, if the construct is extended to L5, routine posterolateral graft application is indicated. The paraspinous musculature is then reapproximated over a drain. The patient is immobilized in a lumbosacral orthosis with the leg included for 3 months. Recovery of bowel and bladder function may be slow and take up to 12 to 18 months.

COMPLICATIONS

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Few complications specic to these injuries are encountered. However, failure of recognition is the most common problem in both insufciency fractures and traumatic injuries. In an elderly patient with an insidious onset of back pain and disability, the use of a bone scan or MRI will usually lead to the diagnosis. In a patient with acute trauma, careful evaluation of sphincter function is critical along with MRI if the neurologic assessment is not consistent in a patient with a history conducive to such an injury.

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Presentation

FIGURE 3511 Continued. G, A bicortical hole is drilled and tapped, and then the screw inserted. H, The second screw in S1 is inserted and directed medially into the body. The screw hole is likewise tapped and the screw inserted either to the full depth of the body or bicortically.

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Presentation

FIGURE 3511 Continued. I, The starting site for the most distal screw is selected. A minimum of two and preferably three points of xation need to be present distal to the fracture line. These screws are angled obliquely parallel to the sacroiliac joint for maximal length and xation. An attempt should be made to place pairs of adjacent screws so that they converge in the caudocephalad direction for maximal pull-out strength. The distal-most screws rarely exceed 20 mm, whereas the more proximal screws average between 35 and 45 mm. The screw is tightened into position but is not used to achieve fracture reduction. If the reduction is not complete and the plate is completely in contact with the posterior aspect of the sacrum, further manual reduction is done before nal tightening of all screws. Screws are then placed in every hole that does not fall directly over a dorsal foramen (J). The contralateral side is plated in a similar fashion (K).

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SECTION III Pelvis 24. Finiels, H.; Finiels, P.J.; Jacquot, J.M.; Strubel, D. Fractures du sacrum par insufsance osseuse meta-analysis de 508 cas. Presse Med 26:15681573, 1997. 25. Fountain, S.S.; Hamilton, R.D.; Jameson, R.M. Transverse fractures of the sacrum. A report of six cases. J Bone Joint Surg Am 59:486489, 1977. 26. Frederickson, B.E.; Yuan, H.A.; Miller, H.E. Treatment of painful longstanding displaced fracture dislocations of the sacrum. A case report. Clin Orthop 166:9395, 1982. 27. Frederickson, B.E.; Yuan, H.A.; Miller, H.E. Burst fractures of the fth lumbar vertebra. J Bone Joint Surg Am 64:10881094, 1982. 28. Furey, W.W. Fractures of the pelvis with special reference to associated fractures of the sacrum. J Bone Joint Surg 47:8996, 1942. 29. Gellad, F .E.; Levine, A.M.; Joslyn, J.N.; et al. Pure thoracolumbar facet dislocation: Clinical features and CT appearance. Radiology 161:505508, 1986. 30. Gibbons, K.J.; Soloniuk, D.S.; Razack, N. Neurologic injury and patterns of sacral fractures. J Neurosurg 72:889893, 1991. 31. Gotis-Graham, I.; McGuigan, L.; Diamond, T.; et al. Sacral insufciency fractures in the elderly. J Bone Joint Surg Br 76:882886, 1994. 32. Grangier, C.; Garcia, J.; Howarth, N.R.; et al. Role of MRI in the diagnosis of insufciency fractures of the sacrum and acetabular roof. Skeletal Radiol 26:517524, 1997. 33. Grasland, A.; Pouchot, J.; Mathieu, A.; et al. Sacral insufciency fractures: An easily overlooked cause of back pain in elderly women. Arch Intern Med 156:668674, 1996. 34. Guterberg, B. Effects of major resection of the sacrum. Acta Orthop Scand 162(Suppl):118, 1976. 35. Hanely, E.N.; Know, B.D.; Moossy, J.J. Traumatic lumbopelvic spondyloptosis. J Bone Joint Surg Am 75:16951698, 1993. 36. Herron, L.D.; Williams, R.C. Fracture dislocation of the lumbosacral spine: Report of a case and review of the literature. Clin Orthop 186:205211, 1984. 37. Holdsworth, F .W.; Hardy, A. Early treatment of paraplegia from fractures of the thoracolumbar spine. J Bone Joint Surg Br 35:540550, 1953. 38. Jacquot, J.M.; Finiels, H.; Fardjad, S.; et al. Neurologic complications in insufciency fractures of the sacrum. Rev Rhum Engl Ed 66:109114, 1999. 39. Kaehr, D.M; Anderson, P.A.; Mayo, K.; et al. Classication of sacral features based on CT imaging. J Orthop Trauma 3:163, 1989. 40. Knight, R.Q.; Stornelli, D.P; Chan, D.P.K.; et al. Comparison of operative versus nonoperative treatment of lumbar burst fractures. Clin Orthop 293:112121, 1993. 41. Krag, M.H.; Weaver, D.L.; Beynnon, B.D.; Haugh, B.D. Morphometry of the thoracic and lumbar spine related to the transpendicular screw placement for surgical spinal xation. Spine 13:2732, 1988. 42. Kramer, K; Levine, A.M. Unilateral facet dislocation of the lumbosacral junction. J Bone Joint Surg Am 71:12581261, 1989. 43. Levine, A.M. Fixation of fractures of the sacrum. Operative Techn Orthop 7:221231, 1997. 44. Levine, A.M.; Edwards, C.C. Low lumbar burst fractures. Reduction and stabilization using the modular spine xation system. Orthopedics 11:14271432, 1988. 45. Levine, A.M.; Bosse, M.; Edwards, C.C. Bilateral facet dislocations in the thoracolumbar spine. Spine 13:630640, 1988. 46. Lewis, J.; McKibbin, B. The treatment of unstable fracturedislocations of the thoracolumbar spine accompanied by paraplegia. J Bone Joint Surg Br 56:603612, 1974. 47. Louis, R. Fusion of the lumbar and sacral spine by internal xation with screw plates. Clin Orthop 203:1833, 1986. 48. McAfee, P.C.; Yuan, H.A.; Frederickson, B.E.; et al. The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classication. J Bone Joint Surg Am 65:461473, 1983. 49. Meyer, T.L.; Wilkberger, G. Displaced sacral fractures. Am J Orthop 4:187, 1962. 50. Mirkovic, M.A.; Abitbol, J.J; Steinman, J.; et al. Anatomic consideration for sacral screw placement. Spine 16(Suppl):289294, 1991. 51. Montana, M.A.; Richardson, M.L.; Kilcoyne, R.F et al. CT of sacral .; injury. Radiology 161:499503, 1986. 52. Moreno, A.; Clemente J.; Crespo C.; et al. Pelvic insufciency fractures in patients with pelvic irradiation. Int J Radiat Oncol Biol Phys 44:6066, 1999.

SUMMARY

zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Recognition of the importance of sacral fractures both in patients with pelvic injuries and in patients with isolated traumatic fractures or insufciency fractures is a relatively late occurrence. With increased awareness has come improved recognition of the natural history and the development of improved treatment methodologies.
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