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SACARAL SPINE FRACUREEsfahan 2015
1
anatomyanatomy
• foundation for lumbarfoundation for lumbar as well as pelvic ring alignment
2
anatomyanatomy
• Transmission of load onTransmission of load on the trunk is distributed by the first sacral segment through the iliac wings to the
t b l ithacetabulum on either side
• Pohlemann T, Angst M, Schneider E, Ganz R, Tscherne H. f f l fFixation of transforaminal sacrum fractures: a
biomechanical study. J Orthop Trauma. 1993;7:107‐17
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anatomyanatomy
• Strong posteriorStrong posterior lumbosacral and lumboiliac ligaments stabilize the osseous components of this t iti hi h itransition zone, which is characterized by nonconstrainednonconstrainedarticulations.
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• The sacrum is a kyphoticypstructure with a sagittalangulation ranging from 0° to 90°0 to 90 .
• This contributes to the sacral inclination angle of h d l fthe superior end plate of S1, which then determines the compensatory lordosis of the lumbar spine.
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anatomyanatomy
• protection for theprotection for the lumbosacral (L4‐S1) and sacral (S2‐S4) plexuses and iliac vessels.
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anatomyanatomy
• The sacral spinal canal isThe sacral spinal canal is capacious and provides more than adequate space for the caudaequina
• the ability of this area to withstand blunt trauma and toleratetrauma and tolerate bulky implant systems.
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anatomyanatomy
• The anterior rami of the S2 th h S5 t t ib t tthrough S5 roots contribute to sexual function as well as bowel and bladder control by providing parasympathetic p g p y pinnervation to the bladder and rectum.
• The sympathetic ganglia of th i f i h t i lthe inferior hypogastric plexus extend from the anterolateralL5 and S1 vertebral bodies caudally to the anterior ysurface of the sacrum along the medial margin of the anterior foramina of S2, S3, and S45and S45
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EvaluationEvaluation
• Approximately 30% ofApproximately 30% of sacral fractures are identified late
• Delayed diagnosis‐> negative impact on long‐term outcome
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Physical examinationPhysical examination
• peripelvic painp p p• high‐energy blunt trauma, especially in h fthe presence of an altered sensorium
• Lacerations bruising• Lacerations, bruising, tenderness, swelling, and crepitus are clear signs of a potential underlying injury.
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Physical examinationPhysical examination
• a posterior sacrala posterior sacral osseous prominence
• Morel‐Lavelle lesion
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Physical examinationPhysical examination
• rectal examination is arectal examination is a standard component of the evaluation
• Sacral fracture should also undergo functional assessment of the lower sacral roots
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Physical examinationPhysical examination
• Maximum voluntary yrectal sphincter contraction
f l h h• presence of light touch• pinprick sensation
ifi fl• specific reflexes including perianal wink and the bulbocavernosus and cremasteric reflexes
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Physical examinationPhysical examination
• Pelvic ring stability canPelvic ring stability can be tested manually
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Physical examinationPhysical examinationgently applied internal andexternal rotation of the iliac wings
push‐and‐pull testsi h l l di hi d iexternal rotation of the iliac wings with supplemental radiographic documentation
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ImagingImaging
• Advanced Trauma LifeAdvanced Trauma Life Support protocol
• Pelvic AP
• InletInlet
• Outlet
• Ferguson viewFerguson view
• lateral sacrum view
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ImagingImaging
• Specefic finding: • 3)stepladder sign p g• 1) fractured L5 transverse process f d
) p gindicative of anterior sacral foraminaldisruptionfound in 61%
• 2) a paradoxical pelvic inlet view found on
disruption• 4) radiographic landmarks may beinlet view found on
supine anteroposteriorradiographic projections
landmarks may be obscured in a patient with osteopenia or l b lfound in 92% lumbosacraldysmorphism
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ImagingImaging
• Ct – scan: ComputedCt scan: Computed tomography is the preferred modality for diagnosing suspected or known posterior injury f th l i iof the pelvic ring.
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ImagingImaging
• MRI:MRI:
• 1) may be helpful for patients presenting p p gwith unexplained sacral neurological deficits after trauma
• 2) reveal sacral stress ffractures
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ImagingImaging
• Bone scan and SPECT:Bone scan and SPECT: identifying posttraumatic arthritis as well as insufficiency fractures.
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ClassificationClassification
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Denis classificationDenis classification
• Zone1 ‐50% N.deficit 6%Zone1 50% N.deficit 6%
(typically L4‐L5 root)
• Zone 2‐34% N deficit 28%Zone 2 34% N.deficit 28%
(usually L5‐S1‐S2 root)
(malunion >poor out come)(malunion‐>poor out come)
• Zone 3‐16% N.deficit 57%
• (Bowel and bladder control• (Bowel and bladder control or sexual function was impaired in 76% )impaired in 76% )
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Denis classificationDenis classification
• Two additional factorsTwo additional factors to consider:
• 1)injury is bilateral) j y
• 2) the axial level of the fracture
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complex sacral Denis zone‐III fractures.
©2004 by The Journal of Bone and Joint Surgery, Inc.24
Subclassification of Denis zone‐III fractures as suggested by Roy‐Camille et al. and modified by Strange‐Vognsen and Lebech
©2004 by The Journal of Bone and Joint Surgery, Inc.25
Classification of injuries at the lumbosacral junction, as suggested by Isler.suggested by Isler.
©2004 by The Journal of Bone and Joint Surgery, Inc.26
Neurological impairment classificationNeurological impairment classification Gibbons et al
4 t4 stage
• 1)no injury
2) h i l• 2)paresthesis only
• 3)motor loss but
bowel and bladder
control intact
• 4)Impaired bowel and
bladder control
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classificationclassificationsystemic conceptual approach is more important than any classification
In patient evaluationp
5 basic principle should be followed
1)Presence of active bleeding
2)Presence of an open fracture
3)Pattern and stability of skeletal injury
4)Neurologically injury) g y j y
5)Systemic injury load
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TreatmentTreatment
• Early ManagementEarly Management
• pelvic reductionpelvic reduction
• minimize additional• minimize additional blood loss
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Non op. treatment
• Indications are vagueIndications are vague
• Contraindications are relative :
• soft‐tissue compromise
• incomplete neurological deficit with objective evidence of neural compression
• extensive disruption of the posterior lumbosacral ligaments
• Patients with multiple injuries
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Non op. treatmentNon op. treatment
• Activity modification c y od ca oaimed at preventing further fracture di ldisplacement
• prolonged bed rest in skeletal tractionskeletal traction
• bed rest in a brace or cast
• protected weightbearingprotected weightbearing, or early mobilization
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Non op. treatmentNon op. treatment
• potential dangers:potential dangers:
Thromboembolism
pulmonary complicationspulmonary complications
skin breakdown
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Surgical Decision‐MakingSurgical Decision Making
should incorporate clear and realistically attainable goals :
1)fracture stabilization1)fracture stabilization2)Lumbosacral realigment3) optimization of the chances
f l i lfor neurological recovery4) adequate débridement of
open injuries and compromised soft tissues
5) Minimization of additional morbidity.morbidity.
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Surgical optionsSurgical options
Fixation techniquesTechniques for neural decompressionFixation techniques
• Minimally invasive techniques
decompression
• laminotomy and foraminotomy
• open reduction and internal f
• anterior bone disimpaction
• lumbosacral plexus lfixation neurolysis
34
timing of any surgical interventiontiming of any surgical intervention
on the basis :on the basis :
1) treatment goals
2) patient’s general2) patient s general medical status
3) invasiveness of the3) invasiveness of the surgical procedure
35
Neurologic impairmentNeurologic impairment• range from incomplete
monoradiculopathies to amonoradiculopathies to a complete cauda equina syndrome
• Neurological improvement of approximately 80% regardless of treatment
• decompression may be less useful in root transection and root avolsion
• Decompression of compromised neural elements is preferably performed early, within the first twenty‐four to seventy‐two hourstwenty four to seventy two hours following injury
• Repair any dural tears
36
acceptable approach for decomresionacceptable approach for decomresion
• minimal reduction and stabilization for indirect decompresion
d h• assessed with Ct‐scan and physical exam
• focal limitedseverely displaced fracture should beconsidered for a comprehensive • focal limited
decompression may be performed within the
pposteriordecompression and stabilization
first two weeks after injury
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Surgical Stabilization TechniquesSurgical Stabilization Techniques
• EvolveEvolve
• goal of surgical intervention‐> restore the stability of the lumbosacral articulation and pelvic ring
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Surgical Stabilization TechniquesSurgical Stabilization Techniques
• Anterior approaches toAnterior approaches to the sacrum‐> morbidity and limitted exposure
• role of external fixation ‐>limited to the emergent management or as supplemental treatment devicestreatment devices
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Surgical Stabilization TechniquesSurgical Stabilization Techniques
• anterior stabilizationanterior stabilization should be considered before embarking on any posterior lumbosacral procedure
• Posterior fixation offers a high degree of mechanical constructmechanical construct stiffness , a low implant profile ,profile ,
40
Surgical Stabilization TechniquesSurgical Stabilization Techniques
• Sacroiliac screw: • Potential drawbacks 1)Either supine or prone 2) conventional c‐arm 3)Safty has been
1)limited biomechanical strength 2) reliance on closed3)Safty has been
established• Cotraindication:
) l l
2) reliance on closed reduction 3)lack of c‐arm
1) anomalous transitional lumbosacral anatomy 2) closed fracture )reduction cannot be accomplished
41
Surgical Stabilization TechniquesSurgical Stabilization Techniques
• indications for sacroiliacindications for sacroiliac screws: 1) Denis zone‐I, II which can be adequately reduced
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Surgical Stabilization TechniquesSurgical Stabilization Techniques
• Zone‐II fractures with segmental comminutionare susceptible to overcompressionovercompression .
• Use bilateral midline‐crossing sacroiliaccrossing sacroiliac screws when the technique is used to t t III “H”treat a zone‐III “H” or “U” fracture configuration.g
43
Surgical Stabilization TechniquesSurgical Stabilization Techniques
• posterior iliac tension‐band plate as a supplemental internal fixation method with
l fsacroiliac screw fixation can facilitate open fracture reduction and
h bi h i lenhance biomechanical stiffness.
• it requires a posterior two incision approach, increased rate of wound‐healing complications
44
Surgical Stabilization TechniquesSurgical Stabilization Techniques
• the most stablethe most stable method: lower lumbar pedicle screw fixation and iliac screw fixation
• allows complete neurological decompression
d b l• immediate stability
45
Thanks for attention
46
Thanks for attention