Transverse sacral fracture in children: a case report presenting with neurological injury and review of the literature

Transverse fractures of the sacrum are exceptional in children. We report a case in a 10-year-old girl. The patient presented an isolated flexion fracture of the sacrum in Denis zone III (transverse "U" fracture) of S1-S2 with neurological signs at the initial examination: sensorial deficit in the perineum and sphincter dysfunction. Treatment consisted in laminectomy and bone resection to relieve compression causing the neurological injury. Orthopedic treatment led to correct bone healing. Outcome was favorable with complete resolution of the neurological deficit and stability at three years. Eight cases of transverse sacral fracture before the age of 18 years have been reported in the literature. The diagnostic elements are similar to those in adults, but can be missed in children who rarely present sacral fracture. The therapeutic approach has varied, both for children and adults. We advocate surgical treatment in the event of neurological complications and orthopedic treatment of stable bone lesions.     

DenisⅢ型骶骨骨折合并神经损伤的外科治疗

目的探讨髂骨螺钉联合椎弓根螺钉重建骨盆环的稳定性治疗Denis噩型骶骨骨折合并神经损伤。方法回顾性分析自2002年2月至2006年3月期间来我院治疗的14例DenisⅢ型骶骨骨折合并神经损伤的患者，所有患者均为外伤所致，其中车祸伤6例，坠落伤4例，重物压伤4例。在该组患者中，9例仅伴有坐骨神经损伤，而不伴有马尾神经损伤的症状，另外5例既有坐骨神经损伤，也有马尾神经损伤的临床表现。所有患者均采用后路减压，髂骨螺钉联合椎弓根螺钉重建骨盆环稳定性，术前术后以及随访时按照Majeed骨盆骨折评价标准进行评分。结果14例患者中，男9例，女5例，年龄23-48岁，平均37岁。随访时间12～52个月，平均35个月。所有14例患者均重新获得了骨性愈合，在合并有马尾神经损伤的5例患者中，有3例完全恢复正常，Majeed评分大于85分；另外2例获得部分恢复，Majeed评分分别为71分和78分；在9例仅伴有坐骨神经损伤的患者中，有7例完全恢复正常，Majeed评分大于85分；另外2例仅获得部分恢复，Majeed评分分别为67分和64分。结论对于骨盆稳定性受到破坏，合并有神经受损的DenisⅢ型骶骨骨折，应在神经探查的同时采用髂骨螺钉联合椎弓根螺钉重建骨盆的稳定性，能保留骶髂关节的功能，获得优良的预后。     

Transverse fracture of the 2nd sacral vertebra with neurological signs. Apropos of a case

The authors report a case of transverse fracture of the second part of the sacrum with neurological signs. Whilst such a lesion would appear very rare, associated involvement of the sacral roots is very common. Recovery of the neurological deficit syndrome is hazardous. A review of the literature fails to provide the basis for a defined programme of management.     

Open reduction and internal fixation of unstable sacral fractures

Sacral fractures are frequently misdiagnosed or overlooked, as the majority of the patients are suffering from polytrauma situations. Obvious clinical signs both of the fracture and the associated neurological complications are missing. A poor longterm outcome with pain and urogenital disorders is frequent. Based on clinical and biomechanical studies a new concept for internal fixation of transsacral pelvic instabilities combined with decompression of the central canal is applied. To approach the sacrum, a posterior longitudinal incision is carried out and can be modified according to the fracture pattern. Decompression and anatomic reduction is performed and the fracture stabilized with minimized small fragment implants which are solely fixed in the sacrum. 32 patients were treated according to this protocol between 1989 and 1996. Bony healing occurred in all but one case. A complete anatomical sacral reconstruction was achieved in 80 % of the cases, another 16 % had close to anatomic (< 5 mm) reconstruction. In eight cases a primary neurologic deficit was present, with five complete or partial recoveries directly postoperative. Complications occurred in seven patients with two secondary displacements.     

The problem of the sacrum fracture. Clinical analysis of 377 cases]

Sacral fractures are rare injuries that are often neglected because of the general severity of the patient's injuries. They are typical injuries in patients with polytraumata. A "hidden" injury, they are often diagnosed late or are even missed. In a well-documented consecutive series of 1,350 patients with pelvic fractures treated in the trauma department of the Hannover Medical School between 1972 and 1991, a total of 377 sacrum fractures were evaluated in a retrospective study. The cause of the accident, mechanism of injury, concomitant injuries, diagnostic procedures, classification of the pelvic injury (TILE), as well as the classification of the sacrum injury (DENIS), treatment and outcome were analyzed in all cases. Observed complications with special attention to injuries to the lumbosacral plexus were correlated with the classification of the sacrum and pelvis, as well as with a detailed analysis of the fracture pattern and fracture characteristics. In 89.4% at least one additional body region was injured in these patients. PTS (Hannover Polytrauma Score) groups III and IV included 42.5% of the patients. With an improved diagnostic protocol (radiological a.p. views, oblique views and CT scan), the observed rate of sacrum fractures was 33%. Neurological deficits occurred in 15.1% of the patients. In contrast to the literature, the rate of neurological deficits was related more to the degree of pelvic instability (TILE) than to the specific fracture pattern in the sacrum. In stable injuries (TILE A) neurological deficits were only seen in exceptions. In type B injuries the maximum rate was 10%, whereas in unstable fractures (TILE C) the rate of neurological deficits was 32.6% in transalar fractures (DENIS zone I), 42.9% in transforaminal fractures (DENIS zone II), and 63.6% in central fracture types (DENIS zone III). Additional risk indicators for neurological impairment are avulsion fractures of the sacrum, comminuted and bilateral fracture lines. The fracture classification should thus be modified. Our own experience with operative therapy for sacral fractures (open revision of the sacral plexus together with internal stabilization of the fracture) is still limited, but based on the experience presented, further development of the treatment protocol for sacrum fractures should be considered.     

An unusual type of fracture in the upper sacrum.

An unusual type of indirect isolated fracture of the upper sacrum is presented. The upper sacrum was markedly comminuted and nondisplaced relative to the lower fragment. There was a neurologic deficit present. On the basis of a review of the literature, a previous classification system and the actual fracture mechanism, this fracture is classified as a special type; type 4, or the neutral position fracture.     

Osseous support in spondylolisthesis. A case report

A true spondylolisthesis in a 14 year old boy was followed from grade II to maximal dislocation. The 5th lumbar vertebra slipped forward on the sacrum until the contact with the sacrum was lost. The 5th lumbar vertebra, which had in the meantime shrunk to a smaller sized wedge, then dropped without tilting in front of the 1st sacral vertebra. This kind of maximal dislocation is rare. In the course of many years a bony support for the spine developed in the shape of a second sacrum, lying ventrally to the anatomical sacrum. The vertebral arch of the forth lumbar vertebra was supported by the real sacrum. This biomechanical correction was unexpected. At the age of 33 years the patient suffers no pain, and there is no restriction of spine movement and no neurological deficit.     

Operative treatment of complex lombosacral fracture dislocation: L5 chance fracture with trans S1-S2 dislocation

Sacral fractures are uncommon injuries that are often diagnosed late, the transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture has never been reported. The purpose of this report is to describe operative treatment of transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance fracture. A 17-year-old woman sustained multiple injuries in a road accident and presented with hypovolumic shock. Radiological assessment demonstrated transverse fracture dislocation of the sacrum at the S1-S2 level associated with a L5 Chance-fracture. Neurologic examination demonstrated L5 root deficit and perineal hypoesthesia. Operative treatment was undertaken. The procedure consisted of laminectomy of L5, S1, and S2 and osteosynthesis of L3-L4 - S3-S4 (in sacral alae). Attempts to reduce dislocation failed. Postoperative recovery was uneventful. One year after operative treatment the patient presented no neurologic deficit and had resumed normal activity. Follow-up radiological imaging demonstrated consolidation of fracture zones. Management for uncommon lumbrosacral junction injuries must take into account various parameters including hemodynamic condition, neurologic status, and stability of the spinal lesions. Decompression of neural impingement and stabilization of fractures by osteosynthesis appear to be a useful alternative that allows patients to stand again and begin rehabilitation quickly.     

Sacral fracture with compression of cauda equina: surgical treatment

Fractures of the sacrum are rare and generally accompany fractures of the pelvis. Isolated transverse sacral fractures are even less frequent, and extensive neurologic deficits may accompany these injuries. This report describes an unusual case of extradural hemorrhage accompanying a complex fracture of the sacrum. The reversal of a serious neurologic deficit was notably aided by sacral laminectomy.     

Burst fracture of the fifth lumbar vertebra.

Burst fracture of the fifth lumbar vertebra is a rare injury. We report the cases of seven patients who were treated conservatively by immobilization for six to eight weeks in a body-jacket cast that included one lower extremity to the knee. The patients were allowed to walk ten to fourteen days after the injury. A thoracolumbosacral orthosis was worn for an additional three months. No patient had an injury to the sacral root. Two patients had mild lower lumbar motor-root deficits that resolved within one year. All patients had an occasional backache, and two had intermittent radicular-type pain in the distribution of the fifth lumbar or first sacral-nerve root. The degree of compromise of the spinal canal could not be directly related to the degree of neurological deficit; that is, a large compromise of the spinal canal did not necessarily result in a major loss of neurological function. There was no early or late loss of lordosis between the cephalad end-plate of the fourth lumbar vertebra and the cephalad aspect of the sacrum, and there were no signs of progressive collapse of the vertebral body in any patient. In our series, the burst fractures of the fifth lumbar vertebra were stable injuries that caused minimum neurological deficits, and treatment by immobilization in a body-jacket cast was effective.     

Transverse sacral fractures with anterior displacement

Transverse fractures of the sacrum with anterior displacement are the rarest type of transverse sacral fractures. They usually occur at the S1–S2 region in suicide jumpers. A clinical study was performed to evaluate the diagnosis, treatment and outcome of transverse sacral fractures with anterior displacement. We present six patients with a transverse fracture of the sacrum with anterior displacement. All patients presented with bowel and bladder dysfunction, perineal anesthesia, sensory and motor deficits at the lower extremities. Prompt diagnosis of the sacral fracture was obtained in five of the six patients. Operative treatment including lumbosacral laminectomies, spine instrumentation and fusion was done in all patients. Neurological recovery was almost complete in one patient, incomplete in four patients, and none in one patient. Although reduction of the fracture was not ideal in many of these patients, long-term clinical and radiographic follow-up, and neurological improvement were rewarding.     

Sacrum fracture associated with neurologic complications]

A care of the patient, aged 39, who sustained a fracture of the sacrum complicated by compression of the roots L5 and S1 is reported. Surgical treatment on root decompression was performed. Following 9 months neurological signs subsided, but some intermittent low back pain persisted.     

Fracture and lateral dislocation of the T12-L1 vertebrae without neurological deficit--case report

A 21-year-old man suffered T12-L1 vertebrae fracture and lateral dislocation without neurological deficit. Computed tomography and magnetic resonance imaging demonstrated the fracture and lateral dislocation of the thoracolumbar spine. The injured spine was realigned with rods and screws, and bony fusion of the affected vertebrae was performed. Patients with thoracolumbar fracture-dislocation without neurological deficit may suffer unintended neurological injury secondary to maneuvers that cause further dislocation of the spine. Severe spinal injury without neurological deficit should be evaluated in detail, especially with spinal computed tomography. Internal fixation and reduction are recommended if the patient's condition is suitable for surgery.     

Midline longitudinal fracture of the sacrum: case report and review of the literature

Abstract Midline longitudinal fracture of the sacrum rarely occurs, and the mechanism of the injury is still unclear. We report a 68-year-old man with midline longitudinal fracture of the sacrum. At the first consultation, he showed no neurological findings. Neither longitudinal nor rotational instability was observed. Therefore, 4 weeks of bed rest was prescribed as conservative treatment. Standing training using a tilt table was initiated 5 weeks after injury and gait training after 6 weeks. However, since radiographic examination in the standing position 7 weeks after injury showed instability, surgery was performed. This instability was due to conic separation of the sacrum (conical instability) during weight bearing and cannot be classified according to the conventional classification of instability which is vertical instability as a parameter of ring fracture of the pelvis or rotational instability. Eleven patients with this fracture have been reported. This report discusses the characteristics of the pathological condition of this fracture and its treatment with a brief review of the literature.     

骶骨骨折合并骶神经损伤的MRI诊断及临床应用

目的 探讨骶骨骨折合并骶神经损伤的MRI诊断及其临床意义.方法 1999年10月-2007年10月,对20例Denis Ⅱ型骶骨骨折合并骶神经损伤患者采用显示骶神经全长的骶骨斜冠状位MRI扫描,观察神经走行及毗邻关系.其中男17例,女3例;年龄30～55岁.受伤至入院时间1 d～23个月.致伤原因:车祸伤10例,重物砸伤8例,挤压伤2例.合并耻骨骨折8例,尿道断裂4例.行常规骨盆X线片、CT、螺旋CT三维重建检查.X线片示骶骨外侧骨折块向后上方移位,骶孔线模糊、扭曲变形、左右不对称;CT示骶管于不同断面水平存在左右不对称及骨折侧结构紊乱、骶骨外侧骨折块向后上方移位,同时存在压缩且向骶骨中央突入.根据临床表现、美国国立脊髓损伤学会和国际截瘫学会1990年推荐的脊髓损伤神经分类标准、与MRI正常侧对比及Gierada等的研究结果进行临床及MRI诊断,并进行手术验证.结果 临床诊断S1神经根损伤17例,S:神经根损伤14例,S,神经根损伤7例,S4神经根损伤6例;MRI诊断s1神经根损伤17例,S2神经根损伤14例,S3神经根损伤3例,S4神经根损伤2例;手术证实S1神经根损伤17例,S2神经根损伤14例,S3神经根损伤7例,S4神经根损伤1例.骶骨斜冠状位MRI扫描示骶神经全长及周围毗邻关系,骶神经损伤时发现有骨块压迫、神经根走行改变5例,损伤处神经根周围脂肪消失19例,骶管狭窄17例,骶神经出现异常增粗11例.结论 骶骨斜冠状位MRI扫描对于骶神经损伤定位及定性诊断有重要价值.     

Zone 2 sacral fractures managed with partially-threaded screws result in low risk of neurologic injury

BackgroundZone 2 sacral fractures account for 34% of sacral fractures with reported neurological deficit in 21−28% of patients. The purpose of this study was to examine the risk factors for neurological injury in zone 2 sacral fractures. The authors hypothesized that partially thread iliosacral screws did not increase incidence of neurologic injury.MethodsA retrospective review of consecutive patients admitted to a level 1 trauma center with zone 2 sacral fractures requiring surgery from September 2010 to September 2014 was performed. Patients were excluded if no neurologic exam was available after surgery. Fractures were classified according to Denis and presence/absence of comminution through the neural foramen was noted. Fixation schema was recorded (sacral screws or open reduction and internal fixation with posterior tension plate). Any change in post-operative neurological exam was documented as well as exam at last clinic encounter.Results90 patients met inclusion criteria, with zone 2 fractures and post-operative neurological exam. No patient with an intact pre-operative neurologic exam had a neurological deficit after surgery. 86 patients (95.6%) were neurologically intact at their last follow-up examination. Four patients (4.4%) had a neurological deficit at final follow-up, all of them had neurological deficit prior to surgery. 81 patients were treated with partially threaded screws of which 1 (1.2%) had neurological deficit at final follow-up.Fifty-seven fractures (63.3%) were simple fractures and 33 fractures (36.7%) were comminuted. All four patients with neurological deficit had comminuted fractures. The association between neurologic deficit in zone 2 sacral fracture and fracture comminution was found to be statistically significant (p-value = 0.016). No nonunion was observed in this cohort.ConclusionsThe use of partially threaded screws for zone 2 sacral fractures is associated with low risk for neurologic injury, suggesting that compression through the fracture does not cause iatrogenic nerve damage. The low rate of sacral nonunion can be attributed to compression induced by the use of partially threaded compression screws. There is a strong association between zone 2 comminution and neurologic injury.     

椎体后凸成形术治疗老年人无神经症状的胸腰段不完全爆裂性骨折

[目的]探讨椎体后凸成形术治疗老年人无神经症状不完全性胸腰段爆裂性骨折的安全性及其疗效.[方法]椎体后凸成形术试行治疗18例尤神经症状的老年人胸腰段爆裂性骨折(Magerl分型:A3.1).术中采用体位复位及逐步球囊扩张技术,在C型臂X线机动态观察卜灌注骨水泥.术前、术后及术后12个月时采用疼痛视觉模拟评分(visual analog score,VAS)评估疼痛程度,并测量术前、术后及术后12个月时骨折椎体前缘高度比、Cobb角及椎管内骨块占位率.[结果]手术操作顺利,术后无神经损伤的并发症发生,患者症状迅速缓解.患者VAS评分平均由术前(8.17±0.618)分降为术后(2.33±0.767)分(P<0.05),术后12个月随访时维持在(2.39±0.698)分.椎体前缘高度从平均73.72%±6.153%纠正为术后的92.78%±1.927%(P<0.05),术后12个月为92.33%±1.534% ; Cobb角由术前平均20.50±12.333"改善为6.000±1.8470(P<0.05),术后12月随访Cobb角部分丢失为8.830±2.056°(P<0.05).椎管内骨块占位率术前平均为16.22%土4.387%,而术后为15.56%±4.162%(P >0.05).[结论]在C型臂X线机动态观察下,利用体位复位结合球囊分次逐步扩张技术,椎体后凸成形术治疗无神经症状的老年人胸腰段不完全性爆裂性骨折手术安全、疗效满意.     

C3–C4 spondyloptosis without neurological deficit—a case report

Background contextTraumatic spondyloptosis of the cervical spine is usually associated with a complete, or rarely a partial, neurological deficit. Traumatic spondyloptosis with bipedicular fracture of the C3 vertebra is uncommon. To the best of the authors' knowledge, there is no report in the literature of bipedicular fracture of C3 with spondyloptosis of C3 over C4 with no neurological deficit. Literature is not clear about the role of preoperative traction in neurologically intact patients, and most authors advise both anterior and posterior fixation for cervical spondyloptosis.PurposeTo report a case of C3–C4 spondyloptosis with C1 and C2 posterior arch fractures with no neurological deficit and its management strategy and underline the fact that closed reduction and limited anterior fusion can preserve the motion segment of cervical spine at other fractured levels and give a stable cervical column with good long-term results.Study designA case report with review of the literature.MethodsA 35-year-old man fell from a height with hyperextension-compression injury to the cervical spine. The patient suffered fracture of the posterior elements of C1–C3 along with spondyloptosis of C3 over C4 without any neurological deficit. The patient was treated with an awake nasotracheal intubation with gradual cervical traction under fluoroscopic guidance to acceptable alignment followed by anterior cervical fusion at C3–C4.ResultsAt 24 months' follow-up, the C3–C4 level fused completely with fracture healing at C1 and C2. The patient remained asymptomatic with normal neurological examination and near complete cervical motion. The patient returned to his preinjury job and recreational activities.ConclusionsA case of C3–C4 spondyloptosis with associated C1–C2 posterior arch fracture is reported. The patient can present without neurological deficit if associated with a fracture of the posterior elements. Spondyloptosis without neurological deficit can be treated with gradual reduction under fluoroscopic guidance. A limited anterior-only fusion at the spondyloptosis level can provide good long-term results with preservation of other motion segments.     

Transverse fracture of the upper sacrum. Suicidal jumper's fracture

Thirteen patients with transverse fractures of the upper sacrum were studied to determine fracture anatomy, clinical presentation, and therapeutic approaches. The injury results from falls from a height and is usually associated with suicidal attempts by jumping. The position of the lumbar spine in lordosis or kyphosis at the time of impact determines which of three types of morbid anatomy will result. Because of associated polytrauma, fracture of the upper sacrum is often not recognized in the acute stage, and awareness of the possibility of such injury, especially in the presence of perineal neurologic deficit should result in securing good quality radiographic study, including tomograms. Surgical treatment is often required.     

Extensive epidural abscess with surgical treatment and long term follow up.

BACKGROUND CONTEXT: Spinal epidural abscess is an uncommon infection. There are few reports on extensive epidural abscesses. PURPOSE: We report a case of an epidural abscess extending from C2 to the sacrum, with a long-term follow-up. STUDY DESIGN: A case report of an extensive epidural abscess with surgical treatment. METHODS: A 36-year-old male patient presented with a history of 15 days of fever and severe lumbar and neck pain. Magnetic resonance imaging disclosed an epidural abscess extending from C2 to the sacrum. Limited laminectomies were performed in the cervical, thoracic, and lumbar spine, and pus was obtained. A peptostreptococus grew in cultures. The patient received 6 weeks of antibiotics. RESULTS: The infection was successfully treated, and no neurological deficit was observed. The patient continued asymptomatic 5 years after surgery, and no deformity has developed. CONCLUSIONS: A case of an extensive epidural abscess was successfully treated with limited laminectomies and antibiotics. This less invasive technique could treat the infection, and no late deformity has been observed.