Bilateral sacroiliac dislocation with intrapelvic intrusion of the lumbosacral spine

Summary A patient sustained bilateral sacroiliac dislocation in which the proximal part of the sacrum was displaced 10 cm anteriorly and 6 cm inferiorly into the pelvis. Stabilisation was initially obtained with an external fixator. Operation was carried out later: reduction was achieved by overhead skeletal traction using sublaminar wires; two screws were inserted through each sacroiliac joint and the two fragments of the sacrum were wired in place.

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Resumé Nous avons observé un cas de fractureluxation bilatérale sacro-iliaque avec atteinte de la surface articulaire du sacrum et protrusion intrapelvienne de la colonne lombo-sacrée. Dans ce cas la portion proximale du sacrum était déplacée de 10 cm vers l'avant et de 6 cm vers le bas. La fracture fut d'abord stabilisée grâce à un fixateur externe d'Hoffmann et ensuite opérée par voie postérieure pour réduire la luxation des deux articulations sacroiliaques et la fracture du sacrum. La réduction fut obtenue par traction au zénith de toute la colonne lombo-sacrée au moyen de fils sous-laminaires. L'ostéosynthèse fut réalisée par deux vis traversant chaque articulation sacroiliaque et des fils métalliques maintenant les deux fragments du sacrum.

     

Traumatic noncontiguous double fracture-dislocation of the lumbosacral spine.

BACKGROUND CONTEXT: To our knowledge, the presence of noncontiguous fracture-dislocation of the lumbosacral spine occurring at two levels has not been reported. The etiology, evaluation, and treatment of the unusual injury is presented. PURPOSE: To notify spinal traumatologists about the possibility of this unusual injury. STUDY DESIGN: A case report of an unusual noncontiguous double fracture-dislocation of the lumbosacral spine. METHODS: A 26-year-old man was involved in a motor vehicle accident where his car fell over a bridge and plummeted approximately 300 feet before hitting the ground. The patient was transported to a major medical center where he was found to be conscious, and amazingly, his only major injury was fracture-dislocations of L2-L3 and L5-S1. His preoperative neurologic status showed a partial paraparesis to all motor groups of the lower extremities bilaterally. RESULTS: The patient underwent a posterior reduction, instrumentation, and fusion from L1 to S1 with autogenous bone graft and segmental pedicle screw instrumentation. One week postoperatively, he underwent an anterior spinal fusion of L5/S1. Postoperatively, his neurologic status improved allowing him to be ambulatory, with a normal lumbosacral alignment being well-maintained. CONCLUSIONS: Noncontiguous double fracture-dislocation of the lumbosacral spine is an unusual injury, which results from a very high-energy trauma. Prompt recognition of the injuries, reduction of the fracture-dislocations, and posterior stabilization is recommended for neural decompression, spinal alignment, and long-term stabilization.     

A modified muscle-splitting approach to the lumbosacral spine.

A modification of a previously reported extraperitoneal approach to the lumbosacral spine is described. The external oblique muscle is split in line with its fibers. The anterior and posterior layers of the rectus sheath are divided vertically medial to the semilunaris without splitting the internal oblique and underlying transversalis abdominus muscles. This allows an extensile retroperitoneal approach suitable for exposure of both the mid-lumbar and lumbosacral spine. There have been no complications of this approach with its use in over 50 patients undergoing anterior lumbar interbody fusion.     

Cost-benefit analysis of posterior fusion of the lumbosacral spine.

In this study the cost-benefit ratio of posterior fusion of the lumbosacral spine was assessed. The calculations were based on 118 operated patients, followed up for an average of 4.8 years. Costs were calculated using the average costs of treatment at central hospitals, visits to the outpatient department and travelling. The costs for one patient exceeded on average 5,569 US dollars. The economic benefits derived from the operations were estimated by the work output of those 36 patients who postoperatively returned to their previous or a corresponding occupation. The postoperative work output was estimated using the coefficients for known causes of retirement (emigration, mortality, disability). The benefits of one lumbosacral fusion amounted on average to 16,075 US dollars. Fusion of the lumbosacral spine prove to be profitable at a cost-benefit ratio of 1 : 2.9. If the selection of patients for operation could be made so as to guarantee that working capacity is restored by operative treatment, the cost-benefit ratio might be improved to 1 : 9.5. It is emphasized that cost-benefit analyses of surgical procedures are important from the standpoint of principles of treatment and priority of operations. This study deals with economic aspects only. The medical aspects of the present material have been presented in two previous papers.     

Pigmented villonodular synovitis of the lumbosacral spine

Pigmented villonodular synovitis commonly occurs in synovial joints of the appendicular skeleton but rarely affects the synovial joint of the spine, and thus information regarding its natural history, treatment and prognosis remains limited. This case report illustrates a male patient with lumbosacral spinal pigmented villonodular synovitis who presented with lower back pain. It was treated by radical surgical excision and posterior instrumentation. Surgical decompression and follow-up of a patient with magnetic resonance imaging (MRI) constitute a satisfactory treatment of pigmented villonodular synovitis.     

Injuries of the lumbosacral segments of the spine

Having studied 470 case histories of patients with injuries of the spine the author found traumas of the 5th lumbar vertebra in 23 cases (4.9%). The characteristic injuries were compression wedge-shaped fractures, multiple fractures of the vertebrae, comminuted and traumatic spondylolistheses and dislocation fractures. A typical mechanism of the injury was a blow in the lumbar region or in the back with subsequent bending of the trunk. The tactics of surgical treatment of such lesions is presented, the main tasks of which are the reconstruction of the shape and the volume of the vertebral canal, the stabilization of the basis compartment of the spine and the prevention of subsequent degenerative changes.