Lumbosacral Fractures Research Articles

Fracture Risk Following Lumbosacral Spine SBRT in Patients Having Received Previous Whole Pelvis Radiation Therapy

Stereotactic body radiation therapy (SBRT) for metastatic spinal disease provides local control with palliative effects1. Previous studies have demonstrated a posttreatment fracture rate range of roughly 5.7-39%2, with 14-17% the most commonly cited fracture risk range. However, the rate of spine fracture after lumbosacral SBRT in patients having received prior pelvic radiation therapy (RT) is unclear. The purpose of this study is to investigate the incidence of fracture in patients receiving lumbosacral spine SBRT following previous whole pelvic RT. This study was a single institution retrospective chart review. All lumbar and sacral spine SBRT cases over a 5-year period (from January 2018 through September 2022) with at least three months of post-treatment follow-up were identified. Patients having previously received pelvic RT were assessed; the development of a vertebral fracture was recorded as was the time to fracture and potential intervention (if any). A total of 35 lumbosacral spine SBRT cases were identified. Of those eight (23%) previously received whole pelvic RT, ranging from 20-70 Gy/5-35 fractions. Of the lumbosacral spine SBRT patients having received prior pelvic RT, two (25%) developed a fracture post-treatment. The average time to fracture was 7.5 months. Both fractures were treated with conservative management; neither required vertebroplasty/kyphoplasty or operative stabilization. The mean dose per SBRT fraction for patients who suffered a fracture (8.5 Gy) did not significantly differ from that for patients who did not suffer a fracture (9 Gy). In the first examination of lumbosacral fracture risk following SBRT to patients having received previous pelvic RT, the fracture rate in this patient population was 25%. Noteworthy is that the SBRT dose per fraction did not differ between patients having suffered a fracture versus those without fracture. These findings indicate that patients having received previous whole pelvis RT should be counseled on the potential increased risk of fracture; however, there is no evidence that decreasing SBRT dose per fraction reduces the likelihood of fracture in this patient population. This increased fracture rate is of concern, and further investigation in larger studies to identify potential risk factors for vertebral fracture such as systemic therapy, age and gender is warranted.

Surgical management of lumbosacral and sacral fractures: roles of the pelvic and spinal surgeons.

In young patients, lumbosacral fractures result primarily from high-energy traumas. Life-threatening lesions (e.g. visceral organs) are frequently associated with these fractures. Management consists of medical intensive care for adequate resuscitation and specialized surgical input. Lumbosacral junction represents a frontier between the spine and pelvic ring. Any injury in this area implies a thorough examination of both spine and pelvis through clinical examinations and CT scans. Patients must be assessed specifically for neurological and bladder/bowel symptoms. Several surgical classifications may be required to describe the entire fracture pattern. In unstable fracture with large displacements, definitive surgical fixation is often recommended. Various pelvic and spine surgery techniques can be used depending on the fracture pattern, surgeon's experience, and available equipment. The use of intraoperative navigation may enhance placement of instrumentation, especially in cases of complex fractures, percutaneous fixations, and/or atypical patients' anatomy. The fracture itself can cause debilitating complications with long-term consequences such as pain, neurological deficits, and bladder/bowel impairments. Wound infection remains the most common postoperative complication and prominent posterior instrumentation is frequently a source of pain. Irrespective of the treatment, leg discrepancy can be problematic in the case of malunion. Management of lumbosacral fractures requires a thorough understanding of both lumbar spine and pelvic injuries. Surgical treatment may involve a combination of spine and pelvic surgery techniques. Therefore, this implies for the surgeon to be trained specifically for these fractures, or else a close cooperation between the pelvic surgeon and the spine surgeon in managing the patients.

RISK FACTORS ASSOCIATED WITH FRACTURE OF THE LUMBOSACRAL SPINE AND ITS COMPROMISE IN THE QUALITY OF LIFE OF CIRRHOTICS.

Chronic hepatic disease is associated with osteoporosis, osteopenia or osteomalacia. Osteoporosis and fractures due to bone fragility present high prevalences and are more frequent in patients with liver cirrhosis than in the general population. The search for a diagnosis of osteopenia and osteoporosis in this population may allow early intervention and modify unfavorable outcomes. To know the prevalence of osteopenia or osteoporosis and of fracture due to bone fragility in individuals with liver cirrhosis, the associated risk factors, and its compromise in their quality of life (QoL). Observational, transversal study performed with 71 liver cirrhosis patients of the Hepatology Service of the Hospital de Base do Distrito Federal, Brasília, DF, Brazil, between July 2017 and December 2018. The patients were submitted to bone densitometry (DXA) of the lumbar spine and of the femoral neck, to x-ray of the lumbosacral spine and to the Chronic Liver Disease Questionnaire (CLDQ) for the evaluation of quality of life (QoL). The Fracture Risk Assessment (FRAX) major was calculated for patients >50 years old. The analyses were performed for the evaluation of the risk factors associated with lumbosacral spine fracture. The majority (62%) of the 71 evaluated patients was diagnosed with osteoporosis or osteopenia on DXA. Of the 44 patients with osteopenia or osteoporosis, 52.3% were female, with a mean age of 62.6±9.51 years old, with the majority (72.7%) being Child A, cirrhotics of alcoholic etiology (36.4%), and with an intermediate QoL according to the CLDQ (3.3). Regarding the patients with lumbosacral spine fracture, the mean age was 61.6±11.1 years old, 60% were female, most of them Child A (66.7%), of alcoholic etiology (46.7%), and with an intermediary QoL according to the CLDQ (3.5). The presence of osteopenia and/or osteoporosis was associated with lumbosacral fracture (P<0.001), without correlation with the other analyzed variables: age, body mass index, gender, presence and absence of ascites, Child-Pugh classification, vitamin D, calcium, and phosphorus serum concentration, cirrhosis etiology and FRAX major. The prevalence of hepatic osteodystrophy was high, and the occurrence of lumbosacral spine fracture was more associated with osteoporosis and/or osteopenia among the cirrhotic patients studied. The QoL was intermediate and with no differences between cirrhotics with and without fracture.

Extension-Distraction Spine Injury at Lumbosacral Junction: A Case Report

Case: We presented a case of extension-distraction spine injury at lumbosacral junction in a patient with fused spine concomitant with a lumbosacral transitional vertebra. Detail of an exceedingly rare case of traumatic lumbosacral hyperextension-distraction fracture in the individual was described and reviewed. Conclusion: Although the occurrence of extension-distraction spine injury at lumbosacral junction is extremely rare, it can occur in some circumstances. Application of damage control spine concept including early definitive stabilization of spine fractures and minimally invasive spine surgery can give satisfactory outcomes in the polytraumatized patient.

Coronal balance with circumferential minimally invasive spinal deformity surgery for the treatment of degenerative scoliosis: are we leaning in the right direction?

Coronal malalignment (CM) in adult spinal deformity is associated with poor outcomes and remains underappreciated in the literature. Recent attempts at classifying CM indicate that some coronal shifts may be more difficult to treat than others. To date, outcomes for circumferential minimally invasive surgery (cMIS) of the spine in the context of these new CM classifications are unreported. A retrospective evaluation of patients with degenerative scoliosis (Cobb angle > 20°) consecutively treated with cMIS at a single institution was performed. Preoperative and 1-year postoperative standing radiographs were used to make the comparisons. Clinical outcome measures were compared. Patients were subgrouped according to the preoperative distance between their C7 plumb line and central sacral vertical line (C7-CSVL) as either coronally aligned (type A, C7-CSVL < 3 cm); shifted ≥ 3 cm toward the concavity (type B); or shifted ≥ 3 cm toward the convexity (type C) of the main lumbar curve. Forty-two patients were included (mean age 67.7 years). Twenty-six patients (62%) were classified as type A, 5 patients (12%) as type B, and 11 patients (26%) as type C. An average of 4.9 segments were treated. No type A patients developed postoperative CM. All type B patients had CM correction. Six of the 11 type C patients had CM after surgery. Overall, there was an improvement in the C7-CSVL (from 2.4 to 1.8 cm, p = 0.04). Among subgroups, only type B patients improved (from 4.5 to 0.8 cm, p = 0.002); no difference was seen for type A patients (from 1.2 to 1.4 cm, p = 0.32) or type C patients (from 4.3 to 3.1 cm, p = 0.11). Comparing type C patients with postoperative CM versus those without postoperative CM, patients with CM had worse visual analog scale back scores at 1 year (5 vs 1, p = 0.01). Moreover, they had higher postoperative L4 tilt angles (11° vs 5°, p = 0.01), indicating inadequate correction of the lumbosacral fractional curve. cMIS improved coronal alignment, curve magnitudes, and clinical outcomes among patients with degenerative scoliosis. It did not result in CM in type A patients and was successful at improving the C7-CSVL in type B patients. Type C patients remain the most difficult to treat coronally, with worse visual analog scale back pain scores in those with postoperative CM. Regional coronal restoration of the lumbosacral fracture curve should be the focus of correction in cMIS for these patients.

Analysis of Fracture Patterns and Characteristics in Sacral Insufficiency Fracture: Do Sacral Fractures Occur in Patients Who Had Previous Lumbosacral Fusion Insufficiency Fractures or Stress Fractures?

Study DesignThis study is a retrospective analysis of a case.PurposeThe purpose of this study is to investigate the fracture patterns and risk factors of sacral insufficiency fractures (SIFs) to improve their diagnosis in clinical practice.Overview of LiteratureSIFs occur when normal stresses are applied to a bone with decreased density, most often due to osteoporosis. Individuals who receive lumbosacral fusion procedures may also suffer from increased incidents of SIFs because of decreased bone density related to aging.MethodsIn total, 55 patients with SIFs were retrospectively investigated in this study. The study population was divided into lumbosacral fusion (n=20) and non-fusion (n=35) groups. Subsequently, the patients’ demographic characteristics, comorbidities, medication history, results of diagnostic imaging studies, and bone mineral density were assessed. The fracture patterns were classified either according to the five typical types (H-pattern bilateral vertical plus horizontal component, unilateral vertical only, bilateral vertical only, unilateral vertical plus horizontal component, and horizontal only fracture) or atypical types.ResultsIn total, 44 of 55 patients (80%) suffered from more than one senile disease and received corresponding medications that caused secondary osteoporosis. A total of 12 patients had S1 lumbosacral fixation. Moreover, three of these 12 patients who developed a SIF immediately after a lumbosacral fracture had an unstable sacral U fracture. The remaining nine patients showed fracture patterns similar to the non-fusion patients. Single-photon emission computed tomography (SPECT)/computed tomography (CT) can identify fracture recurrence in previously healed fractures. In total, 24 patients (43.6%) had fractures of the pelvis, femur, and thoracolumbar spine.ConclusionsSIF develops in elderly patients with multiple adult diseases that can induce secondary osteoporosis. Such fractures may occur in the patients with instrumented lumbosacral fusion. Importantly, some patients showed stress fractures after multilevel instrumented lumbosacral fusion, whereas others showed insufficiency fractures. The different fracture patterns correspond to different grades of SIF, and SPECT/CT can easily identify the fracture status.

The Comparison of Spinopelvic Parameters, Complications, and Clinical Outcomes After Spinal Fusion to S1 with or without Additional Sacropelvic Fixation for Adult Spinal Deformity: A Systematic Review and Meta-analysis.

Systematic review and meta-analysis. The purpose of the study was to compare the outcomes and after spinal fusion with or without iliac screw (IS) insertion for patients with adult spinal deformity (ASD). The number of patients undergoing multilevel spinal stabilization for the treatment of ASD is growing. However, the selection of spinopelvic fixation for ASD patients with long fusion is controversial. A comprehensive literature search was performed without time restriction according to the guidelines from the Cochrane Collaboration in May 2020 using PubMed, EMBASE, and the Cochrane Library. The comparison of the two types of fixation was evaluated by spinopelvic parameters, incidence rate of complications, rate of revision, and clinical outcomes at the last follow-up. The literature search identified 422 records, of which eight studies were included for meta-analysis with a total of 439 patients. All the included studies provided level III evidence. There was no significant difference in the sagittal vertical axis, pelvic incidence, the proximal junctional kyphosis rates, the pseudarthrosis rates, the revision rates, and the clinical outcomes at the last follow-up between those who receive sacrum fixation and sacropelvic fixation. Nevertheless, greater lumbar lordosis (LL) (weighted mean difference [WMD], 4.15; 95% confidence interval [CI] 2.46-5.84, P < 0.01), greater sacral slope (SS) (WMD, 2.32; 95% CI 1.21-3.43, P < 0.01), and lower rate of the distal instrumentation instability (odds ratio, 0.25; 95% CI 0.10-0.61, P = 0.002) were observed in IS group between the comparison. The clinical outcomes in the IS group were similar to those in the non-IS group, but the application of the IS significantly restored LL, prevented decompensation, and reduced the occurrence of the distal instrumentation instability. Therefore, the IS may be a good choice for the operative treatment of ASD patients with sagittal malalignment and other risks of lumbosacral fracture, metal breakage, and screw pullout.Level of Evidence: 3.

Motion preserving management of unstable traumatic clivus fracture extending through bilateral occipital condyles

We describe non-operative management a rare traumatic clival fracture extending through the bilateral occipital condyles. Clinical History: A 26-year-old female who was involved in a high-speed motor vehicle crash presented to an outside facility with difficulty speaking. Subsequent CT of the cervical spine demonstrated a fracture of the clivus with extension through the bilateral occipital condyles. She was then transferred to our hospital for further management where complete trauma survey noted multiple other injuries including traumatic subarachnoid hemorrhage, spinal epidural hematoma, bilateral pneumothoraces, liver laceration, bilateral upper extremity injuries, and lumbosacral fractures. Additional spinal imaging was negative for any associated vascular or spinal cord injury. Given her young age, there was a strong interest to preserve craniocervical motion and the decision was made to treat her with non-operatively with halo placement. After 18 weeks of rigid fixation, follow up imaging demonstrated completely healed fractures and at twenty-one weeks post fixation she demonstrated preserved motion of the craniocervical junction. This is a review of the literature and case report regarding this rare entity and its management.

The Influence of Lumbosacral Spine Pathology on Minimum 2-Year Outcome After Hip Arthroscopy: A Nested Case-Control Analysis

Background: Previous literature has examined the association between lumbosacral pathology and hip pathomechanics. However, the effect of lumbosacral pathologies and previous lumbosacral surgery on achieving meaningful outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has yet to be studied conclusively. Purpose: To determine whether a history of lumbosacral spine pathology has an influence on achieving minimal clinically important differences (MCIDs) after hip arthroscopy for FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing hip arthroscopy for FAIS by a single, fellowship-trained orthopaedic surgeon between January 2012 and April 2017 with minimum 2-year follow-up were retrospectively reviewed. Patients with a history of lumbosacral spine pathology (eg, lumbosacral fusion, disc or vertebral pathology, or history of lumbosacral fractures) were matched 1:2 by age, body mass index, and sex to patients without spine pathology. Clinical outcomes including the Hip Outcome Score–activities of daily living subscale (HOS-ADL), HOS–sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool–12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were compared between the groups using an independent t test. The threshold of every outcome score for achieving MCID was calculated separately for each group and frequencies were compared. Results: A total of 83 of 108 eligible patients with lumbosacral pathology were identified and matched to 166 patients without any spine pathology. When compared with the non–spine pathology group, the lumbosacral pathology group had significantly lower 2-year postoperative outcome score averages across all reported outcome tools (all P < .001). There were significant differences in the proportion achieving the threshold for HOS-ADL (60.6% vs 80.0%; P = .004), HOS-SS (57.6% vs 82.1%; P < .001), mHHS (66.7% vs 81.7%; P = .025), and iHOT-12 (54.8% vs 87.6%; P < .001) scores for MCID when comparing the lumbosacral and nonlumbosacral pathology groups. Conclusion: Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. The present study findings have implications for preoperative patient screening, shared decision-making processes/expectation management, and rehabilitation strategies.

A new minimally invasive U-shaped lumbopelvic stabilization technique.

Lumbopelvic stabilization is a surgical technique used frequently to treat lumbosacral fractures; however, it can also be used in revision cases, infections, or during deformity correction. However, the related soft tissue complication rates associated with open lumbopelvic stabilization are high. Different authors have recently reported minimally invasive surgical techniques. We developed a rigid minimally invasive technique for lumbopelvic stabilization. We present our technique and also present preliminary results from 10 cases. We did not observe soft tissue-related complications in any patient. Implant removal was performed twice, to release healthy disks and because of implant prominence. One patient required revision surgery because of implant loosening due to osteoporosis, and one patient required revision surgery due to screw cap loosening. Postsurgical mobilization was good in all patients without further injuries; however, polytraumatized patients were limited by additional injuries. Thus, minimally invasive U-shaped lumbopelvic stabilization is a useful technique combining the soft tissue-related advantages of minimally invasive surgical techniques as well as a theoretically very rigid construct caused by strong implants.

MicroRNA-199a Upregulation Mediates Lumbar Intervertebral Disc Degeneration and is Associated with Clinical Grades of Degeneration.

To determine the expression profile of miRNA-199a-5p in intervertebral disc degeneration (IDD) and its correlation to the grade of IDD. This case-controlled study was conducted during a 6-month period from 2017 to 2018 in two university hospitals in Shiraz, Iran. We included 15 patients with grade 3 and 4 of Pfirrmann and 5 patients with traumatic lumbosacral fractures with grade I. Total discectomy was performed in all the individuals and the samples were sent to the laboratory. The nucleus pulposus (NP) cells were isolated and the RNA was extracted. cDNA was synthesized by reverse transcriptase and the expression was measured using real-time polymerase chain reaction (RT-PCT). We overall included 20 patients in two study groups. Both study groups were comparable regarding the baseline and clinical characteristics except for age (p=0.026). The fold change (p=0.007), and relative expression (p=0.012) of the miRNA-199a- 5p was found to be significantly higher in patients compared to controls. The fold change (p=0.001), and relative expression (p < 0.001) were also associated with the Pfirrmann grading. We found that the area under curve (AUC) was 0.880 (95%CI: 0.721- 0.938) indicative of moderate accuracy. Expression of the miRNA-199a-5p is increased in the IDD. The expression of the miRNA-199a-5p was also associated with the grade of the degeneration based on the Pfirrmann grading.

Fixation technique segmental modified with Steinmann pins in a Lumbosacral fracture between L7 and S1: Case Report

Equine tail syndrome occurs due to narrowing of the canal causing ischemia of the nerve roots L6, L7, S1 and S2 origin of the pudendal and sciatic nerve.The objective of this work is to report a case of a bitch, with no defined breed of approximately 9 months of age, attended at the veterinary hospital of Piauí, diagnosed with a lumbosacral fracture between l7 and S1, surgically treated by the segmental fixation technique modified with pins of Steinmann. The technique was effective in the stabilization and immobilization of the fracture, showing a good response in the recovery of the patient.

Chronic low back pain after lumbosacral fracture due to sagittal and frontal vertebral imbalance

Problem and hypothesisOver time, some patients with unilateral or bilateral lumbosacral injuries experience chronic low back pain. We studied the sagittal and frontal balance in a population with these injuries to determine whether mismatch in the pelvic and lumbar angles are associated with chronic low back pain. Patients and methodsPatients with posterior pelvic ring fractures (Tile C1, C2, C3 and A3.3) that had healed were included. Foreign patients and those with an associated spinal or acetabular fracture or nonunion were excluded. The review consisted of subjective questionnaires, a clinical examination, and standing A/P and lateral stereoradiographic views. The pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), measured lumbar lordosis (LLm), T9 sagittal offset, leg discrepancy (LD) and lateral curvature (LC). The expected lumbar lordosis (LLe) was calculated using the formula LLe=PI+9°. We defined lumbopelvic mismatch (LPM) as the difference between LLm and LLe being equal or greater than 25% of LLe. ResultsFifteen patients were reviewed after an average follow-up of 8.8 years [5.4–15]. There were four Tile C1, five Tile C2, five Tile C3 and one Tile A3.3 fracture. Ten of the 15 patients had low back pain. The mean angles were: LLm 49.6° and LLe 71.9° (P=0.002), PT 21.3°, SS 44.1°, PI 62.9° in patients with low back pain and LLm 57.4° and LLe 63.2° (P=0.55), PT 13°, SS 43.1°, PI 54.2° in those without. LPM was present in 9 patients, 8 of who had low back pain (P=0.02). Six patients, all of whom had low back pain, had a mean LC of 7.5° [4.5–23] (P=0.02). The mean LD was 0.77cm. DiscussionThe findings of this small study suggest that patients who experience low back pain after their posterior arch of the pelvic ring fracture has healed, have a lumbopelvic mismatch. Early treatment of these patients should aim to reestablish the anatomy of the pelvic base relative to the frontal and sagittal balance. Level of evidenceIV.

Characteristics and treatments of spinal fractures associated with dural tears

Objective To investigate the characteristics and treatment effects in patients with spinal fractures associated with dural tears. Methods A retrospective analysis was made on 185 patients with spinal fractures presenting to hospital from February 2013 to February 2015. There were 103 males and 82 females, aged 17-73 years (mean, 58 years). Causes of injury were high falls in 72 patients , traffic collisions in 58, hitting by heavy objects in 41, ground-level falls in 12, and collision events in two. Cervical spine fractures were seen in 65 patients, thoracic vertebra fractures in 51, and lumbosacral vertebral fractures 69. Neurologic deficit was assessed using the American Spinal Injury Association (ASIA) score, including grade A in 24 patients, grade B in 22, grade C in 26, grade D in 37 and grade E in 76. Eighty patients were managed by simply anterior surgery, 97 by posterior surgery, and eight by anterior-posterior surgery. Twenty-one patients were found with dural tears (group A) and 164 patients without dural tears (group B). Incidence of dural tears in cervical, thoracic and lumbosacral vertebral fractures were recorded and compared. Preoperative neurologic deficit, laminar fracture and spinal canal encroachment rate were compared between groups. Neurological function and complications associated with dural repair were detected. Results In group A, ten patients were rated ASIA grade A, five grade B, three grade C, one grade D and two grade E. In group B, 14 patients were rated ASIA grade A, 17 grade B, 23 grade C, 36 grade D and 74 grade E. Group A accounted for 11%(7/65) of cervical, 10%(5/51) of thoracic, and 13%(9/69)of lumbosacral spine fractures (P>0.05). Nineteen patients (91%) in group A were complicated with neurological deficit, compared to ninety patients (54.9%) in group B (P<0.01). Eighteen patients (86%) in group A had laminar fractures, compared to fifteen patients (9.1%) in group B (P<0.01). In group A, rate of spinal canal encroachment was (62.3±12.1)% and 17 patients (81%) showed spinal canal encroachment of greater than 50%. While in group B, rate of spinal canal encroachment was (36.2±15.6)% and 25 patients (15.2%) showed spinal canal encroachment of greater than 50% (P<0.01). For dural tears in group A, 11 patients were treated by direct suturing, four by thoracolumbar fascia repair, three by artificial dural coverage and three by fibrin glue sealing. In group A, 19 patients were followed up and one of them presented persistent cerebral spinal fluid leak that necessitated an irrigation and debridement to cure. ASIA score was improved from grade A to B in two patients, grade B to C in one, grade C to D in one and grade D to E in one at the final follow-up. Conclusions Majority patients with spinal fractures associated with dural tears exist severe neurologic deficit, spinal canal encroachment and laminar fractures. Incidence of dural tear in cervical, thoracic and lumbosacral vertebral fractures is similar. Incidence of complications related to dural tear repair is low, but the neurological function recovery is poor after operation. Key words: Spinal fractures; Dura mater; Spinal cord injuries; Complications

Spinal injuries affecting the lumbosacral spine and pelvis

Lumbo-sacral fractures are complex injuries that often occur alongside pelvic ring trauma. They are often missed on initial assessment and plain radiography, and delayed treatment can lead to pain, reduced mobility and neurological compromise. Careful clinical examination is essential and identification of the fracture pattern often requires CT imaging. A large number of classification systems are available to help guide decision-making and these have recently been summarised in the comprehensive AO Spine sacral fracture classification system. Surgical intervention includes both neurological decompression and stabilisation and is indicated for patients with neurological compromise, lumbo-sacral instability and significant soft tissue injuries.

Multiple associated injuries are common with spine fractures during war

The nature of concomitant injuries associated with spine fractures in American military personnel engaged in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) has been poorly documented in the literature. To characterize the incidence and epidemiology of associated injuries (AIs) in American military personnel with spine fractures sustained during OEF and OIF from 2001 to 2009. Retrospective study. American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR). Not applicable. The JTTR was queried using International Statistical Classification of Disease, Ninth Revision codes to identify all individuals who sustained spine injuries in OEF or OIF from October 2001 to December 2009. Medical records of all identified service members were abstracted to ensure accuracy and avoid duplication. Demographic information, including sex, age, and military rank, were obtained for all patients. Information regarding fracture type, spine region, mechanism of injury, and the presence of AIs was collected for all patients. Seventy-eight percent of patients with a spine fracture sustained at least one AI, with an average of 3.4 AIs per patient. Musculoskeletal injuries were most common, followed by chest, abdomen, and traumatic brain injuries. Most patients were injured by an explosive mechanism (62%). Head and face traumas were more common with cervical fractures, chest with thoracic injuries, and abdominopelvic injuries with lumbosacral fractures. Pelvis and acetabulum fractures were common after helicopter crashes, tibia/fibula injuries after explosions, thoracoabdominal injuries after gunshot wounds, and traumatic brain injuries after falls. Most patients (76%) sustained multiple spine fractures. Spine fractures sustained in OEF and OIF have high rates of AIs. Musculoskeletal AIs are the most common, but visceral injuries adjacent to the spine fracture frequently occur. Multiple spine injuries are more prevalent after military trauma.

Iliac Artery Injuries and Pelvic Fractures: A National Trauma Database Analysis of Associated Injuries and Outcomes

Although infrequent, injury to the common or external iliac artery in association with pelvic fractures can be devastating, and descriptive data are lacking. This study was performed to determine the incidence, injury patterns, and outcomes of blunt iliac artery injuries (BIAIs) in association with moderate or severe pelvic fractures. Patients with moderate or severe pelvic fractures (abbreviated injury score of 3 or 4) were identified from the National Trauma Databank. Records with and without common or external BIAI were compared. Admission variables included Emergency Department (ED) hypotension (systolic blood pressure <90), Glasgow Coma Score <or=8, Injury Severity Score (ISS) >or=25, femur or lumbosacral fractures, solid organ injury, vascular injury, and hollow viscus injury. The association of BIAI with moderate or severe pelvic fractures was studied. Outcomes were also analyzed, and independent associations with BIAI were determined by logistic regression. Of 6,377 patients with moderate or severe pelvic fractures, 221 (3.5%) had an associated BIAI. Patients with BIAI were more likely to have ED hypotension, Glasgow Coma Score <or=8, ISS >or=25, genitourinary injury, bowel injury, and severe (abbreviated injury score 4) pelvic fractures. BIAI was also associated with higher mortality, lower extremity amputation, compartment syndrome, and overall complications. Independent risk factors for BIAI included severe pelvic fracture, ED hypotension, ISS >or=25, genitourinary injury, and bowel injury. BIAI is a rare diagnosis, but when present it is associated with a higher rate of overall complications and mortality. Vigilance is warranted in the diagnosis and management of this infrequent injury, especially in the setting of severe pelvic fractures.

Complete Traumatic Anterior Dislocation of the Lumbosacral Joint

A case report is presented. This report documents a case of complete traumatic anterior lumbosacral joint dislocation with the sacralization of L5. Traumatic anterior dislocation of the lumbosacral joint is a rare spondylolisthesis. The strategy for surgical treatment of traumatic dislocation of the lumbosacral joint remains controversial. A case of a 29-year-old man sustaining complete traumatic lumbosacral joint dislocation with the sacralization of L5 was treated successfully. Indirect radiologic signs such as bilateral multiple transverse process fractures were strongly suggestive of the diagnosis, which was further confirmed by 3-dimensional-computed tomography scan. This complete spondylolisthesis induced the instabilities of the entire soft tissues and caused severe cauda equina syndrome. The patient underwent an open reduction, decompression, and posterior fixation. Bilateral disrupted nerve roots were partly repaired simultaneously. The patient successfully underwent surgery. An anatomically aligned and preserved solid spinal fusion was obtained during a 17-month follow-up. The patient had neurologic improvement in hip extension and knee flexion, and also could walk with an ankle brace. Posterior instrumentation with the rod and screw system is considered a useful method for the management of complete traumatic anterior lumbosacral joint dislocation. However, prognosis is correlated with the initial neurologic status and the severity of other associated injuries.

Lumbosacral fracture dislocation treated with transforaminal lumbar interbody fusion: A case report

Lumbosacral fracture dislocation treated with transforaminal lumbar interbody fusion: A case report

Use of a Four Pin and Methylmethacrylate Fixation in L7 and the Iliac Body to Stabilize Lumbosacral Fracture–Luxations: A Clinical and Anatomic Study

To describe the clinical outcome of a 4 pin lumbosacral fixation technique for lumbosacral fracture-luxations, and to refine placement technique for iliac pins based on canine cadaver studies. Retrospective and anatomic study. Dogs (n=5) with lumbosacral fracture-luxations and 8 cadaveric canine pelvi. Lumbosacral fracture-luxations were stabilized with a 4 pin (positive-profile threaded) and bone cement fixation. Caudal pins were inserted in the iliac body and cranial pins were inserted into the L7 or L6 pedicle and body. Follow-up examinations and radiographs were performed to assess patient outcome. Intramedullary pins were inserted into the iliac bodies of 8 cadaver pelvi. Radiographs were taken to measure pin insertion angles and define ideal insertion angles that would maximize pin purchase in the ilium. Follow-up neurologic examination was normal in 4 dogs. Radiographic healing of the fracture was evident in 5 dogs. One implant failure occurred but did not require re-operation. For cadaver iliac pins, mean craniocaudal insertion angle was 29 degrees and mean lateromedial insertion angle was 20 degrees. Four pin and bone cement fixation effectively stabilizes lumbosacral fracture luxations. The iliac body provides ample bone stock, which can be maximized using an average craniocaudal pin trajectory of 29 degrees and an average lateromedial pin trajectory of 20 degrees. Lumbosacral fracture-luxations can be stabilized with 4 pin and bone cement fixation in the lumbar vertebrae and iliac body, using 29 and 20 degrees as guidelines for the craniocaudal and lateromedial pin insertion angles in the ilium.