Sacral Fracture and Dislocation
The patient is a 68-year-old female with a history of rheumatoid arthritis, treated for many years with steroids, who suffered a minor fall. She presents with severe sacral area pain and urinary incontinence.
She is very tender to palpation over the sacrum and is unable to sit or stand due to the pain. There is diminished peri-anal sensation and rectal tone.
Imaging shows traumatic fracture dislocation at S1-S2. There is spinal canal compromise.
Traumatic S1-S2 grade 4 traumatic spondylolisthesis.
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Due to the severity of clinical and neurological symptoms, surgical intervention was performed. S1 and S2 laminectomies were performed followed with L2 through iliac instrumentation. Adequate pelvic fixation was performed to permit substantial reduction of the spondylolisthesis. Dual iliac fixation was performed due to the patient's poor bone quality and the need to stabilize both the spine and pelvis.
Postoperative imaging shows pedicle screw fixation from L2 to S1 with dual iliac fixation.
One-year following the surgical procedure, the patient experienced minimal pain and had regained substantial bowel and bladder continence. Only mild stress incontinence persisted. The patient ambulated without difficulty using only a cane for longer distances.
Doctor Shaffrey's case describes a very favorable outcome in an elderly woman with a complex sacral fracture. It is important to recognize this is not a sacral insufficiency fracture, which usually runs parallel to the spine in the sagittal plane and typically involves the ala. This fracture is in the transverse plane, which demonstrates why the canal compromise is so profound. The instrumentation exhibits several key features for optimizing purchase in osteoporotic bone. First, the pedicle screws are well-medialized. The screws are quite long providing additional cortical fixation in the anterior cortical bone. There is redundant iliac fixation and two crosslinks.
The extensive fixation was performed because of the "H" type configuration of the sacral fracture. The fractures included complete fracture of both sacral ALAs that resulted in spinopelvic kyphosis. The number of spinal fixation points were needed due to poor bone quality and concerns about loss of fixation with shorter segment fixation.