Clinical and therapeutic analysis of 22 patients with traumatic spinopelvic dissociation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 WU Min , GUAN Jianzhong , CHEN Xiaotian , WANG Xiaopan , ZHAO Peishuai , WANG Yongsheng , CHEN Jiaqiang , LIU Leyu , LI Renjie

Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical University, Anhui Provincial Key Laboratory of Tissue Transplantation, Bengbu Anhui, 233004, P. R. China;

Corresponding author：

WU Min, Email: wumin200207@163.com

Keywords：

Sacral fracture; spinopelvic dissociation; surgical treatment; fracture fixation

DOI：

10.7507/1002-1892.202504029

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Objective To review the clinical characteristics of patients with traumatic spinopelvic dissociation (SPD) and explore the diagnostic and therapeutic methods. Methods A clinical data of 22 patients with SPD who underwent surgical treatment between March 2019 and August 2024 was retrospectively analyzed. There were 13 males and 9 females, with an average age of 35.5 years (range, 14-61 years). The causes of injury included falling from height in 16 cases, traffic accidents in 5 cases, and compression injury in 1 case. Sacral fractures were classified based on morphology into “U” type (9 cases), “H” type (7 cases), “T” type (4 cases), and “λ” type (2 cases). According to the Roy-Camille classification, there were 4 cases of type Ⅰ, 12 cases of type Ⅱ, 2 cases of type Ⅲ, and 4 cases of type Ⅳ. The Cobb angle was (35.7± 22.0)°. Sixteen patients were accompanied by lumbosacral trunk and cauda equina nerve injury, which was classified as grade Ⅱ in 5 cases, grade Ⅲ in 5 cases, and grade Ⅳ in 6 cases according to the Gibbons grading. The time from injury to operation was 2-17 days (mean, 5.7 days). Based on the type of sacral fracture and sacral nerve injury, 6 cases were treated with closed reduction and minimally invasive percutaneous sacroiliac screw fixation, 16 cases were treated with open reduction and lumbar iliac fixation (8 cases)/triangular fixation (8 cases). Among them, 11 patients with severe fracture displacement and kyphotic deformity leading to sacral canal stenosis or bony impingement within the sacral foramen underwent laminectomy and sacral nerve decompression. X-ray films and CT were reviewed during followed-up. The Matta score was used to evaluate the quality of fracture reduction. At last follow-up, the Majeed score was used to assess the functional recovery, and the Gibbons grading was used to evaluate the nerve function. Results All operations were successfully completed. All patients were followed up 8-64 months (mean, 20.4 months). Two patients developed deep vein thrombosis of the lower limbs, 2 had incision infections, and 1 developed a sacral pressure ulcer; no other complications occurred. Radiological examination showed that the Cobb angle was (12.0±6.8)°, which was significantly different from the preoperative one (t=6.000, P<0.001). The Cobb angle in 16 patients who underwent open reduction was (14.9±5.5)°, which was significantly different from the preoperative one [(46.8±13.9)° ] (t=8.684, P<0.001). According to the Matta scoring criteria, the quality of fracture reduction was rated as excellent in 8 cases, good in 7 cases, fair in 5 cases, and poor in 2 cases, with an excellent and good rate of 68.2%. Bone callus formation was observed at the fracture site in all patients at 12 weeks after operation, and bony union achieved in all cases at last follow-up, with a healing time ranging from 12 to 36 weeks (mean, 17.6 weeks). At last follow-up, the Majeed score was rated as excellent in 7 cases, good in 10 cases, fair in 4 cases, and poor in 1 case, with an excellent and good rate of 77.3%. One patient experienced a unilateral iliac screw breakage at 12 months after operation, but the fracture had already healed, and there was no loss of reduction. Among the 16 patients with preoperative sacral nerve injury, 11 cases showed improvement in nerve function (6 cases) or recovery (5 cases). Conclusion SPD with low incidence, multiple associated injuries, and high incidence of sacral nerve injury, requires timely decompression of the sacral canal for symptomatic sacral nerve compression, fractures reduction, deformities correction, and stable fixation.

1.	Bäcker HC, Vosseller JT, Deml MC, et al. Spinopelvic dissociation: A systematic review and meta-analysis. J Am Acad Orthop Surg, 2021, 29(4): e198-e207.
2.	Morris CA, Moo Young JP, Savakus JC, et al. Neurologic injury after spinopelvic dissociation: Incidence, outcome, and predictors. Injury, 2023, 54(2): 615-619.
3.	Hirschfeld M, Pascual-López FJ, Guerado E. Spinopelvic dissociation: Current concepts. Rev Esp Cir Ortop Traumatol, 2024, 68(4): 398-408.
4.	Purser DW. Displaced fracture of the sacrum. Report of a case. J Bone Joint Surg (Br), 1969, 51(2): 346-347.
5.	Bents RT, France JC, Glover JM, et al. Traumatic spondylopelvic dissociation. A case report and literature review. Spine (Phila Pa 1976), 1996, 21(15): 1814-1819.
6.	Park YS, Baek SW, Kim HS, et al. Management of sacral fractures associated with spinal or pelvic ring injury. J Trauma Acute Care Surg, 2012, 73(1): 239-242.
7.	Moo Young JP, Savakus JC, et al. Lumbopelvic fixation in the treatment of spinopelvic dissociation: union, complications, and neurologic outcomes of a multicenter case series. Eur J Orthop Surg Traumatol, 2024, 34(5): 2391-2396.
8.	Voort WV, O’Donnell E, Haffner M, et al. Biomechanical analysis of a modified triangular osteosynthesis technique for treatment of spinopelvic dissociation. J Orthop Trauma, 2024, 38(11S): S35-S39.
9.	Quacinella MA, Morrissey PB, Parry JA, et al. Spinopelvic dissociation: assessment, reduction strategies, and fixation techniques. J Am Acad Orthop Surg, 2020, 28(24): e1086-e1096.
10.	Roy-Camille R, Saillant G, Gagna G, et al. Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine (Phila Pa 1976), 1985, 10(9): 838-845.
11.	Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum. J Orthop Trauma, 1991, 5(2): 200-203.
12.	Gibbons KJ, Soloniuk DS, Razack N. Neurological injury and patterns of sacral fractures. J Neurosurg, 1990, 72(6): 889-893.
13.	Zhao P, Wang X, Chen X, et al. Preoperative CT simulation of iliosacral screws for treating unstable posterior pelvic ring injury. BMC Musculoskelet Disord, 2022, 23(1): 220. doi: 10.1186/s12891-022-05155-6.
14.	Matta JM, Tornetta P. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res, 1996(329): 129-140.
15.	Majeed SA. Grading the outcome of pelvic fracture. J Bone Joint Surg (Br), 1989, 71(2): 304-306.
16.	Santolini E, Kanakaris NK, Giannoudis PV. Sacral fractures: issues, challenges, solutions. EFORT Open Rev, 2020, 5(5): 299-311.
17.	Godolias P, Plümer J, Cibura C, et al. Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review. Arch Orthop Trauma Surg, 2024, 144(4): 1627-1635.
18.	Matsugaki T, Shibata H, Esaki Y, et al. Suicidal jumper’s fracture reduced with hyperextension and the joystick method: A case report. Trauma Case Rep, 2021, 32: 100444. doi: 10.1016/j.tcr.2021.100444.
19.	Ruatti S, Kerschbaumer G, Gay E, et al. Technique for reduction and percutaneous fixation of U- and H-shaped sacral fractures. Orthop Traumatol Surg Res, 2013, 99(5): 625-629.
20.	Chou DTS, El-Daly I, Ranganathan A, et al. Spinopelvic dissociation: A retrospective case study and review of treatment controversies. J Am Acad Orthop Surg, 2018, 26(14): e302-e312.
21.	Williams SK, Quinnan SM. Percutaneous lumbopelvic fixation for reduction and stabilization of sacral fractures with spinopelvic dissociation patterns. J Orthop Trauma, 2016, 30(9): e318-e324.
22.	Gross A, Kuttner H, Shariat K, et al. The surgical management of highly unstable fragility fractures of the sacrum with spinopelvic dissociation: A case series and proposal of a surgical treatment algorithm. Injury, 2022, 53(10): 3377-3383.
23.	Chen W, Hou Z, Su Y, et al. Treatment of posterior pelvic ring disruptions using a minimally invasive adjustable plate. Injury, 2013, 44(7): 975-980.
24.	张银光, 贾健, 刘兆杰. 髂腰内固定治疗创伤性脊柱骨盆分离. 中华骨科杂志, 2015, 35(4): 328-334.
25.	Romoli S, Petrella L, Becattini E, et al. Treatment of unstable spinopelvic fractures: outcome of three surgical techniques-a retrospective single-center case series. Eur Spine J, 2023, 32(1): 93-100.
26.	Tian W, Chen WH, Jia J. Traumatic spino-pelvic dissociation with bilateral triangular fixation. Orthop Surg, 2018, 10(3): 205-211.
27.	Brodell JD, Lawlor MC, Santangelo G, et al. Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures. Injury, 2024, 55(11): 111825. doi: 10.1016/j.injury.2024.111825.
28.	Kaye ID, Yoon RS, Stickney W, et al. Treatment of spinopelvic dissociation: A critical analysis review. JBJS Rev, 2018, 6(1): e7. doi: 10.2106/JBJS.RVW.16.00119.
29.	郑博隆, 庄岩, 袁雷红, 等. 影响骶管减压髂腰固定治疗“H”形骶骨骨折疗效的相关因素分析. 中华骨科杂志, 2017, 37(13): 810-816.

1. Bäcker HC, Vosseller JT, Deml MC, et al. Spinopelvic dissociation: A systematic review and meta-analysis. J Am Acad Orthop Surg, 2021, 29(4): e198-e207.
2. Morris CA, Moo Young JP, Savakus JC, et al. Neurologic injury after spinopelvic dissociation: Incidence, outcome, and predictors. Injury, 2023, 54(2): 615-619.
3. Hirschfeld M, Pascual-López FJ, Guerado E. Spinopelvic dissociation: Current concepts. Rev Esp Cir Ortop Traumatol, 2024, 68(4): 398-408.
4. Purser DW. Displaced fracture of the sacrum. Report of a case. J Bone Joint Surg (Br), 1969, 51(2): 346-347.
5. Bents RT, France JC, Glover JM, et al. Traumatic spondylopelvic dissociation. A case report and literature review. Spine (Phila Pa 1976), 1996, 21(15): 1814-1819.
6. Park YS, Baek SW, Kim HS, et al. Management of sacral fractures associated with spinal or pelvic ring injury. J Trauma Acute Care Surg, 2012, 73(1): 239-242.
7. Moo Young JP, Savakus JC, et al. Lumbopelvic fixation in the treatment of spinopelvic dissociation: union, complications, and neurologic outcomes of a multicenter case series. Eur J Orthop Surg Traumatol, 2024, 34(5): 2391-2396.
8. Voort WV, O’Donnell E, Haffner M, et al. Biomechanical analysis of a modified triangular osteosynthesis technique for treatment of spinopelvic dissociation. J Orthop Trauma, 2024, 38(11S): S35-S39.
9. Quacinella MA, Morrissey PB, Parry JA, et al. Spinopelvic dissociation: assessment, reduction strategies, and fixation techniques. J Am Acad Orthop Surg, 2020, 28(24): e1086-e1096.
10. Roy-Camille R, Saillant G, Gagna G, et al. Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine (Phila Pa 1976), 1985, 10(9): 838-845.
11. Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum. J Orthop Trauma, 1991, 5(2): 200-203.
12. Gibbons KJ, Soloniuk DS, Razack N. Neurological injury and patterns of sacral fractures. J Neurosurg, 1990, 72(6): 889-893.
13. Zhao P, Wang X, Chen X, et al. Preoperative CT simulation of iliosacral screws for treating unstable posterior pelvic ring injury. BMC Musculoskelet Disord, 2022, 23(1): 220. doi: 10.1186/s12891-022-05155-6.
14. Matta JM, Tornetta P. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res, 1996(329): 129-140.
15. Majeed SA. Grading the outcome of pelvic fracture. J Bone Joint Surg (Br), 1989, 71(2): 304-306.
16. Santolini E, Kanakaris NK, Giannoudis PV. Sacral fractures: issues, challenges, solutions. EFORT Open Rev, 2020, 5(5): 299-311.
17. Godolias P, Plümer J, Cibura C, et al. Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review. Arch Orthop Trauma Surg, 2024, 144(4): 1627-1635.
18. Matsugaki T, Shibata H, Esaki Y, et al. Suicidal jumper’s fracture reduced with hyperextension and the joystick method: A case report. Trauma Case Rep, 2021, 32: 100444. doi: 10.1016/j.tcr.2021.100444.
19. Ruatti S, Kerschbaumer G, Gay E, et al. Technique for reduction and percutaneous fixation of U- and H-shaped sacral fractures. Orthop Traumatol Surg Res, 2013, 99(5): 625-629.
20. Chou DTS, El-Daly I, Ranganathan A, et al. Spinopelvic dissociation: A retrospective case study and review of treatment controversies. J Am Acad Orthop Surg, 2018, 26(14): e302-e312.
21. Williams SK, Quinnan SM. Percutaneous lumbopelvic fixation for reduction and stabilization of sacral fractures with spinopelvic dissociation patterns. J Orthop Trauma, 2016, 30(9): e318-e324.
22. Gross A, Kuttner H, Shariat K, et al. The surgical management of highly unstable fragility fractures of the sacrum with spinopelvic dissociation: A case series and proposal of a surgical treatment algorithm. Injury, 2022, 53(10): 3377-3383.
23. Chen W, Hou Z, Su Y, et al. Treatment of posterior pelvic ring disruptions using a minimally invasive adjustable plate. Injury, 2013, 44(7): 975-980.
24. 张银光, 贾健, 刘兆杰. 髂腰内固定治疗创伤性脊柱骨盆分离. 中华骨科杂志, 2015, 35(4): 328-334.
25. Romoli S, Petrella L, Becattini E, et al. Treatment of unstable spinopelvic fractures: outcome of three surgical techniques-a retrospective single-center case series. Eur Spine J, 2023, 32(1): 93-100.
26. Tian W, Chen WH, Jia J. Traumatic spino-pelvic dissociation with bilateral triangular fixation. Orthop Surg, 2018, 10(3): 205-211.
27. Brodell JD, Lawlor MC, Santangelo G, et al. Percutaneous lumbopelvic fixation is effective in the management of unstable transverse sacral fractures. Injury, 2024, 55(11): 111825. doi: 10.1016/j.injury.2024.111825.
28. Kaye ID, Yoon RS, Stickney W, et al. Treatment of spinopelvic dissociation: A critical analysis review. JBJS Rev, 2018, 6(1): e7. doi: 10.2106/JBJS.RVW.16.00119.
29. 郑博隆, 庄岩, 袁雷红, 等. 影响骶管减压髂腰固定治疗“H”形骶骨骨折疗效的相关因素分析. 中华骨科杂志, 2017, 37(13): 810-816.

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