Date Published: April 10, 2018
Author(s): Jeffrey M. Pearson, Thomas E. Niemeier, Gerald McGwin, Sakthivel Rajaram Manoharan.
Spinopelvic dissociation injuries are historically treated with open reduction with or without decompressive laminectomy. Recent technological advances have allowed for percutaneous fixation with indirect reduction. Herein, we evaluate outcomes and complications between patients treated with open reduction versus percutaneous spinopelvic fixation.
Retrospective review of patients undergoing spinopelvic fixation from a single, level one trauma center from 2012 to 2017. Patient information regarding demographics, associated injuries, and treatment outcome measures was recorded and analyzed. All fractures were classified via the AO Spine classification system.
Thirty-one spinopelvic dissociations were identified: 15 treated with open and 16 with percutaneous techniques. The two treatment groups had similar preoperative characteristics including spinopelvic parameters (pelvic incidence and lumbar lordosis). Compared to open reduction internal fixation, percutaneous fixation of spinopelvic dissociation resulted in statistically significantly lower blood loss (171 cc versus 538 cc; p = 0.0013). There were no significant differences in surgical site infections (p = 0.48) or operating room time (p = 0.66).
Percutaneous fixation of spinopelvic dissociation is associated with significantly less blood loss. Treatment outcomes in terms of infection, length of stay, operative cost, and final alignment between the open and percutaneous group were similar.
Spinopelvic dissociation or U type sacrum fracture is a rare injury that involves a transverse sacral fracture pattern and can be associated with a high rate of neurologic injury, up to 57% (Figure 1) [1–4]. In large case series, spinopelvic dissociative injuries account for only 2.9% of all pelvic ring traumas [5, 6]. Traditional treatment methods involving open reduction with internal fixation have been observed to have high rates of postoperative infections up to 14–16% [7–10]. In the last decade, percutaneous fixation (Figure 2) of these injuries has gained popularity with reported improved clinical outcomes [11, 12].
A retrospective review was conducted on all operatively managed spinopelvic dissociations treated between January 2012 and March 2017 at a single, level one trauma center. Institutional review board approval was obtained. Inclusion criteria were patients over 18 years of age with diagnosed spinopelvic dissociation based on pelvic X-rays and CT scans. Patients with preoperative lower lumbar, sacral, or pelvic hardware were excluded. Patient characteristics and demographics were collected for all patients including age, gender, mechanism of injury, associated injuries, neurological injury, and tobacco use. The injuries were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) sacrum classification. Pelvic X-rays were also subclassified based on modifiers M3 being anterior pelvic ring injury and M4 sacroiliac joint injury .
Thirty-one patients with spinopelvic dissociation were identified at our institution from 2012 to 2017. The cohort consisted of 15 patients treated with open reduction and lumbopelvic fixation and 16 with indirect reduction and percutaneous lumbopelvic fixation. Age, sex, and tobacco use were similar between the two groups (p > 0.05) (Table 1). Outpatient follow-up was on average 7.8 months for the open group and 9.9 months for the closed group (p = 0.50). Both groups included three patients with preoperative symptoms of cauda equina.
Modern technologic advances in orthopedic instrumentation have allowed for the adoption of percutaneous techniques to treat spinopelvic dissociation. Historic treatment with open reduction with lumbopelvic fixation of spinopelvic dissociation has been associated with a high infection rate [9, 10]. Schildhauer et al. observed an infection rate of 16% with open reduction and internal fixation of spinopelvic dissociations . With current minimally invasive strategies, percutaneous instrumentation has been shown to have low rates of wound complication and decreased blood loss .