Session V - Pelvis
Fri., 10/8/04 Spine & Pelvis, Paper #29, 5:01 pm
Operatively Treated Fractures of Sacrum: Neurological Dysfunction One Year Postoperatively
Purpose: Sacral fractures resulting from high-energy traumas are frequently associated with lesions to the lumbosacral nerve plexus or the intrapelvic organs. These injuries may result in long-term sequelae related to natural functions and mobility. We describe the prevalence of associated injuries secondary to unstable sacral fractures and characterize patient dysfunctions in a prospective longitudinal single-cohort study with a minimum 1-year follow-up.
Methods: Of 39 consecutive patients admitted to a trauma referral hospital for treatment of an unstable sacral fracture, 32 were available for follow-up at a minimum of 1 year postoperatively and constituted the study group. At the time of initial treatment, the following data were collected: demographics, trauma mechanism, mortality, surgical treatment, neurologic findings, additional injuries, Injury Severity Score (ISS), and fracture classification (OTA, Denis). Long-term outcome measures obtained included: impairment of defecation (questionnaire), voiding functions (questionnaire, urodynamic tests), sexual function (male patients, International Index of Erectile Function questionnaire, IIEF). Clinical testing of sensorimotor function (modified ASIA, Cybex ankle index). Multifactor assessment was performed a minimum of 1 year after surgery (mean, 15 months; range 12 to 30).
Results: The ratio of male to female patients was 24:8; the mean age was 33 years (range, 16 to 57). Admission delay was 41 hours (range, 0 hours to 12 days). All patients had been sustained high-energy injuries. Morbidity matched for ISS was 27 (range, 9 to 57). The criterion for polytrauma was filled in 16 cases (5%). Additional injuries were seen in 28 patients (88%). Additional vertebral body injuries occurred in nine patients (28%), six of which were stabilized. Urogenital injury was seen in three patients (9%), rectal injury, in one (3%). Sacral fracture as part of pelvic fracture was seen in 29 cases (OTA C1, 16; C2, 7; C3, 6), isolated sacral fractures were seen in three (ratio, 91%: 3%). According to the Denis classification, 2 (6%) of the fractures were in zone I, 23 (72%) in zone II, and 7 (22%) in zone III. Internal fixation was performed 5 days after injury (range, 1 to 13). Five patients were intubated prior to admission (19%). A general neurologic status was available for the remaining 27 patients, 19 (59% of all, 70% of tested) of whom had signs of neurologic injury. At 1 year, 28 (87%) reported sensory dysfunction affecting the lower extremities, and 14 showed evidence of motor dysfunction (44%). Voiding problems were reported by 15 (47%), all of whom demonstrated altered urodynamics. Bowel dysfunction was reported by 7 (22%). Altered sexual function was seen in 3 of the 11 male patients (27%) for whom the IIEF questionnaire was applicable (39% of all male patients).
Conclusions: Fractures to the sacrum are frequently associated with serious neurologic injuries affecting the lower extremities as well as the natural functions with little or no restitution at 1 year postoperatively. These injuries should be recognized early in order to institute adequate treatment and follow-up.