Fri., 10/5/12 Pelvis & Acetabulum, PAPER #62, 3:40 pm OTA-2012
Displaced Sacral Fractures: Do Long-Term Radiologic Findings Correlate to Neurologic Deficits and Pain?
Aron Adelved, MD1,5; Anna Tötterman, MD, PhD2; Thomas Glott, MD3;
Johan C. Hellund, MD, PhD4; Jan Erik Madsen, MD, PhD5; Olav Røise, MD, PhD5;
1Orthopaedic Department, Akershus University Hospital, Akershus, Norway;
2Orthopaedic Department, Karolinska University Hospital, Stockholm, Sweden;
3Department for Spinal Cord Injuries, Sunnaas Hospital, Nesodden, Norway;
4Radiologic Department, Oslo University Hospital, Oslo, Norway;
5Orthopaedic Department, Oslo University Hospital, Oslo, Norway
Background/Purpose: Long-term neurologic deficits and pain are common after high-energy sacral fractures. However, little is known about the correlation between these long-term clinical outcomes and radiologic findings. The aim of the present study was to assess whether long-term radiologic findings after surgically treated displaced sacral fractures correlated with pelvic-related pain or neurologic dysfunctions in the lower extremities and the perineum.
Methods: 28 consecutive patients with displaced (>1 cm) sacral fractures were followed for mean 10.7 years (range, 8.1-13.4) postinjury. Two had H-type sacral fractures, while 26 had AO/OTA type-C pelvic ring disruptions involving the sacrum. In 27 of 28, the sacral fractures were transforaminal. All fractures were treated with reduction and internal fixation. Sensorimotor impairments in the lower extremities were classified according to the American Spinal Injury Association (ASIA) and pain was assessed using a visual analog scale (VAS) ranging from 0 to 10. CT and plain radiograph images were scrutinized for nonunion, cranial and posterior residual displacement, and ankylosis/osteoarthritis (OA) in the L5-S1 facet joints and the sacoiliac joints. Changes of sacral configuration, including narrowing of the L5 and sacral neural foramina, as well as postforaminal encroachment of L5 and S1 nerves were recorded. The statistical analyses were calculated using Spearman correlation coefficients.
Results: No sacral nonunions were encountered. Residual cranial displacement >10 mm was present in 13 patients (46%) averaging 15.4 mm (range, 10-28). Posterior displacement averaging 18.9 mm (range, 11-35) was observed in 10 (36%). In the L5-S1 facet joints, OA was present in 18 (64%), and ankylosis in 9 (32%). 26 (93%) had narrowing of one or more neural root foramina L5-S4. According to the VAS, 8 patients (29%) reported no pain. Of the remaining 20, 11 had only pain in the lumbosacral (LS) area and 9 had a combination of LS and radiating pain in the L5-S2 dermatomes. A statistically significant correlation was found between the narrowing of the sacral neural foramina and neurologic deficits in corresponding dermatomes (S1: P = 0.03, S2: P <0.001, S3: P = 0.001). In L5 dermatomes, a significant correlation was found between postforaminal affection of L5 nerves for both sensory (P = 0.025) and motor (P = 0.01) deficits correspondingly. No statistically significant correlations were found between pain and any of the pathologic radiologic findings.
Conclusion: In patients with surgically treated sacral fractures, persistent lumbosacral pain is common, but does not correlate to radiologic sequelae after fracture healing or residual displacement in the posterior pelvic ring. However, pathologic radiologic findings involving the neuroforamina correlate significantly to neurologic deficits. This suggests that reconstruction of the sacral neural foramina at the time of surgery may play a greater role in the long-term outcome compared to overall pelvic alignment. Further studies are needed to assess the natural history of these secondary changes involving the sacral neural foramina.
Alphabetical Disclosure Listing (808K PDF)
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.