Session VII - Pelvic Trauma

Neurologic Outcomes of Sacral Fractures: Is Decompression Beneficial?

Gary S. Gruen, MD, Steven R. Speth, MD, Timothy J. Hunt, MD, Gregory Bijak, BSE, Bruce H. Ziran, MD

University of Pittsburgh, Pittsburgh, Pennsylvania, USA

Purpose: A major complication of a sacral fracture following trauma is a neurological injury. The purpose of this study is to determine the incidence of sacral fractures with significant neurological deficits followed by an outcomes assessment of patients treated with operative decompression versus those not having a decompression.

Materials and Methods: All patients with an unstable pelvic ring fracture admitted to our hospital were considered for inclusion in this study. Specific inclusion criteria consisted of patients with severe radicular leg pain, a motor deficit of less than 3/5 muscle strength, or bowel/bladder dysfunction. The time to surgical decompression and the post-operative results were recorded.

Neurological outcomes were assessed using the modified SOFCOT score. (Figure 1) The score was tabulated at the time of injury and at their follow- up examination. Additionally, an SF-36 health survey was utilized. This was subdivided into its 8 component parts as well as a score for the mental and physical components. Statistical analysis was performed by the students' t-test and analysis of variance, with p < .05 considered significant.

Results: Three hundred seventy-eight patients with unstable pelvic ring fractures were identified between 1988 and 1996. One hundred seventy-seven of these patients (47%) had a significant sacral fracture without sacroiliac joint involvement. Thirteen patients (7%) met our inclusion criteria of having a major neurologic injury and were available for follow-up at an average duration of 20.7 months. Six patients had undergone operative decompression (Tile B 20%, C 80%) whereas 7 patients did not have a surgical decompression. (Tile B 33%, C 67%). One patient from the decompressed group had a transverse fracture, whereas 1 patient from the group not decompressed, had an H type sacral fracture. The remaining 11 patients had a Type II or Type III vertical Denis sacral fracture.

A significant difference was noted (p=0.02) using the modified SOFCOT score in the group which was decompressed when compared to the non-decompressed group, 8.33 vs. 4.29 points, respectively. Similarly, there was a significant difference (p < 0.05) in the SF-36 with the decompressed group scoring higher in physical function (decompressed 76.2, not decompressed 43.6).

Discussion: A sacral fracture, with a significant neurologic deficit, is a rare injury and represented 7% of our fractures. Further, patient outcomes of those sacral fractures decompressed versus those not decompressed, showed a significant benefit with operative decompression with the operative patients improving a minimum of 1 motor grade in function, having a diminution in radiculopathy and better control of bowel/bladder function. This correlated with the patient's subjective assessment using the SF-36.

Conclusion: We recommend operative decompression of sacral fractures associated with significant neurological injury since it leads to an improved functional outcome.

Table 1: Modified SOFCOT Scoring

Category/Score	0	1	2	3	4	5	6
Radicular pain	Severe		Moderate		Mild		None
Motor	0/5-1/5		2/5-3/5		4/5		5/5
Sensory	Moderate	Mild	None
Bowel/Bladder	None			Partial			Intact