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Long-term functional outcome after traumatic lumbosacral dissociation. A retrospective case series of 13 patients
Injury, Int. J. Care Injured 47 (2016) 1562–1568
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Long-term functional outcome after traumatic lumbosacral dissociation. A retrospective case series of 13 patients Aron Adelved a,b,f,*, Anna To¨tterman c, Thomas Glott d, Johan C. Hellund e, Jan Erik Madsen a,f, Olav Røise a,f,g a
Department of Orthopaedic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway Department of Orthopaedic Surgery, Karolinska University Hospital, Stockholm, Sweden d Department of Spinal Cord Injury and Multitrauma Unit, Sunnaas Hospital, Nesodden, Norway e Department of Radiology, Oslo University Hospital, Ullevaal, Oslo, Norway f Faculty of Medicine, University of Oslo, Norway g Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway b c
A R T I C L E I N F O
A B S R A C T
Article history: Accepted 9 April 2016
Study design: Retrospective case series. Introduction: Traumatic lumbosacral dissociation (TLSD) is a rare subgroup of sacral fractures caused by high-energy trauma in healthy adults. There are no accepted treatment algorithms for these injuries. Neurologic deficits and pain are commonly associated with these injuries, however, little is known about the long-term functional outcome in patients with TLSD. The objective of this study was to assess longterm functional outcome in patients with traumatic lumbosacral dissociation (TLSD) injuries. Materials and methods: Thirteen patients with TLSD were retrospectively identified and followed with clinical and radiological examination mean 7.7 (312) years after the injury. Five were treated operatively, and eight non-operatively. Sensorimotor impairments in the lower extremities were classified according to ASIA. Urinary function was assessed with uroflowmetry, and bowel- and sexual functions were assessed using a structured interview. Pain was assessed using a visual analogue scale (VAS), and patient-reported health with SF-36. CT images were scrutinized for non-union and kyphotic angulation across the fracture. Results: Eleven patients had neurologic deficits corresponding to L5 and sacral roots. Urinary dysfunction was observed in nine, and bowel dysfunction in three patients. Eight patients reported problems associated with sexual activities, with pain during intercourse and erectile dysfunction being the most common problems. Twelve patients reported pain in the lumbosacral area, in combination with radiating pain in the majority. The overall patient-reported health (SF-36) was significantly lower than the normal population. All sacral fractures were united as seen on CT. Sacral kyphotic angulation was present in 11, which had increased in three patients comparing with the initial radiographs. Conclusion: In this long-term follow-up, functional impairments, pain, and poor patient-reported health were common findings among patients with TLSD. High rates of neurologic, urinary and sexual dysfunctions were reported. Extended follow-up several years after the injury with a special focus on urogenital dysfunctions and pain management may be beneficial to these patients. ß 2016 Elsevier Ltd. All rights reserved.
Keywords: Lumbosacral dissociation U-shaped sacral fractures Long-term outcome Neurologic deficits Urinary dysfunction Sexual dysfunction Pain Sacral kyphotic angulation
Introduction
* Corresponding author at: Department of Orthopaedic Surgery, Akershus University Hospital, Sykehusveien 25, 1478 Lørenskog, Norway. Tel.: +47 93404190; fax: +47 67960506. E-mail address: [email protected] (A. Adelved). http://dx.doi.org/10.1016/j.injury.2016.04.006 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.
Traumatic lumbosacral dissociation (TLSD) is a rare subgroup of sacral fractures mostly reported as single cases or small case series [1–5]. It is also commonly denoted as a U or H-shaped sacral fracture, and mainly results from high energy trauma, such as fall from height or motor vehicle accidents [6]. Combat-related blast injuries have also been reported recently [7]. Neurologic deficits in
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the lower extremities and pain are common findings in patients after TLSD [8–10]. There is a lack of good quality reports documenting which fractures need to be treated operatively and which can be treated non-operatively. Furthermore, little information is available on functional outcome of these injuries, regarding neurologic and urogenital functions, residual pain, as well as patient-reported health in a long-term perspective. The aim of this study was to assess long-term functional outcome, patient-reported health and radiological outcome in patients with TLSD. Materials and methods In this retrospective study, all patients with traumatic lumbosacral dissociation (TLSD) were identified from the Pelvic Fracture Registry at Oslo University Hospital, Ullevaal during the period of March 1997 to September 2006. Low energy, osteoporotic fractures or sacral insufficiency fractures, as well as sacral fractures as part of pelvic ring disruptions were excluded. Nineteen patients met the inclusion criteria, of which three were foreign residents and two were deceased. Of the remaining 14 eligible patients, one was not traceable and the remaining 13 patients constituted the study population of this long-term follow-up. The following data were extracted from the patient charts: Injury mechanism, Injury Severity Score (ISS), fracture pattern, neurologic presentation, additional injuries, and treatment. At follow-up, collected data included assessment of neurologic function, urinary, bowel and sexual function, pain, ADL, and patient-reported health (PRH) measured by SF-36. All patients also underwent radiologic examination with CT of the lumbar spine and the pelvis. All fractures were zone-III injuries, according to the classification of Denis et al. [11]. They were further subdivided according to Roy-Camille et al. [6] on the basis of their transverse fracture pattern (Table 1). In addition, one had an undisplaced acetabular fracture, which was treated non-operatively. Five patients were treated operatively; all with open reduction and internal fixation with iliolumbar interpedicular screws (Universal Spine System), and concomitant sacral laminectomy. The remaining eight patients were treated non-operatively. Indication for operative treatment was based on an overall assessment of neurologic deficits, radiographic signs (CT) of mechanical instability or compression of neural elements, and patients’ pain preventing mobilization (Fig. 1). In the absence of radiographic signs of instability or neural compression, non-operative treatment was applied (Fig. 2). Sensory and motor function in the lower extremities and perineum was assessed using the American Spinal Injury Association (ASIA) impairment scale [12], focusing on the lumbar and
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sacral roots only. Neurologic function was then graded according to Gibbon et al. [13], however modified to focus on the neurologic deficits in the L5 and sacral dermatomes; 1- no neurologic deficits, 2- sensory deficits only, 3- partial, combined sensory and motor deficits; and 4- complete loss of neurologic function. Bladder and bowel functions were assessed separately. Urinary bladder function was assessed by a structured interview [14] concerning frequency, urgency, hesitation or incontinence. In addition, patients with volitional voiding underwent flowmetry to measure maximum flow. Post-micturition volume was measured by ultrasound within 10 min after bladder emptying. Measurements of maximum flow were classified and graded into percentiles according to the Liverpool nomograms [15]. Overall bladder dysfunction was then graded based on theresults from the interview, flowmetry, ultrasonography, and the nomograms as; 1- normal voiding pattern (same as before injury), 2slightly changed voiding pattern, but normal flow and residual urine less than 50 mL and no incontinence, 3-significantly changed voiding pattern with reduced flow below 5th percentiles, or more than 50 mL residual urine or incontinence, and 4- no volitional voiding and regular intermittent catheterization or urinary deviation. Bowel function was assessed by a structured interview, addressing frequency and problems with urgency, diarrhoea, constipation, or incontinence. Bowel function was graded as: (1) normal bowel patterns (same as before injury), (2) slightly changed (changes in frequency or need of medication such as laxatives), (3) completely changed with incontinence and/or need of enema or colostomy. Problems associated with sexual function were assessed by interview with open questions. In female patients, problems related to sexual function, in particular pain during sexual intercourse or reduced arousal, was noted. In male patients, erectile dysfunction was assessed using selected questions from the Norwegian version of the International Index of Erectile Function (IIEF) questionnaire [16], pertaining to sexual activity during the past 4 weeks. Pain was self-assessed by the patients, using a visual analogue scale (VAS) ranging from 0 to 10, with 0 representing no pain and 10 the most severe pain experienced within the last 24 h. The patients were asked to grade their average pain particularly in the lower back and posterior pelvic area. When present, radicular pain to the lower extremities was recorded. Only pain related to the lumbosacral injury was recorded, and peripheral pain caused by injures to the lower extremities were not considered in the pain assessment. The information regarding ambulation, activities of daily living (ADL), and return to work was obtained by a structured interview. Ambulation was defined as dependence or independence of
Table 1 Patient characteristics. Patient no
Sex
Injury mechanism
ISS
Roy-Camille (classification, U/H)
Treatment
Age at FU
FU time Years, months
1 2 3 4 5 6 7 8 9 10 11 12 13
F M F M F M M M M M F M F
MVA MVA MVA MVA MVA MVA Fall MVA MVA Fall Fall* Fall* Fall*
29 9 19 14 9 22 17 22 29 10 29 45 50
1 1 1 2 1 1 1 1 3 3 1 3 1
non-op. non-op. non-op. non-op. non-op. non-op. non-op. non-op. op. op. op. op. op.
29 45 36 36 35 64 46 41 56 59 39 38 21
9,10 9,7 9,5 9,4 6,7 5,5 3,8 3,0 11,11 9,10 9,3 8,10 3,10
(H) (U) (H) (H) (U) (U) (H) (U) (H) (U) (H) (H) (U)
F: female, M: male, MVA: motor vehicle accident, ISS: Injury Severity Score, U/H: fracture shape, FU: follow-up. * Suicidal jump.
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Fig. 1. CT scans of a patient treated operatively. Pre-operative (a) images and at (b) follow-up.
walking aids/wheelchair, and ADL as dependence or independence of another person or healthcare services in the daily activities. Patient-reported health was assessed using a general health survey, namely Short Form-36 (SF-36) (SF-36 v2, QualityMetric Inc., Lincoln, RI, USA). The SF-36 results were analyzed by comparing them with the gender- and age-adjusted norm-based scores (NBS) for the Norwegian population [17]. The Norwegian NBS is based on SF-36 version 1, with slight differences from version 2. In order to ease comparison of our data with the normbased data, the Version 2 scores were converted to version 1 scores using the QualityMetric Health OutcomesTM Scoring Software 4.0, provided by QualityMetric Inc., Lincoln, RI, USA.
Radiologic assessment Multidetector CT (MDCT) volume scans were obtained from the level of L3 to below the lesser trochanter region. 2D axial, coronal and sagittal reconstructions were used to evaluate fracture status including any signs of non-union. Fracture healing was confirmed by the presence of bridging trabecular bone across the fracture lines on CT. On the mid-sagittal image, kyphotic angulation across the fracture site was measured using the methods described by Kuklo et al. [18]. Any narrowing of the spinal canal was recorded, using the midline sagittal images evaluating the inner tapering AP-diameter.
Fig. 2. CT scans of a patient treated non-operatively. (a) Initial images and at (b) follow-up.
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Statistics SPSS Statistics 21 software (IBM SPSS Inc., Chicago, IL, USA) was used for the statistical analyses. Z-scores were calculated, using sex- and age-adjusted norm-based scores for the general Norwegian population, published by Loge et al. [17]. The onesample t-test was used to compare the SF-36 scores with normbased scores. Ethics The study was reviewed and approved by the Regional Committee for Medical and Health Research Ethics, Region SouthEast Norway. All patients signed an informed consent at follow-up. Results The mean follow-up time was 7.7 years (range 312) postinjury, with a female: male ratio of 5:8, and mean age of 42 years (range 2164). Mean injury severity score (ISS) was 23 (range 950). In five cases, the mechanism of injury was fall from height, including three suicidal jumps, and in the remaining eight cases, motor vehicle accidents (MVA). Patient characteristics, including fracture types and treatments are shown in Table 1. Only two patients had normal neurologic function at follow-up, both were treated non-operatively. One had no neurologic deficits at the time of injury, and was also asymptomatic at follow-up. The other had unilateral sensory deficits in the sacral dermatomes initially, which went to complete recovery, but had slightly altered bladder function at follow-up. Among the remaining 11 with neurologic deficits at follow-up; early adequate evaluation of the neurological injuries in two patients was precluded by the severity of their condition, both of whom had neurologic deficits at followup. One patient with normal neurologic function initially, developed secondary sensory and motor deficits in L5-S4 dermatomes bilaterally, after non-operative treatment of the fracture (Table 2). Bladder function was not assessed at the time of injury, as this was not practically feasible. At follow-up, four patients had normal Table 2 Clinical findings at follow-up. Results based on interview, clinical examination and flowmetry. Patient no
Neurologic function
Bladder function
Bowel function
Sexual function
Pain VAS
1 2 3 4 5 6 7 8 9 10 11 12 13
2 1 3 2 1 3 3 2 3 3 3 3 3
1 1 4 1 2 2 3 2 1 3 3 4 2
1 1 3 1 1 2 1 1 1 1 1 3 1
pain * normal pain ** normal normal pain + ED normal pain + ED normal ED
6 1 8 0 3 6 6 5 8 2 4 7 5
(NA) (1) (3) (2) (2) y (1) yy (3) (2) (3) (3) (3) (3) (NA)
#
ED ** pain
Neurologic function: 1-normal, 2-sensory deficit, 3-sensory and motor deficit, 4Complete loss of neurologic function. (Neurologic function at admission is given in brackets). NA: not available. y Neurologic recovery. yy Neurologic deterioration. Bladder function: 1-normal, 2-slightly altered, 3-significantly altered, 4-no volitional voiding. Bowel function: 1-normal, 2-slightly altered, 3- completely altered. Sexual function: * Decreased lubrication. ** Decreased genital sensation, ED: erectile dysfunction. # Altered self-image. Pain- refers to pain in the lumbosacral area.
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bladder function. Of the remaining nine, four had slightly altered and another three patients had significantly altered bladder function. In two cases, the bladder function was completely altered, with no volitional urinary voiding and dependence of intermittent self- catheterization. Three out of five patients with initially reduced anal sphincter tone had regained full anal sphincter function at follow-up. Of the remaining two, one had still reduced sphincter tone at follow-up, and the other received a permanent colostomy shortly after the injury. These two patients in addition to one patient, who developed secondary neurologic deficits, reported altered bowel function. At follow-up, eight out of 13 patients reported problems associated with their sexual activity, including lumbosacral pain, erectile dysfunction and reduced genital sensation as frequently reported symptoms. All but one reported pain on the VAS scale; with an average VAS score of 4.7 (range 18). An overview of the clinical findings and patient-reported symptoms is listed in Tables 2 and 3. The majority of patients, 12 out of 13 were ambulant without walking aids. One patient used wheelchair. Of the ambulant patients, eight reported problems with walking on non-level surfaces or walking in the dark. Six were not able to run and reported problems such as pain or reduced endurance when walking longer distances. One patient required help for strenuous activities, and one was dependent on daily assistance for ADL. The remaining 11 patients were independent in ADL. Five out of eight patients returned to their full time jobs that they had before injury, and three went on to permanent disability pension (DP). Two students before injury were still engaged in studies at the time of follow-up. The remaining three patients, who were unemployed or were on DP before injury, were on permanent DP at follow-up.
Table 3 Clinical examination and patient-reported functions at current follow-up. The figures in italics may not add up, as patients may have several symptoms/findings, N = 13. N Normal neurologic function Neurologic deficits - Sensory deficits - Sensory and motor deficits Normal bladder function Altered bladder function - Subjective symptoms (urge, stress incontinence, abdominal straining) - No voluntary voiding (Intermittent self-catheterization) Normal Bowel function Altered bowel function - Constipation - Reduced sphincter function - Colostomy Normal sexual function Reported problems with sexual activity - Lumbosacral pain during intercourse - Erectile dysfunction - Reduced genital sensation/reduced lubrication - Reduced arousal/altered self-image Pain (VAS) -0 - 13 - 47 -8 Pain area - Lumbosacral area only - Lumbosacral + radicular pain - Radicular pain only
2 11 3 8 4 9 3 2 10 3 3 2 1 5 8 5 4 2 2 1 3 7 2 1 9 2
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Table 4 Patient-reported health at follow-up compared with the age and gender adjustedy Norwegian norm based scores (NBS), n = 13. SF-36 domains
Mean scores at FU (SD)
Mean NBS Norwegiany (SD)
Difference of means (95% Confidence Interval)
P-value
PF RP BP GH VT SF RE MH
56.5 (25.8) 32.7 (40) 43.1 (25) 50.6 (28) 45.7 (27.4) 67.3 (19.5) 59 (45.4) 73.1 (19.7)
91.2 (3.1) 83 (5.4) 71 (21.5) 78.7 (4.2) 61 (4.2) 86.8 (1.9) 84.4 (4.3) 79 (1.8)
-
< 0.001 0.001 0.002 0.004 0.07 0.004 0.07 0.3
34.7 (-50.2)–(-19) 50.2 (-74.4)–(-26) 27.9 (-43)–(-12.7) 28.1 (-45)–(-11.2) 15.3 (-32)–(1.2) 19.5 (-31.3)–(-7.7) 25.4 (-53)–(2) 5.9 (-17.9)–(6)
SD: standard deviation, CI: confidence interval, NBS: norm-based scores, PF: physical functioning, RP: role physical, BP: bodily pain, GH: general health, VT: vitality, SF: social functioning, RE: role emotional, MH: mental health.
The overall patient-reported health scores were significantly lower than the normal population, although without statistical significance in three domains, namely vitality, role emotional, and mental health (Table 4 and Fig. 3). All the sacral fractures were healed at follow-up as seen on CT images. Kyphotic angulation across the fracture site was seen in 11 patients, with an average of 338 (range 1563). An increase of sacral kyphosis was seen in three patients, one of whom was treated operatively. In one of the other two patients who were treated non-operatively, also a secondary narrowing of the central canal was present at follow-up, although not present initially. In the remaining patients, no significant changes were seen in kyphotic angulation from the time of injury to the follow-up visit. Bony narrowing of the central canal was observed in five patients (Table 5). Discussion In the current study, we evaluated the long-term functional outcome in 13 patients after traumatic lumbosacral dissociation (TLSD) injuries with a follow-up time of seven (312) years. We found considerable morbidity in the majority of our patients, including neurologic sequelae in the lower extremities, bladder dysfunction and chronic pain. The patient-reported health scores, measured by the SF-36 were significantly lower than the normal population, and limitations in sexual activities were frequently
reported. However, all fractures were healed with an increase in kyphosis in only three patients, and the majority was independent in ambulation and ADL. Comparing studies describing TLSD injuries is complicated, as most of the studies are case reports or small case series, in addition to a wide variety in patient selection, injury type, and the magnitude of injury severity/additional injuries. Due to the rarity of TLSD, the severity of associated injuries, and lack of information from larger studies, no accepted treatment strategy is formulated for these injuries [19]. Operative treatment with internal fixation has been reported by some authors to be beneficial in terms of early mobilization and to achieve mechanical fracture stability in TLSD [20–22]. However, our own experience is that these fractures are difficult to reduce and there is so far no reports comparing conservative versus operative treatment. Furthermore, the benefits of decompressive surgery are uncertain, as varying rates of neurological recovery are reported from different studies [9,10,22,23]. The variation in neurologic restitution after surgery observed in these studies may reflect the variability in type of nerve lesion acquired at the time of injury. Huittinen et al. [24] observed three types of nerve injury in an autopsy study of 42 patients who died following severe pelvic and sacral fractures; traction injuries, compression injuries or avulsion of the neural elements. Thus, referring to Huittinen’s findings, neurologic recovery may depend not only on decompressive surgery, but also on the characteristics of the neurologic injury [25]. In our series, only partial or no recovery was seen in patients who underwent decompressive laminectomy, suggesting irreversible neurologic injuries in these patients. Full recovery was observed in only one of 13 patients, after non-operative treatment. Table 5 Radiographic findings on CT.
Patient no
Fig. 3. Z-scores at follow-up. The 0-line represents the norm-based scores for the Norwegian general population. The mean scores are significantly lower than the norms, except for VT, RE, and MH domains. The outliers represent patient no. 1 and no. 4. PF-physical functioning, RP-role physical, BP-bodily pain, GH-general health, VT-vitality, SF-social functioning, RE-role emotional, MH-mental health.
1 2 3 4 5 6 7 8 9 10 11 12 13
RoyCamille
1 1 1 2 1 1 1 1 3 3 1 3 1
Kyphosis initially (degrees)
NA 0 38 53 19 7 42 27 15 0 36 45 48
At
follow-up
Kyphosis
Central canal narrowing/level
at follow-up (degrees) 24 0 57 49 21 36 42 29 15 0 37 63 52
NA: Sagittal CT reformats not available. * Secondary bony narrowing of the central canal.
S1S2 S2* S2 S2S3 S1S2
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Due to the great heterogeneity and small number of patients in our study, comparing the results of operative versus non-operative treatment was not useful. We considered the high rate of pathologic urinary bladder function in our series to be neurogenic, as no urogenital injuries had been documented initially. Furthermore, we assessed the bladder function by urodynamic tests in order to evaluate the extent of dysfunction. In a separate, long-term follow-up study on a patient cohort with displaced sacral fractures as part of type C vertical shear injures, we found similarly high rates of bladder dysfunctions [26]. In that study, we also observed that bladder function deteriorated over time, between 1-year and 10-year follow-ups. In the present study, we did not have previous urodynamic data on the patients, as urodynamic tests are not feasible in the initial setting. Whether further deterioration in bladder function over time may occur also in these patients remains to be assessed. Chronic pain following pelvic and sacral fractures is common [27–29], and in TLSD significant pain problems have been reported in 40100% of the patients [7,9,10]. In the present study, 12 out of 13 patients reported pain, including five who also reported lumbosacral pain during intercourse, causing limitations in their sexual activity. As all sacral fractures were radiologically healed, other factors obviously influence the occurrence of pain. Severe pain has been reported in patients after spine fractures with posttraumatic kyphotic spine deformity [30,31]. The influence of sacral kyphotic deformity on lumbosacral pain is not documented. However, similar to the spinal post-traumatic deformities, the possibility of kyphosis as a main contributor to lumbosacral pain may be considered. Even so, kyphotic angulation did not correlate with VAS pain or pain during intercourse in our series. Further studies are needed to determine the relationship between sacral deformity and lumbosacral pain. Limitations in sexual function following TLSD injures are sparsely described previously. Siebler et al. [10] evaluated 11 patients with non-operatively treated zone III fractures, and reported sexual dysfunctions in four out of 11 patients. In our series, eight out of 13 had problems with their sexual function; the most frequently reported limitations being erectile dysfunction (ED) and pain in the lumbosacral area during intercourse. Problems with sexual function following polytrauma and pelvic injures may have both physical and psychosocial components [32,33]. The reported pain during intercourse may thus be caused by fracture sequelae and deformity, and ED may be the result of neurologic deficits. Further psychosocial aspects of ED could not be determined by this study. There are several limitations in the present study. Due to the retrospective design, we had limited comparable data from the time of injury on neurologic deficits, as this was insufficiently examined and documented in some patients. Consequently, detailed neurological recovery could not be determined for all patients. The patients certainly constituted a heterogeneous group and the number of patients was low. Consequently, reliable correlation analyses between the outcome measures and their impact on patient-reported health could not be performed. Furthermore, comparisons between the operative and the non-operative groups in terms of role of surgery or functional outcome were not performed. These questions could only be answered by studies with a larger number of patients, and due to the low incidence of these injuries, multicenter collaborative studies would be needed. Despite the limitations of our study, the results may have some clinical implications. Considering the poor patient-reported health among our patients, pain, neurologic deficits, bladder, and sexual dysfunctions presumably contribute to the overall low ratings of own health. By addressing these impairments with multidisciplinary follow-ups
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in the rehabilitation period, and even several years after the injury would be beneficial to the TLSD patients. Conclusion In this long-term follow-up of patients after traumatic lumbosacral dissociation injuries, all the sacral fractures united and the majority of patients were independent in ambulation and ADL. However, functional impairments and pain were common findings. High rates of neurologic deficits, urinary bladder dysfunction and limitations in sexual activities were found, and patient-reported health was significantly lower than the normal population. The correlation between these impairments and the reported poor quality of life could not be determined, and should be explored in future studies. Our findings suggest a multidisciplinary extended follow-up of these patients several years after the initial injury. Conflicts of interest None declared. Acknowledgments This work was partly supported by research funds from Sophies Minde Foundation, Oslo, Norway. The funds were merely used to cover the operational costs of the study. The sponsor had no involvement in the study design; collection, analysis and interpretation of data; the writing of the manuscript; the decision to submit the manuscript for publication. References [1] Fardon DF. Displaced fracture of the lumbosacral spine with delayed cauda equina deficit: report of a case and review of literature. Clin Orthop Relat Res 1976;15:5–15. 8. [2] Ferris B, Hutton P. Anteriorly displaced transverse fracture of the sacrum at the level of the sacro-iliac joint. A report of two cases. J Bone Joint Surg Am 1983;3:407–9. [3] Bents RT, France JC, Glover JM, Kaylor KL. Traumatic spondylopelvic dissociation. A case report and literature review. Spine 1996;15:1814–9. [4] Verlaan JJ, Oner FC, Dhert WJ, Verbout AJ. Traumatic lumbosacral dislocation: case report. Spine (PhilaPa 1976) 2001;17:1942–4. [5] Vresilovic EJ, Mehta S, Placide R, Milam RA. Traumatic spondylopelvic dissociation. A report of two cases. J Bone Joint Surg Am 2005;5:1098–103. [6] Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine 1985;9:838–45. [7] Helgeson MD, Lehman Jr RA, Cooper P, Frisch M, Andersen RC, Bellabarba C. Retrospective review of lumbosacral dissociations in blast injuries. Spine (PhilaPa 1976) 2011;7:E469–75. [8] Schmidek HH, Smith DA, Kristiansen TK. Sacral fractures. Neurosurgery 1984;5:735–46. [9] Gribnau AJ, van Hensbroek PB, Haverlag R, Ponsen KJ, Been HD, Goslings JC. Ushaped sacral fractures: surgical treatment and quality of life. Injury 2009;10:1040–8. [10] Siebler JC, Hasley BP, Mormino MA. Functional outcomes of Denis zone III sacral fractures treated nonoperatively. J Orthop Trauma 2010;5:297–302. [11] Denis F, Davis S, Comfort T. Sacral fractures: an important problem, Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988;(February):67–81. [12] Maynard Jr M, Bracken MB, Creasey G, Ditunno Jr JF, Donovan WH, Ducker TB, et al. International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association. Spinal Cord 1997;5:266–74. [13] Gibbons KJ, Soloniuk DS, Razack N. Neurological injury and patterns of sacral fractures. J Neurosurg 1990;6:889–93. [14] Glott T, Stanghelle JK, Rand-Hendriksen S, Johnsen V, Thyberg M, Melhus M, et al. [Voiding problems and urinary tract complications in adolescents and adults with myelomeningocele]. Tidsskr Nor Laegeforen 2001;10:1211–5. [15] Haylen BT, Ashby D, Sutherst JR, Frazer MI, West CR. Maximum and average urine flow rates in normal male and female populations–the Liverpool nomograms. Br J Urol 1989;1:30–8. [16] Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997;6:822–30. [17] Loge JH, Kaasa S. Short form 36 (SF-36) health survey: normative data from the general Norwegian population. Scand J Soc Med 1998;4:250–8.
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[25] Vaccaro AR, Kim DH, Brodke DS, Harris M, Chapman JR, Schildhauer T, et al. Diagnosis and management of sacral spine fractures. Instr Course Lect 2004;37:5–38. 5. [26] Adelved A, To¨tterman A, Glott T, Madsen JE, Røise O. Functional outcome 10 years after surgical treatment of displaced sacral fractures. Spine (Phila Pa 1976) 2012;16:E1009-16. [27] Pohlemann T, Ga¨nsslen A, Schellwald O, Culemann U, Tscherne H. Outcome after pelvic ring injuries. Injury 1996;(Suppl 2):B31–8. [28] Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, O’brien PJ. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma 1999;2:107–13. [29] Tornetta PI, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 1996;18:6–19. 3. [30] Vaccaro AR, Silber JS. Post-traumatic spinal deformity. Spine (Phila Pa 1976) 2001;24(Suppl):S111–8. [31] Munting E. Surgical treatment of post-traumatic kyphosis in the thoracolumbar spine: indications and technical aspects. Eur Spine J 2010;S69–73. [32] Sorensen MD, Wessells H, Rivara FP, Zonies DH, Jurkovich GJ, Wang J, et al. Prevalence and predictors of sexual dysfunction 12 months after major trauma: a national study. J Trauma 2008;5:1045–52. [33] Machtens S, Gansslen A, Pohlemann T, Stief CG. Erectile dysfunction in relation to traumatic pelvic injuries or pelvic fractures. BJU Int 2001;5:441–8.
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Long-term functional outcome after traumatic lumbosacral dissociation. A retrospective case series of 13 patients Aron Adelved a,b,f,*, Anna To¨tterman c, Thomas Glott d, Johan C. Hellund e, Jan Erik Madsen a,f, Olav Røise a,f,g a
Department of Orthopaedic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway Department of Orthopaedic Surgery, Karolinska University Hospital, Stockholm, Sweden d Department of Spinal Cord Injury and Multitrauma Unit, Sunnaas Hospital, Nesodden, Norway e Department of Radiology, Oslo University Hospital, Ullevaal, Oslo, Norway f Faculty of Medicine, University of Oslo, Norway g Division of Surgery and Clinical Neuroscience, Oslo University Hospital, Oslo, Norway b c
A R T I C L E I N F O
A B S R A C T
Article history: Accepted 9 April 2016
Study design: Retrospective case series. Introduction: Traumatic lumbosacral dissociation (TLSD) is a rare subgroup of sacral fractures caused by high-energy trauma in healthy adults. There are no accepted treatment algorithms for these injuries. Neurologic deficits and pain are commonly associated with these injuries, however, little is known about the long-term functional outcome in patients with TLSD. The objective of this study was to assess longterm functional outcome in patients with traumatic lumbosacral dissociation (TLSD) injuries. Materials and methods: Thirteen patients with TLSD were retrospectively identified and followed with clinical and radiological examination mean 7.7 (312) years after the injury. Five were treated operatively, and eight non-operatively. Sensorimotor impairments in the lower extremities were classified according to ASIA. Urinary function was assessed with uroflowmetry, and bowel- and sexual functions were assessed using a structured interview. Pain was assessed using a visual analogue scale (VAS), and patient-reported health with SF-36. CT images were scrutinized for non-union and kyphotic angulation across the fracture. Results: Eleven patients had neurologic deficits corresponding to L5 and sacral roots. Urinary dysfunction was observed in nine, and bowel dysfunction in three patients. Eight patients reported problems associated with sexual activities, with pain during intercourse and erectile dysfunction being the most common problems. Twelve patients reported pain in the lumbosacral area, in combination with radiating pain in the majority. The overall patient-reported health (SF-36) was significantly lower than the normal population. All sacral fractures were united as seen on CT. Sacral kyphotic angulation was present in 11, which had increased in three patients comparing with the initial radiographs. Conclusion: In this long-term follow-up, functional impairments, pain, and poor patient-reported health were common findings among patients with TLSD. High rates of neurologic, urinary and sexual dysfunctions were reported. Extended follow-up several years after the injury with a special focus on urogenital dysfunctions and pain management may be beneficial to these patients. ß 2016 Elsevier Ltd. All rights reserved.
Keywords: Lumbosacral dissociation U-shaped sacral fractures Long-term outcome Neurologic deficits Urinary dysfunction Sexual dysfunction Pain Sacral kyphotic angulation
Introduction
* Corresponding author at: Department of Orthopaedic Surgery, Akershus University Hospital, Sykehusveien 25, 1478 Lørenskog, Norway. Tel.: +47 93404190; fax: +47 67960506. E-mail address: [email protected] (A. Adelved). http://dx.doi.org/10.1016/j.injury.2016.04.006 0020–1383/ß 2016 Elsevier Ltd. All rights reserved.
Traumatic lumbosacral dissociation (TLSD) is a rare subgroup of sacral fractures mostly reported as single cases or small case series [1–5]. It is also commonly denoted as a U or H-shaped sacral fracture, and mainly results from high energy trauma, such as fall from height or motor vehicle accidents [6]. Combat-related blast injuries have also been reported recently [7]. Neurologic deficits in
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the lower extremities and pain are common findings in patients after TLSD [8–10]. There is a lack of good quality reports documenting which fractures need to be treated operatively and which can be treated non-operatively. Furthermore, little information is available on functional outcome of these injuries, regarding neurologic and urogenital functions, residual pain, as well as patient-reported health in a long-term perspective. The aim of this study was to assess long-term functional outcome, patient-reported health and radiological outcome in patients with TLSD. Materials and methods In this retrospective study, all patients with traumatic lumbosacral dissociation (TLSD) were identified from the Pelvic Fracture Registry at Oslo University Hospital, Ullevaal during the period of March 1997 to September 2006. Low energy, osteoporotic fractures or sacral insufficiency fractures, as well as sacral fractures as part of pelvic ring disruptions were excluded. Nineteen patients met the inclusion criteria, of which three were foreign residents and two were deceased. Of the remaining 14 eligible patients, one was not traceable and the remaining 13 patients constituted the study population of this long-term follow-up. The following data were extracted from the patient charts: Injury mechanism, Injury Severity Score (ISS), fracture pattern, neurologic presentation, additional injuries, and treatment. At follow-up, collected data included assessment of neurologic function, urinary, bowel and sexual function, pain, ADL, and patient-reported health (PRH) measured by SF-36. All patients also underwent radiologic examination with CT of the lumbar spine and the pelvis. All fractures were zone-III injuries, according to the classification of Denis et al. [11]. They were further subdivided according to Roy-Camille et al. [6] on the basis of their transverse fracture pattern (Table 1). In addition, one had an undisplaced acetabular fracture, which was treated non-operatively. Five patients were treated operatively; all with open reduction and internal fixation with iliolumbar interpedicular screws (Universal Spine System), and concomitant sacral laminectomy. The remaining eight patients were treated non-operatively. Indication for operative treatment was based on an overall assessment of neurologic deficits, radiographic signs (CT) of mechanical instability or compression of neural elements, and patients’ pain preventing mobilization (Fig. 1). In the absence of radiographic signs of instability or neural compression, non-operative treatment was applied (Fig. 2). Sensory and motor function in the lower extremities and perineum was assessed using the American Spinal Injury Association (ASIA) impairment scale [12], focusing on the lumbar and
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sacral roots only. Neurologic function was then graded according to Gibbon et al. [13], however modified to focus on the neurologic deficits in the L5 and sacral dermatomes; 1- no neurologic deficits, 2- sensory deficits only, 3- partial, combined sensory and motor deficits; and 4- complete loss of neurologic function. Bladder and bowel functions were assessed separately. Urinary bladder function was assessed by a structured interview [14] concerning frequency, urgency, hesitation or incontinence. In addition, patients with volitional voiding underwent flowmetry to measure maximum flow. Post-micturition volume was measured by ultrasound within 10 min after bladder emptying. Measurements of maximum flow were classified and graded into percentiles according to the Liverpool nomograms [15]. Overall bladder dysfunction was then graded based on theresults from the interview, flowmetry, ultrasonography, and the nomograms as; 1- normal voiding pattern (same as before injury), 2slightly changed voiding pattern, but normal flow and residual urine less than 50 mL and no incontinence, 3-significantly changed voiding pattern with reduced flow below 5th percentiles, or more than 50 mL residual urine or incontinence, and 4- no volitional voiding and regular intermittent catheterization or urinary deviation. Bowel function was assessed by a structured interview, addressing frequency and problems with urgency, diarrhoea, constipation, or incontinence. Bowel function was graded as: (1) normal bowel patterns (same as before injury), (2) slightly changed (changes in frequency or need of medication such as laxatives), (3) completely changed with incontinence and/or need of enema or colostomy. Problems associated with sexual function were assessed by interview with open questions. In female patients, problems related to sexual function, in particular pain during sexual intercourse or reduced arousal, was noted. In male patients, erectile dysfunction was assessed using selected questions from the Norwegian version of the International Index of Erectile Function (IIEF) questionnaire [16], pertaining to sexual activity during the past 4 weeks. Pain was self-assessed by the patients, using a visual analogue scale (VAS) ranging from 0 to 10, with 0 representing no pain and 10 the most severe pain experienced within the last 24 h. The patients were asked to grade their average pain particularly in the lower back and posterior pelvic area. When present, radicular pain to the lower extremities was recorded. Only pain related to the lumbosacral injury was recorded, and peripheral pain caused by injures to the lower extremities were not considered in the pain assessment. The information regarding ambulation, activities of daily living (ADL), and return to work was obtained by a structured interview. Ambulation was defined as dependence or independence of
Table 1 Patient characteristics. Patient no
Sex
Injury mechanism
ISS
Roy-Camille (classification, U/H)
Treatment
Age at FU
FU time Years, months
1 2 3 4 5 6 7 8 9 10 11 12 13
F M F M F M M M M M F M F
MVA MVA MVA MVA MVA MVA Fall MVA MVA Fall Fall* Fall* Fall*
29 9 19 14 9 22 17 22 29 10 29 45 50
1 1 1 2 1 1 1 1 3 3 1 3 1
non-op. non-op. non-op. non-op. non-op. non-op. non-op. non-op. op. op. op. op. op.
29 45 36 36 35 64 46 41 56 59 39 38 21
9,10 9,7 9,5 9,4 6,7 5,5 3,8 3,0 11,11 9,10 9,3 8,10 3,10
(H) (U) (H) (H) (U) (U) (H) (U) (H) (U) (H) (H) (U)
F: female, M: male, MVA: motor vehicle accident, ISS: Injury Severity Score, U/H: fracture shape, FU: follow-up. * Suicidal jump.
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Fig. 1. CT scans of a patient treated operatively. Pre-operative (a) images and at (b) follow-up.
walking aids/wheelchair, and ADL as dependence or independence of another person or healthcare services in the daily activities. Patient-reported health was assessed using a general health survey, namely Short Form-36 (SF-36) (SF-36 v2, QualityMetric Inc., Lincoln, RI, USA). The SF-36 results were analyzed by comparing them with the gender- and age-adjusted norm-based scores (NBS) for the Norwegian population [17]. The Norwegian NBS is based on SF-36 version 1, with slight differences from version 2. In order to ease comparison of our data with the normbased data, the Version 2 scores were converted to version 1 scores using the QualityMetric Health OutcomesTM Scoring Software 4.0, provided by QualityMetric Inc., Lincoln, RI, USA.
Radiologic assessment Multidetector CT (MDCT) volume scans were obtained from the level of L3 to below the lesser trochanter region. 2D axial, coronal and sagittal reconstructions were used to evaluate fracture status including any signs of non-union. Fracture healing was confirmed by the presence of bridging trabecular bone across the fracture lines on CT. On the mid-sagittal image, kyphotic angulation across the fracture site was measured using the methods described by Kuklo et al. [18]. Any narrowing of the spinal canal was recorded, using the midline sagittal images evaluating the inner tapering AP-diameter.
Fig. 2. CT scans of a patient treated non-operatively. (a) Initial images and at (b) follow-up.
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Statistics SPSS Statistics 21 software (IBM SPSS Inc., Chicago, IL, USA) was used for the statistical analyses. Z-scores were calculated, using sex- and age-adjusted norm-based scores for the general Norwegian population, published by Loge et al. [17]. The onesample t-test was used to compare the SF-36 scores with normbased scores. Ethics The study was reviewed and approved by the Regional Committee for Medical and Health Research Ethics, Region SouthEast Norway. All patients signed an informed consent at follow-up. Results The mean follow-up time was 7.7 years (range 312) postinjury, with a female: male ratio of 5:8, and mean age of 42 years (range 2164). Mean injury severity score (ISS) was 23 (range 950). In five cases, the mechanism of injury was fall from height, including three suicidal jumps, and in the remaining eight cases, motor vehicle accidents (MVA). Patient characteristics, including fracture types and treatments are shown in Table 1. Only two patients had normal neurologic function at follow-up, both were treated non-operatively. One had no neurologic deficits at the time of injury, and was also asymptomatic at follow-up. The other had unilateral sensory deficits in the sacral dermatomes initially, which went to complete recovery, but had slightly altered bladder function at follow-up. Among the remaining 11 with neurologic deficits at follow-up; early adequate evaluation of the neurological injuries in two patients was precluded by the severity of their condition, both of whom had neurologic deficits at followup. One patient with normal neurologic function initially, developed secondary sensory and motor deficits in L5-S4 dermatomes bilaterally, after non-operative treatment of the fracture (Table 2). Bladder function was not assessed at the time of injury, as this was not practically feasible. At follow-up, four patients had normal Table 2 Clinical findings at follow-up. Results based on interview, clinical examination and flowmetry. Patient no
Neurologic function
Bladder function
Bowel function
Sexual function
Pain VAS
1 2 3 4 5 6 7 8 9 10 11 12 13
2 1 3 2 1 3 3 2 3 3 3 3 3
1 1 4 1 2 2 3 2 1 3 3 4 2
1 1 3 1 1 2 1 1 1 1 1 3 1
pain * normal pain ** normal normal pain + ED normal pain + ED normal ED
6 1 8 0 3 6 6 5 8 2 4 7 5
(NA) (1) (3) (2) (2) y (1) yy (3) (2) (3) (3) (3) (3) (NA)
#
ED ** pain
Neurologic function: 1-normal, 2-sensory deficit, 3-sensory and motor deficit, 4Complete loss of neurologic function. (Neurologic function at admission is given in brackets). NA: not available. y Neurologic recovery. yy Neurologic deterioration. Bladder function: 1-normal, 2-slightly altered, 3-significantly altered, 4-no volitional voiding. Bowel function: 1-normal, 2-slightly altered, 3- completely altered. Sexual function: * Decreased lubrication. ** Decreased genital sensation, ED: erectile dysfunction. # Altered self-image. Pain- refers to pain in the lumbosacral area.
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bladder function. Of the remaining nine, four had slightly altered and another three patients had significantly altered bladder function. In two cases, the bladder function was completely altered, with no volitional urinary voiding and dependence of intermittent self- catheterization. Three out of five patients with initially reduced anal sphincter tone had regained full anal sphincter function at follow-up. Of the remaining two, one had still reduced sphincter tone at follow-up, and the other received a permanent colostomy shortly after the injury. These two patients in addition to one patient, who developed secondary neurologic deficits, reported altered bowel function. At follow-up, eight out of 13 patients reported problems associated with their sexual activity, including lumbosacral pain, erectile dysfunction and reduced genital sensation as frequently reported symptoms. All but one reported pain on the VAS scale; with an average VAS score of 4.7 (range 18). An overview of the clinical findings and patient-reported symptoms is listed in Tables 2 and 3. The majority of patients, 12 out of 13 were ambulant without walking aids. One patient used wheelchair. Of the ambulant patients, eight reported problems with walking on non-level surfaces or walking in the dark. Six were not able to run and reported problems such as pain or reduced endurance when walking longer distances. One patient required help for strenuous activities, and one was dependent on daily assistance for ADL. The remaining 11 patients were independent in ADL. Five out of eight patients returned to their full time jobs that they had before injury, and three went on to permanent disability pension (DP). Two students before injury were still engaged in studies at the time of follow-up. The remaining three patients, who were unemployed or were on DP before injury, were on permanent DP at follow-up.
Table 3 Clinical examination and patient-reported functions at current follow-up. The figures in italics may not add up, as patients may have several symptoms/findings, N = 13. N Normal neurologic function Neurologic deficits - Sensory deficits - Sensory and motor deficits Normal bladder function Altered bladder function - Subjective symptoms (urge, stress incontinence, abdominal straining) - No voluntary voiding (Intermittent self-catheterization) Normal Bowel function Altered bowel function - Constipation - Reduced sphincter function - Colostomy Normal sexual function Reported problems with sexual activity - Lumbosacral pain during intercourse - Erectile dysfunction - Reduced genital sensation/reduced lubrication - Reduced arousal/altered self-image Pain (VAS) -0 - 13 - 47 -8 Pain area - Lumbosacral area only - Lumbosacral + radicular pain - Radicular pain only
2 11 3 8 4 9 3 2 10 3 3 2 1 5 8 5 4 2 2 1 3 7 2 1 9 2
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Table 4 Patient-reported health at follow-up compared with the age and gender adjustedy Norwegian norm based scores (NBS), n = 13. SF-36 domains
Mean scores at FU (SD)
Mean NBS Norwegiany (SD)
Difference of means (95% Confidence Interval)
P-value
PF RP BP GH VT SF RE MH
56.5 (25.8) 32.7 (40) 43.1 (25) 50.6 (28) 45.7 (27.4) 67.3 (19.5) 59 (45.4) 73.1 (19.7)
91.2 (3.1) 83 (5.4) 71 (21.5) 78.7 (4.2) 61 (4.2) 86.8 (1.9) 84.4 (4.3) 79 (1.8)
-
< 0.001 0.001 0.002 0.004 0.07 0.004 0.07 0.3
34.7 (-50.2)–(-19) 50.2 (-74.4)–(-26) 27.9 (-43)–(-12.7) 28.1 (-45)–(-11.2) 15.3 (-32)–(1.2) 19.5 (-31.3)–(-7.7) 25.4 (-53)–(2) 5.9 (-17.9)–(6)
SD: standard deviation, CI: confidence interval, NBS: norm-based scores, PF: physical functioning, RP: role physical, BP: bodily pain, GH: general health, VT: vitality, SF: social functioning, RE: role emotional, MH: mental health.
The overall patient-reported health scores were significantly lower than the normal population, although without statistical significance in three domains, namely vitality, role emotional, and mental health (Table 4 and Fig. 3). All the sacral fractures were healed at follow-up as seen on CT images. Kyphotic angulation across the fracture site was seen in 11 patients, with an average of 338 (range 1563). An increase of sacral kyphosis was seen in three patients, one of whom was treated operatively. In one of the other two patients who were treated non-operatively, also a secondary narrowing of the central canal was present at follow-up, although not present initially. In the remaining patients, no significant changes were seen in kyphotic angulation from the time of injury to the follow-up visit. Bony narrowing of the central canal was observed in five patients (Table 5). Discussion In the current study, we evaluated the long-term functional outcome in 13 patients after traumatic lumbosacral dissociation (TLSD) injuries with a follow-up time of seven (312) years. We found considerable morbidity in the majority of our patients, including neurologic sequelae in the lower extremities, bladder dysfunction and chronic pain. The patient-reported health scores, measured by the SF-36 were significantly lower than the normal population, and limitations in sexual activities were frequently
reported. However, all fractures were healed with an increase in kyphosis in only three patients, and the majority was independent in ambulation and ADL. Comparing studies describing TLSD injuries is complicated, as most of the studies are case reports or small case series, in addition to a wide variety in patient selection, injury type, and the magnitude of injury severity/additional injuries. Due to the rarity of TLSD, the severity of associated injuries, and lack of information from larger studies, no accepted treatment strategy is formulated for these injuries [19]. Operative treatment with internal fixation has been reported by some authors to be beneficial in terms of early mobilization and to achieve mechanical fracture stability in TLSD [20–22]. However, our own experience is that these fractures are difficult to reduce and there is so far no reports comparing conservative versus operative treatment. Furthermore, the benefits of decompressive surgery are uncertain, as varying rates of neurological recovery are reported from different studies [9,10,22,23]. The variation in neurologic restitution after surgery observed in these studies may reflect the variability in type of nerve lesion acquired at the time of injury. Huittinen et al. [24] observed three types of nerve injury in an autopsy study of 42 patients who died following severe pelvic and sacral fractures; traction injuries, compression injuries or avulsion of the neural elements. Thus, referring to Huittinen’s findings, neurologic recovery may depend not only on decompressive surgery, but also on the characteristics of the neurologic injury [25]. In our series, only partial or no recovery was seen in patients who underwent decompressive laminectomy, suggesting irreversible neurologic injuries in these patients. Full recovery was observed in only one of 13 patients, after non-operative treatment. Table 5 Radiographic findings on CT.
Patient no
Fig. 3. Z-scores at follow-up. The 0-line represents the norm-based scores for the Norwegian general population. The mean scores are significantly lower than the norms, except for VT, RE, and MH domains. The outliers represent patient no. 1 and no. 4. PF-physical functioning, RP-role physical, BP-bodily pain, GH-general health, VT-vitality, SF-social functioning, RE-role emotional, MH-mental health.
1 2 3 4 5 6 7 8 9 10 11 12 13
RoyCamille
1 1 1 2 1 1 1 1 3 3 1 3 1
Kyphosis initially (degrees)
NA 0 38 53 19 7 42 27 15 0 36 45 48
At
follow-up
Kyphosis
Central canal narrowing/level
at follow-up (degrees) 24 0 57 49 21 36 42 29 15 0 37 63 52
NA: Sagittal CT reformats not available. * Secondary bony narrowing of the central canal.
S1S2 S2* S2 S2S3 S1S2
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Due to the great heterogeneity and small number of patients in our study, comparing the results of operative versus non-operative treatment was not useful. We considered the high rate of pathologic urinary bladder function in our series to be neurogenic, as no urogenital injuries had been documented initially. Furthermore, we assessed the bladder function by urodynamic tests in order to evaluate the extent of dysfunction. In a separate, long-term follow-up study on a patient cohort with displaced sacral fractures as part of type C vertical shear injures, we found similarly high rates of bladder dysfunctions [26]. In that study, we also observed that bladder function deteriorated over time, between 1-year and 10-year follow-ups. In the present study, we did not have previous urodynamic data on the patients, as urodynamic tests are not feasible in the initial setting. Whether further deterioration in bladder function over time may occur also in these patients remains to be assessed. Chronic pain following pelvic and sacral fractures is common [27–29], and in TLSD significant pain problems have been reported in 40100% of the patients [7,9,10]. In the present study, 12 out of 13 patients reported pain, including five who also reported lumbosacral pain during intercourse, causing limitations in their sexual activity. As all sacral fractures were radiologically healed, other factors obviously influence the occurrence of pain. Severe pain has been reported in patients after spine fractures with posttraumatic kyphotic spine deformity [30,31]. The influence of sacral kyphotic deformity on lumbosacral pain is not documented. However, similar to the spinal post-traumatic deformities, the possibility of kyphosis as a main contributor to lumbosacral pain may be considered. Even so, kyphotic angulation did not correlate with VAS pain or pain during intercourse in our series. Further studies are needed to determine the relationship between sacral deformity and lumbosacral pain. Limitations in sexual function following TLSD injures are sparsely described previously. Siebler et al. [10] evaluated 11 patients with non-operatively treated zone III fractures, and reported sexual dysfunctions in four out of 11 patients. In our series, eight out of 13 had problems with their sexual function; the most frequently reported limitations being erectile dysfunction (ED) and pain in the lumbosacral area during intercourse. Problems with sexual function following polytrauma and pelvic injures may have both physical and psychosocial components [32,33]. The reported pain during intercourse may thus be caused by fracture sequelae and deformity, and ED may be the result of neurologic deficits. Further psychosocial aspects of ED could not be determined by this study. There are several limitations in the present study. Due to the retrospective design, we had limited comparable data from the time of injury on neurologic deficits, as this was insufficiently examined and documented in some patients. Consequently, detailed neurological recovery could not be determined for all patients. The patients certainly constituted a heterogeneous group and the number of patients was low. Consequently, reliable correlation analyses between the outcome measures and their impact on patient-reported health could not be performed. Furthermore, comparisons between the operative and the non-operative groups in terms of role of surgery or functional outcome were not performed. These questions could only be answered by studies with a larger number of patients, and due to the low incidence of these injuries, multicenter collaborative studies would be needed. Despite the limitations of our study, the results may have some clinical implications. Considering the poor patient-reported health among our patients, pain, neurologic deficits, bladder, and sexual dysfunctions presumably contribute to the overall low ratings of own health. By addressing these impairments with multidisciplinary follow-ups
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in the rehabilitation period, and even several years after the injury would be beneficial to the TLSD patients. Conclusion In this long-term follow-up of patients after traumatic lumbosacral dissociation injuries, all the sacral fractures united and the majority of patients were independent in ambulation and ADL. However, functional impairments and pain were common findings. High rates of neurologic deficits, urinary bladder dysfunction and limitations in sexual activities were found, and patient-reported health was significantly lower than the normal population. The correlation between these impairments and the reported poor quality of life could not be determined, and should be explored in future studies. Our findings suggest a multidisciplinary extended follow-up of these patients several years after the initial injury. Conflicts of interest None declared. Acknowledgments This work was partly supported by research funds from Sophies Minde Foundation, Oslo, Norway. The funds were merely used to cover the operational costs of the study. The sponsor had no involvement in the study design; collection, analysis and interpretation of data; the writing of the manuscript; the decision to submit the manuscript for publication. References [1] Fardon DF. Displaced fracture of the lumbosacral spine with delayed cauda equina deficit: report of a case and review of literature. Clin Orthop Relat Res 1976;15:5–15. 8. [2] Ferris B, Hutton P. Anteriorly displaced transverse fracture of the sacrum at the level of the sacro-iliac joint. A report of two cases. J Bone Joint Surg Am 1983;3:407–9. [3] Bents RT, France JC, Glover JM, Kaylor KL. Traumatic spondylopelvic dissociation. A case report and literature review. Spine 1996;15:1814–9. [4] Verlaan JJ, Oner FC, Dhert WJ, Verbout AJ. Traumatic lumbosacral dislocation: case report. Spine (PhilaPa 1976) 2001;17:1942–4. [5] Vresilovic EJ, Mehta S, Placide R, Milam RA. Traumatic spondylopelvic dissociation. A report of two cases. J Bone Joint Surg Am 2005;5:1098–103. [6] Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine 1985;9:838–45. [7] Helgeson MD, Lehman Jr RA, Cooper P, Frisch M, Andersen RC, Bellabarba C. Retrospective review of lumbosacral dissociations in blast injuries. Spine (PhilaPa 1976) 2011;7:E469–75. [8] Schmidek HH, Smith DA, Kristiansen TK. Sacral fractures. Neurosurgery 1984;5:735–46. [9] Gribnau AJ, van Hensbroek PB, Haverlag R, Ponsen KJ, Been HD, Goslings JC. Ushaped sacral fractures: surgical treatment and quality of life. Injury 2009;10:1040–8. [10] Siebler JC, Hasley BP, Mormino MA. Functional outcomes of Denis zone III sacral fractures treated nonoperatively. J Orthop Trauma 2010;5:297–302. [11] Denis F, Davis S, Comfort T. Sacral fractures: an important problem, Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988;(February):67–81. [12] Maynard Jr M, Bracken MB, Creasey G, Ditunno Jr JF, Donovan WH, Ducker TB, et al. International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association. Spinal Cord 1997;5:266–74. [13] Gibbons KJ, Soloniuk DS, Razack N. Neurological injury and patterns of sacral fractures. J Neurosurg 1990;6:889–93. [14] Glott T, Stanghelle JK, Rand-Hendriksen S, Johnsen V, Thyberg M, Melhus M, et al. [Voiding problems and urinary tract complications in adolescents and adults with myelomeningocele]. Tidsskr Nor Laegeforen 2001;10:1211–5. [15] Haylen BT, Ashby D, Sutherst JR, Frazer MI, West CR. Maximum and average urine flow rates in normal male and female populations–the Liverpool nomograms. Br J Urol 1989;1:30–8. [16] Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997;6:822–30. [17] Loge JH, Kaasa S. Short form 36 (SF-36) health survey: normative data from the general Norwegian population. Scand J Soc Med 1998;4:250–8.
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