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This is an enhanced PDF from The Journal of Bone and Joint Surgery

86:166-175, 2004. J Bone Joint Surg Am.Chip Routt and Rick C. Sasso Alexander R. Vaccaro, David H. Kim, Darrel S. Brodke, Mitchel Harris, Jens Chapman, Thomas Schildhauer, M.L.

Diagnosis and Management of Sacral Spine Fractures

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The American Academy of Orthopaedic SurgeonsPrinted with permission of the

American Academy ofOrthopaedic Surgeons. This article,

as well as other lectures presentedat the Academys Annual Meeting,will be available in March 2004 in

Instructional Course Lectures,Volume 53. The complete

volume can be ordered onlineat www.aaos.org, or by

calling 800-626-6726(8 A.M.-5 P.M., Central time).

DAVID L. HELFETEDITOR, VOL. 53

COMMITTEE VINCENT D. PELLEGRINI JR.CHAIRMAN

DAVID L. HELFETDONALD C. FERLICTERRY R. LIGHTJ. LAWRENCE MARSH

EX-OFFICIODEMPSEY S. SPRINGFIELDDEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERYFOR INSTRUCTIONAL COURSE LECTURES

JAMES D. HECKMANEDITOR-IN-CHIEF, THE JOURNAL OF BONE AND JOINT SURGERY

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TH E JO U R NA L OF BONE & JOINT SURGER Y JBJS .ORGVO LU M E 86-A NUMB ER 1 JA NU A R Y 2004

DI A G N O S I S AND MANAGEM ENT OF SA CR A L SP I N E FR A C TURE S

Look for these related articles in Instructional Course Lectures, Volume 53, which will be published by the American Academy of Orthopaedic Surgeons in March 2004:

Cervical Spine and Spinal Cord Injuries: Recognition and Treat-ment, by Frank J. Eismont, MD, Bradford L. Currier, and Robert A. McGuire, MD

Diagnosis and Management of Sacral Spine Fractures

BY ALEXANDER R. VACCARO, MD, DAVID H. KIM, MD, DARREL S. BRODKE, MD, MITCHEL HARRIS, MD, JENS CHAPMAN, MD, THOMAS SCHILDHAUER, MD, M.L. CHIP ROUTT, MD, AND RICK C. SASSO, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Determining the optimal treatment of sacral fractures is a challenge for spine surgeons and traumatologists alike. Because of the relative rarity and heter-ogeneous nature of sacral fractures, individual surgeons have limited ex-posure to these injuries and studies of sacral fractures have been largely retro-spective in nature and have involved nonhomogeneous or small treatment groups. Few scientifically based insights can be gathered from the current litera-ture in this field.

The sacrum is the mechanical nucleus of the axial skeleton, serving as the base for the spinal column as well as the keystone for the pelvic ring. De-spite its mechanical importance, the transitional location of the sacrum be-tween the spine and the pelvis has re-sulted in its being relatively neglected by both spine surgeons and traumatol-ogists and in both specialties having in-complete experience with treatment of this spinal region.

Biomechanical testing of the sacrum has proven difficult because of

the complexities of load transfer from the mobile lumbar spine to the hips and the added variables of regional ligamentous and muscle support1. Be-cause of the traumatic comorbidities in patients with a sacral fracture, any attempt to formulate standardized treatment approaches is challenging, if not impossible.

In a large retrospective study of sacral fractures, Denis et al. reported that the chance of identifying a sacral fracture was increased by the presence of an associated neurological injury2. An existing sacral fracture was correctly identified in 76% of patients presenting with a neurological deficit but in only 51% of neurologically intact patients.

Unrecognized and inadequately treated sacral fractures may lead to painful deformity and progressive loss of neurological function3. Delayed sur-gery for posttraumatic sacral defor-mity is complex, and the results are often less favorable than those of early surgery4. Therefore, determination of an integrated diagnostic and therapeu-

tic approach to sacral fractures should be a goal.

Sacral AnatomyThe sacrum provides the foundation for lumbar as well as pelvic ring alignment. A combination of intact osseous and lig-amentous components is necessary to provide a sound weight-bearing plat-form as well as protection for the lum-bosacral (L4-S1) and sacral (S2-S4) plexuses and iliac vessels. Transmission of load on the trunk is distributed by the first sacral segment through the iliac wings to the acetabulum on either side1. Strong posterior lumbosacral and lum-boiliac ligaments stabilize the osseous components of this transition zone, which is characterized by noncon-strained articulations. The sacrum is a kyphotic structure with a sagittal angu-lation ranging from 0 to 90. This con-tributes to the sacral inclination angle of the superior end plate of S1, which then determines the compensatory lordosis of the lumbar spine. The thin posterior soft-tissue coverage of the sacrum, con-sisting of a thin layer of multifidus muscle and the lumbosacral fascia, has implications in terms of the ability of this area to withstand blunt trauma and tolerate bulky implant systems.

The sacral spinal canal is capa-cious and provides more than adequate space for the cauda equina. Of the ante-riorly exiting sacral roots, S1 has pro-portionally the least foraminal exit area,

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TH E JO U R NA L OF BONE & JOINT SURGER Y JBJS .ORGVO LU M E 86-A NUMB ER 1 JA NU A R Y 2004

DI A G N O S I S AND MANAGEM ENT OF SA CR A L SP I N E FR A C TURE S

occupying up to one-third of the fora-men. The lower sacral roots have pro-gressively more relative space, with the S4 root occupying only one-sixth of the available anterior foraminal area5. The anterior rami of the S2 through S5 roots contribute to sexual function as well as bowel and bladder control by provid-ing parasympathetic innervation to the bladder and rectum. The sympathetic ganglia of the inferior hypogastric plexus extend from the anterolateral L5 and S1 vertebral bodies caudally to the anterior surface of the sacrum along the medial margin of the anterior foramina of S2, S3, and S45. The posterior rami of the sacral roots consist of small sensory fibers, with contributions to the cluneal nerves.

EvaluationPhysical ExaminationApproximately 30% of sacral fractures are identified late6. Delayed diagnosis of these injuries can have a negative im-pact on long-term outcome and can be avoided by a targeted clinical evalua-tion. Sacral injury should be suspected in any patient reporting peripelvic pain. Inspection and palpation of the entire body is necessary following high-energy blunt trauma, especially in the presence of an altered sensorium. Lacerations, bruising, tenderness, swelling, and crepitus are clear signs of a potential underlying injury. More specific signs suggesting possible sacral injury include a posterior sacral osseous prominence or a palpable subcutaneous fluid mass consistent with lumbosacral fascial de-gloving (Morel-Lavelle lesion)7.

Although rectal examination is a standard component of the evalua-tion of a patient who has sustained traumatic injury, patients with a sus-pected sacral fracture should also un-dergo functional assessment of the lower sacral roots, including determi-nation of spontaneous and maximum voluntary rectal sphincter contrac-tion, checking for the presence of light touch and pinprick sensation along the perianal concentric dermatomes of S2 through S5, and elicitation of specific reflexes including perianal wink and the bulbocavernosus and

cremasteric reflexes5. Female patients should undergo a vaginal examination so that an occult open pelvic fracture is not missed.

Pelvic ring stability can be tested manually by gently applied internal and external rotation of the iliac wings8. Lower-extremity push-and-pull tests with supplemental radiographic docu-mentation of pelvic shifting have been described but are not commonly performed9. In patients who can walk, the presence of mechanically related low-back or buttock pain may indicate a sacral insufficiency fracture.

ImagingThe ATLS (Advanced Trauma Life Sup-port) protocol for imaging in the set-ting of a suspected sacral fracture includes an anteroposterior radiograph of the pelvis10. Because of the inclina-tion angle of the sacrum, however, only limited visualization is possible with this view. Pelvic inle