Spinopelvic dissociation: multidetector computed tomographic ...

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Feb 25, 2016 - Abstract. The objective of the present study is to evaluate multidetector computed tomographic (MDCT) fracture patterns and associated injuries ...
Emerg Radiol DOI 10.1007/s10140-016-1383-4

ORIGINAL ARTICLE

Spinopelvic dissociation: multidetector computed tomographic evaluation of fracture patterns and associated injuries at a single level 1 trauma center Pushpender Gupta 1 & Jonathan C. Barnwell 2 & Leon Lenchik 1 & Scott D. Wuertzer 1 & Anna N. Miller 2

Received: 19 December 2015 / Accepted: 1 February 2016 # American Society of Emergency Radiology 2016

Abstract The objective of the present study is to evaluate multidetector computed tomographic (MDCT) fracture patterns and associated injuries in patients with spinopelvic dissociation (SPD). Our institutional trauma registry database was reviewed from Jan. 1, 2006, to Sept. 30, 2012, specifically evaluating patients with sacral fractures. MDCT scans of patients with sacral fractures were reviewed to determine the presence of SPD. SPD cases were characterized into the following fracture patterns: U-shaped, Y-shaped, T-shaped, Hshaped, and burst. The following MDCT features were recorded: level of the horizontal fracture, location of vertical fracture, kyphosis between major fracture fragments, displacement of fracture fragment, narrowing of central spinal canal, narrowing of neural foramina, and extension into sacroiliac joints. Quantitative evaluation of the sacral fractures was performed in accordance with the consensus statement by the Spine Trauma Study Group. Medical records were reviewed to determine associated pelvic and non-pelvic fractures, bladder and bowel injuries, nerve injuries, and type of surgical intervention. Twenty-one patients had SPD, of whom 13 were men and eight were women. Mean age was 41.8 years (range 18.8 to 87.7). Five fractures (24 %) were U-shaped, six (29 %) H-shaped, four (19 %) Y-shaped, and six (29 %) burst. Nine

patients (43 %) had central canal narrowing, and 19 (90 %) had neural foramina narrowing. Eleven patients (52 %) had kyphotic angulation between major fracture fragments, and seven patients (33 %) had either anterior (24 %) or posterior (10 %) displacement of the proximal fracture fragment. Fourteen patients (67 %) had associated pelvic fractures, and 20 (95 %) had associated non-pelvic fractures. Two patients (10 %) had associated urethral injuries, and one (5 %) had an associated colon injury. Seven patients (33 %) had associated nerve injuries. Six patients (29 %) had surgical fixation while 15 (71 %) were managed non-operatively. On trauma MDCT examinations, patients with SPD have characteristic fracture patterns. It is important to differentiate SPD from other pelvic ring injuries due to high rate of associated injuries. Although all SPD injuries are unstable and need fixation, the decision for operative management in an individual patient depends on the systemic injury pattern, specific fracture pattern, and the ability to attain stable screw fixation. Keywords Spinopelvic dissociation . MDCT . Sacral fractures . Blunt trauma

Introduction * Pushpender Gupta [email protected]

1

Department of Radiology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA

2

Department of Orthopedic Surgery, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA

Pelvic ring injuries are seen in approximately 9.3 % of patients following blunt trauma [1]. Based on multidetector computed tomographic (MDCT) examinations, pelvic ring injuries are usually classified as stable, partially stable, or unstable [2]. Unstable injuries have a complete disruption of the posterior ring, involving some combination of sacroiliac joint diastasis, fractures of the ilium, or fractures of the sacrum [2]. Unstable pelvic ring injuries have high morbidity, often from associated

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neurologic injuries, as well as high mortality, frequently attributed to associated vascular injuries (8.3 %) [3]. Spinopelvic dissociation (SPD) is seen in a small but important subset of pelvic ring injuries, most commonly in patients following high-energy trauma, including motor vehicle crashes and falls [4–12]. SPD is a distinct entity from bilateral sacroiliac joint dissociation. Sacral fractures are present in approximately 30 % of patients with pelvic fractures [4]. An important subset of unstable sacral fractures is known as SPD [5]. In some of the older literature, SPD injuries were described as Ushaped sacral fractures. Nork et al. reported 2.9 % incidence of U-shaped sacral fractures in patients with pelvic ring fractures [6]. SPD is a highly complex and unstable sacral fracture pattern. On MDCT, SPD is defined by a sagittally oriented bilateral sacral ala fractures and a transverse fracture involving either the S1 or the S2 vertebra. Resulting mechanical dissociation of the lumbar spine and upper sacrum from the lower sacrum and pelvis differentiates SPD from isolated sacral fractures (Fig. 1) [5, 7–9]. Transverse fracture is an essential component of SPD. Isolated longitudinal sacral fractures commonly associated with lateral compression-type pelvic ring injuries are typically more stable than SPD injuries. SPD has a very high incidence of associated polytrauma (95 %) [5, 10], which may result in a delayed diagnosis. In addition, SPD has a very high incidence of associated skeletal, extra-skeletal, and neurological injuries as well as higher morbidity and mortality compared with other sacral (or pelvic) fractures [6, 9, 11–18]. Finally, SPD may need to be managed differently from other sacral fracture patterns, occasionally requiring lumbopelvic fixation. SPD also has a high rate (38 %) of surgical complication, mainly due to wound complications (>25 %) [5, 10, 19]. Fig. 1 Anterior 3D MDCT shaded surface display (SSD) projection of the sacrum with overlying line drawings showing the major fracture patterns in SPD: U-shaped (a), H-shaped (b), Y-shaped (c), T-shaped (d), and burst (e)

Accurate MDCT characterization of sacral fractures is essential to differentiate the rare cases of SPD from other sacral fractures (Figs. 1 and 2). The purpose of the study was to evaluate multidetector computed tomographic (MDCT) fracture patterns and associated injuries in patients with spinopelvic dissociation (SPD).

Materials and methods This was a retrospective study performed following approval from the Institutional Review Board, which waived the requirement for patient’s informed consent. Patients The trauma registry database from our Level 1 Trauma Center was reviewed including the dates from Jan. 9, 2006, to Sept. 30, 2012. All patients with pelvic ring injuries older than age 17 were included in the study. All pelvic ring injuries were categorized based on the presence or absence of sacral fracture. In the patients with sacral fractures, the MDCT examinations were retrospectively reviewed to further characterize the fracture patterns. Imaging methods The MDCT examinations were obtained on General Electric (GE LightSpeed VCT 64 Slice CT and GE LightSpeed 16 Slice CT) scanners, using 2-mm axial slices, with 0.625-mm reconstructions. Coronal, sagittal, and oblique coronal (in plane with the sacrum) reconstructions were obtained on a TeraRecon workstation.

Emerg Radiol Fig. 2 Anterior 3D MDCT shaded surface display (SSD) projection of the sacrum with overlying line drawings showing major sacral fracture patterns that are excluded from SPD. a Unilateral vertical fracture of the right sacral ala, without an associated horizontal component. b Vertical fractures of the both sacral ala, without an associated horizontal component. c Low transverse sacral fracture without an associated vertical component

Data collection Two readers independently reviewed the MDCT images, and a final assessment of each case was made by consensus. On MDCT images, two diagnostic criteria for SPD had to be present: (1) a transverse sacral fracture involving either the S1 or the S2 vertebra and (2) sagittal plane fractures of the right and left sacral ala, in continuity with the axial fracture as described in (1). Based on MDCT images, the following sacral injuries were excluded: (1) bilateral sacroiliac joint diastasis, (2) unilateral sacral fractures, (3) isolated transverse sacral fractures, and (4) sacral fractures isolated to S3 or S4. SPD cases were then characterized into the following fracture patterns: U-shaped, Y-shaped (with unilateral rather than bilateral sagittal component below the transverse component), T-shaped, H-shaped, and burst (with extensive comminution leading to inability to accurately classify into one of the other patterns) (Fig. 1). In each case, the following MDCT features were recorded: level of the horizontal fracture component (S1 or S2), location of sagittal fracture component (transforaminal, extraforaminal, or midline), kyphosis between major fracture fragments, displacement of the distal fracture fragment, narrowing of the central spinal canal, narrowing of neural foramina, and extension into sacroiliac joint. Quantitative evaluation of the sacral fractures was performed in accordance with the consensus statement by the Spine Trauma Study Group (Kuklo et al.) [20]. These included anterior-posterior and horizontal displacement measured on axial MDCT images, vertical displacement measured on coronal MDCT images, and anterior-posterior translation and kyphotic segmental angulation measured on sagittal MDCT images. To assess the sagittal alignment of the sacrum, the sacral table angle, global sacral kyphosis using the Cobb method, and pelvic incidence were measured [21–24]. Medical records of all SPD cases were reviewed. The following clinical data were recorded: patient age and gender, mechanism of injury, injury severity score, presence of

associated pelvic and non-pelvic fractures, presence of bladder and bowel injuries, presence of nerve injuries, and types of surgical intervention. Statistical analysis An independent two-sample Student’s t test was used to compare continuous variables. Chi-square test was used to compare categorical variables. A p value < 0.05 was considered statistically significant.

Results There were 21 total patients with SPD: 13 male and eight female. The mean age was 41.8 years (range 18.8 to 87.7). The mechanism of injury was motor vehicle collision in 13 (62 %) and falls in six (29 %). One patient was a pedestrian struck by a motor vehicle, and one was involved in a horse accident. On admission to the emergency department, the mean injury severity score was 11.6 (range 4 to 50). Only four fracture patterns were observed on MDCT scan: 5 (24 %) U-shaped, 6 (29 %) H-shaped, 4 (19 %) Y-shaped, and 6 (29 %) burst; there were no T-shaped patterns (Fig. 3). Sixteen (76 %) SPD cases had the transverse component at the level of S2 and five (24 %) at S2–S3 level. Sixteen (73 %) SPD cases had transforaminal vertical component, and five (24 %) SPD cases had the vertical component medial to neural foramina. None of the SPD cases had vertical component lateral to neural foramina. Eleven (52 %) SPD cases had kyphotic angulation between major fracture fragments, and seven (33 %) had either anterior (24 %) or posterior (10 %) displacement of the proximal fracture fragment. Spinal canal stenosis was present in nine (43 %) cases and neural foraminal narrowing in 19 (90 %) cases. Of 19 patients with fractures extending into the neural foramina, 9 (47 %) had mild, 8 (42 %) moderate, and 2 (11 %) severe stenosis. Extension to the sacroiliac joint was present in 20 (95 %) cases. Quantitative measurements were as follows: Mean segmental kyphosis was 17.4° across the injury site. Mean global

Emerg Radiol Fig. 3 Oblique coronal reformatted (ray sum projection) MDCT images in the plane of the sacrum showing the major fracture patterns in SPD. a Note H-shaped (arrows) fracture pattern and associated right L5 transverse process fracture (dashed arrow). b Note the Ushaped (arrows) fracture pattern. c Note Y-shaped (arrows) fracture pattern. d Note the highly comminuted burst pattern

sacral kyphosis measured by the Cobb method was 40.1°. The mean sacral table angle (STA) was 98.9°. Mean pelvic incidence was 64.7°. Mean AP translation was 2.5 mm, with the upper sacral segment translating anteriorly most often. Mean anterior-posterior (AP) displacement was 3.5 mm. Mean transverse displacement was 4.8 mm. Mean craniocaudal displacement was 3.1 mm. Injuries associated with SPD are summarized in Table 1. All 21 patients had associated injuries. Fourteen (67 %) had non-sacral pelvic fractures, and 20 (95 %) had non-pelvic fractures. Two (10 %) had urethral injury, and one (5 %) had bowel injury. Seven (33 %) had associated nerve injuries. One patient developed left psoas hematoma, managed by coil embolization. One patient developed pelvic hematoma, managed conservatively. At 4 months after injury, three patients with nerve injuries (43 % of those with nerve injuries) recovered completely, one (14 %) had partial recovery, and three (43 %) had persistent neurological deficits. Clinical management of SPD was as follows: 15 patients (71 %) were managed non-operatively, and six (29 %) had surgical fixation. Three patients (14 %) were managed with posterior lumbopelvic instrumentation and fusion. Three patients (14 %) had sacroiliac screw placement.

Discussion Spinopelvic dissociation (SPD) is an unstable sacral fracture pattern, defined by the mechanical dissociation of the lumbar spine and upper sacrum from the lower sacrum and pelvis [5, 9]. Fortunately, SPD is relatively uncommon [9]. In one series of 442 patients, U-shaped SPD accounted for approximately

Table 1 Injuries associated with SPD

Associated injuries Fractures

21 (100 %) 20 (95.2 %)

Pelvic fractures Rami fractures Acetabular fractures

14 (66.7 %) 11 (42.4 %) 3 (14.3 %)

Spine fractures Cervical spine Thoracic spine Lumbar spine Coccyx

18 (85.7 %) 3 (14.3 %) 4 (19.0 %) 15 (71.4 %) 1 (4.8 %)

Lower extremity fractures

15 (71.4 %)

Upper extremity fractures Rib and sternum fractures

5 (23.8 %) 6 (28.6 %)

Facial fractures Intracranial injury Abdominal solid organ injury Splenic laceration Liver laceration Kidney laceration Urethral injuries Colon injury

4 (19.0 %)

5 (23.8 %) 3 (14.3 %) 1 (4.8 %) 2 (9.5 %) 1 (4.8 %)

Perineal laceration Degloving injury Morel-Lavelle lesion Bowel (colon) injury Psoas hematoma Pelvic hematoma Pneumothorax Neurological injuries

2 (9.5) 1 (4.8 %) 1 (4.8 %) 1 (4.8 %) 1 (4.8 %) 1 (4.8 %) 4 (19.0 %) 7 (33.4 %)

1 (4.8 %) 6 (28.6 %)

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2.9 % of all patients with pelvic ring disruptions [6]. However, the low incidence of SPD may be due to underreporting, owing to inconsistent nomenclature in literature and relatively recent awareness of SPD as a distinct injury pattern [5]. The presence of associated skeletal and visceral injuries may lead to delays in diagnosis of SPD [9], further contributing to underreporting. In a retrospective literature review, Robles LA reported that 37 % of patients with transverse sacral fractures had a delayed diagnosis of this problem [25]. Conventional radiographic findings suggestive of SPD include the paradoxical appearance of an inlet view of the pelvis when the patient is positioned to perform a standard anteroposterior pelvic radiograph. Another suggestive finding is a Bstepladder sign,^ which is seen due to fracture of the anterior sacral foramina and interruption of the arcuate lines [6, 26]. CT allows for accurate diagnosis of SPD by virtue of its characterization of both the sagittal and transverse fracture components (Fig. 3). In our study, four fracture patterns were seen with similar prevalence. Comparison to published reports is made difficult by the fact that the widely used Denis classification [4] of sacral fractures does not specifically address transverse sacral fractures or SPD. The Roy-Camille classification [27] specifically addresses the transverse sacral fractures but does not describe SPD or consider the level of the transverse sacral fracture. The Lumbosacral Injury Classification System (LSICS) is the first to address SPD [28]. The LSICS recognizes SPD as a distinct and important injury pattern [28]. In our study, the prevalence of associated injuries was extremely high with all patients having associated musculoskeletal and/or visceral injuries. Previous studies have reported that more than 95 % of patients with SPD have associated visceral and musculoskeletal injuries [5, 10]. In our study, 95.2 % of patients had associated fractures, 66.7 % involving the pelvis and 85.7 % involving the spine. These numbers are higher than the 44.4 % incidence of pelvic ring and 31.7–62 % incidence of spinal injuries reported by others [10, 25]. In our study, 33 % of patients had neurological deficits, as compared to 81 % reported by Konig et al. [10]. This difference may be related to the mechanisms of injury. In our series, the most common mechanism of injury was motor vehicle collision (MVC) (61.9 %), followed by fall (28.6 %), unlike Konig’s much higher rate of 81.3 % MVC. In our study, the rate of neurological deficits was higher in patients with a history of falls (66.7 %) compared with MVC patients (15.4 %). Another factor may be that Konig et al. reviewed only patients with U-shaped sacral fractures. In our series, neurological deficits recovered in 42.8 %, partially recovered in 14.3 %, and did not recover in 42.8 % of patients. Konig et al. [10] reported complete neurological recovery in 32.6 %, partial neurological recovery in 32.6 %, and no neurological recovery in 21.9 % of patients. The mean segmental kyphosis was 17.4 degrees (range 0 to 33 degrees). The mean segmental kyphosis

was greater (20.7 degrees) in patients with neurological deficit as compared to patients without neurological deficit (15.8 degrees); however, there was a significant overlap in the range of kyphosis in patients with and without neurological deficit. The degree of initial and post-surgical residual translational displacement and kyphosis of transverse sacral fracture are associated with neurological recovery and clinical outcomes. The completely displaced sacral fractures and greater residual kyphosis are associated with worse clinical outcomes [29]. In our study, the prevalence of associated extremity fractures was high with 71.4 % of SPD patients with lower extremity fractures and 23.8 % with upper extremity fractures. This is higher than the 31.7 % prevalence of lower extremity fractures and 6.3 % prevalence of upper extremity fractures reported by Konig et al.[10]. Similar to their review, we found that the prevalence of associated lower extremity fractures was higher than upper extremity fractures. In our study, the tibia was the most common associated lower extremity fracture, unlike the high incidence of calcaneus fractures reported by Konig et al.[10]. These differences may again be due to differences in mechanism of injury, MVC being the most common in our series and falls in theirs. We found that 33.3 % of patients with SPD patients had abdominopelvic organ injury, most commonly splenic laceration (23.8 %). This rate is much higher than the 16.5 % reported for all pelvic fractures from blunt trauma [1]. In our series, the rates of genitourinary and gastrointestinal injuries were lower than fractures (two patients with urethral injuries and one with a colon injury); however, significance of these rates is unclear due to our small sample size. SPDs are much more serious injuries than other traumatic sacral fractures because of their high association with sacral nerve root injuries and the high rate of missed diagnoses [25, 30]. It is important to identify various patterns of SPD preoperatively because this helps the surgeon select appropriate operative approach, specifically related to the ability for percutaneous versus open fixation, the need for nerve decompression and reduction, and safe screw corridor delineation [5, 28, 29]. Description of various SPD fracture patterns is also important for prognosis [29]. They allow the orthopedic surgeon to discuss potential short- and long-term complications with their patients and to give a better description of long-term outcomes and potential for permanent impairment. In particular, increased kyphotic angulation and increased impaction at the fracture site have more serious prognosis for nerve injury [29]. Although all SPD injuries are unstable, the decision for operative management in an individual patient depends on the overall patient status, systemic injury pattern, and other factors including SPD fracture pattern and ability to attain stable screw fixation [28]. The decision for non-operative management was made when patients were not expected to tolerate complex surgery or if stable screw fixations were not

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considered possible. In some cases, the amount of sacral comminution was so extensive to preclude screw fixation. In addition, some patients in this series may have been candidates for lumbopelvic fixation, which was not an option at our institution at that time. There are several potential limitations of this study. First, the study was retrospective in design, bringing with it the limitations of using data from our trauma registry. Second, some patients in the registry, especially from our older dates, did not have MDCT imaging available for evaluation. Third, the small sample size prevented a more extensive statistical analysis. However, SPD is an uncommon injury so more extensive analysis would most likely require a multi-institutional study. We did not have sufficient data to associate specific SPD fracture patterns with non-skeletal injuries. In conclusion, the results of our study highlight the importance of SPD. SPD is a diagnosis that radiologists interpreting trauma CT examinations cannot afford to miss. By becoming familiar with the imaging findings of SPD, radiologists will be able to distinguish it from other pelvic fractures, make a timely diagnosis, and help prevent long-term complications.

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18. Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest.

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