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ORIGINAL ARTICLE
Year : 2023 | Volume
: 14
| Issue : 1 | Page : 55-58
Traumatic spinopelvic dissociation: A case series
Sami I Aleissa1, Abdullah Al Zahrani2, Faisal Konbaz3, Khalid Alsheikh1, Fahad H Alhelal2, Ali Alshehri2, Majed Abalkhail2, Faisal Alzahrani2, Abdulaziz Almowina4, Abdullah Al Harbi4, Faris Al Wahhabi4, Firas M Alsebayel1
1 Department of Orthopedic Surgery, National Guard Health Affairs; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Saudi Arabia
2 Department of Orthopedic Surgery, National Guard Health Affairs, Riyadh, Saudi Arabia
3 King Faisal Specialized Hospital and Research Center, Riyadh, Saudi Arabia
4 College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
Correspondence Address:
Firas M Alsebayel
College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, P. O. Box 3660, Riyadh 11481
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jcvjs.jcvjs_158_22
Abstract
Introduction: Spinopelvic dissociation was described first in 1969. It is an injury characterized by the separation of the lumbar spine, with parts of the sacrum, from the rest of the sacrum and pelvis with the appendicular skeleton through the sacral ala. Spinopelvic dissociation has an incidence of approximately 2.9% of all pelvic disruptions and corresponds with high-energy trauma. The objective of this study was to review and analyze a case series of spinopelvic dissociations that were treated in our institution from May 2016 to December 2020.
Methods: This was a retrospective study reviewing medical records of a series of cases with spinopelvic dissociating. A total of nine patients were encountered. Demographic data including gender and age were analyzed with the mechanism of injury, fracture characteristics, and classifications in addition to neurological deficits. Fractures were classified by the AO Spine Sacral Classification System. Moreover, neurological deficits were classified using the Gibbon's classification score. Finally, the Majeed score was utilized for the assessment of the functional outcome after the injury.
Results: A total of nine patients with spinopelvic dissociation were encountered, seven males and two females. Seven patients were due to motor vehicle accidents, one patient was due to a suicidal attempt, and one patient was due to seizure. Four patients suffered from neurological deficits. One patient needed an intensive care unit admission. Spinopelvic fixation was done for all patients. One patient had surgical wound infection with wound dehiscence, one had infected instruments with confirmed spine osteomyelitis, and one had a focal neurological deficit. Six patients went on to heal and showed complete neurological improvements.
Conclusion: Spinopelvic dissociation injuries represent a variety of injuries that are commonly associated with high-energy trauma. The triangular fixation method has proven to be a stable construct in dealing with such injuries.
Keywords: Pelvis fractures, spinopelvic dissociation, trauma
Introduction 
Spinopelvic dissociation (SPD) was first described in 1969. It is an injury characterized by a combination of transverse and vertical sacral fractures leading to the separation of the lumbar spine, with parts of the sacrum, from the rest of the sacrum and pelvis with the appendicular skeleton through the sacral ala.[1] SPD is considered relatively rare and has an incidence of approximately 2.9% of all pelvic disruption and corresponds with high-energy trauma. Of note, airborne activities carry a distinctively high risk for spinopelvic dissociation injuries, with rates reported to be 36.4% of all sacral fractures. However, motor vehicle accidents (MVAs), blast injuries, crush injuries, and fall from heights also frequently seen.[2] SPD carries a great risk of morbidity and mortality, including intra-abdominal, vascular, neurological, and concurrent orthopedic injuries. It is estimated that neurological deficits can reach up to 53%.[3]
Due to the rarity of the injury, multiple fixation methods have been suggested; however, a single treatment model is yet to be established. Traditionally, open reduction with internal fixation is the standard approach to SPD. This includes multiple options such as tension band plating, iliosacral screws, and adjustable screws.[1],[4] In recent decades, there has been a shift toward a triangular fixation method that employs an indirect iliosacral lumbopelvic fixation with direct fixation of sacral fractures by screws leading to a tridimensional structure that provides maximum stability and fixation, which allows early mobilization, excellent clinical, neurological, and radiological outcome.[5]
There have been a limited number of studies that examine spinopelvic dissociation and its presentation, management, postoperative complications, and outcome. Herein, we present a case series of spinopelvic dissociations that were treated in our institution from May 2016 to December 2020.
Methods This was a retrospective case series study that reviews the medical records of all patients admitted with a diagnosis of spinopelvic dissociation to a tertiary-care level 1 trauma care center between May 2016 and December 2020. The study variables included gender, age, mechanism of injury, fracture classifications, neurological deficits, and postoperative functional outcome.
Fractures were classified by the AO Spine Sacral Classification System. Moreover, neurological deficits were classified using the Gibbon's classification score. Finally, the Majeed score was utilized for the assessment of the functional outcome after the injury.
Data collection and statistical analysis
Data were gathered utilizing BESTCare 2.0 system. Inclusion was based on the following criteria: (1) adult patients above the age of 14; (2) imaging-confirmed traumatic spinopelvic dissociation; (3) patients who underwent surgical intervention; and (4) follow-up period with a minimal of 2 weeks postoperatively. Data were collected and uploaded ino Microsoft Excel sheet. Descriptive analysis was utilized to calculate frequencies and percentages.
Management and surgical technique
Patients were admitted from the emergency department, following trauma team activation. The Advanced Trauma Life Support protocol was utilized and performed. After resuscitation and stabilization, all patients underwent detailed neurological assessment, radiological workup, and damage control procedures. During their admission, a multidisciplinary team consisted of fellowship-trained spine and trauma surgeons was involved. After medical optimization, the patients underwent surgery.
Patients were positioned in the prone position over the Jackson table; bilateral skeletal tractions were applied on both limbs. A trial of closed reduction using traction with extension is attempted. A midline posterior approach was used to expose L4-S2 and up to the sacral foramen. After careful dissection, pedicle screws were applied over L4-S1. After that, sacral alar iliac screws were applied under the visualization of C-arm. The rods were applied thereafter, achieving an acceptable reduction and fixation of the spine. After that, trauma team augmented the fixation using transiliac screw. The wound was irrigated and closed in the usual fashion.
Results A total of nine patients were included in this study. Seven patients were male (77%) and two were female (22%) with the mean age of 28 years (range, 14–60). The main mechanism of injury was due to MVA (77%), while one was due to a fall from 8 m high in a suicidal attempt (11%) and one was due to seizure (11%). The most common associated injury is pelvic ring fracture in 57.1% of the patients, followed by facial fractures and acetabular fracture in 42.8% and 28.5%, respectively. Regarding fracture morphology, U-shaped fractures were the most common with six patients [Figure 1], followed by T-shaped in two patients and one case of H-shaped. The Roy-Camille classification showed eight patients developed flexion type fracture, while the extension type was observed in the case of suicidal attempt (fall from heights). AO classification showed all patients to have C3 type, four patients developed pelvic ring fractures (M3), one patient sustained pelvic ring injury with open fracture (M1, M3), and one patient sustained sacroiliac joint disruption (M4). Two patients had no other modifiers.
The Denis classification of displacement showed five angulated (type 2), two undisplaced (type 1), and one case for each of completely displaced (type 3) and impacted (type 4). Whereas six were neurologically intact (N0), one had transient neurological deficit (N1), and two had radicular symptoms (N2).
Figure 1: (a-b) Preoperative three dimensional CT scan of pelvis of spinopelvic dissociationPostoperatively, one patient was admitted to the intensive care unit care, one patient had surgical wound infection with wound dehiscence, one patient developed infected instruments with confirmed spine osteomyelitis, and one had a permanent focal neurological deficit. Six patients went on to heal and showed complete neurological improvements. Regarding the Majeed score, a response rate of 66% was obtained. The average score was 68%, with young age associated with a better score. However, the patient who had depression had the lowest score of 47%.
Discussion Spinopelvic dissociation is an infrequent injury that lacks an extensive research on its modalities of management, treatment, and outcome. Although the literature studies have demonstrated that surgical intervention is the most feasible option to allow early mobilization, functional recovery, and improved quality of life, its yet to reach a consensus on the optimal technique of reduction and fixation.[6],[7] While the trends of surgery are shifting to a minimally invasive surgical reduction, SPD remains to require a relatively invasive approach.
The triangular fixation method has been the most extensively studied approach and has been associated with an excellent biomechanical stability [Figure 2].[8] However, it has been observed that it is associated with an increased prevalence of surgical wound infections and wound dehiscence reaching up to 26%.[9] In the current study, two cases (20%) developed an infection and required a prolonged IV antibiotic course and multiple irrigation and debridement procedures. Other less invasive percutaneous methods have been mentioned in the literature.[3],[10] In a recent study, Pearson et al. compared the outcome of percutaneous versus open fixation methods and found the former to be associated with less blood loss, operative cost, length of stay, and final alignment.[3] However, it is limited by patient factors such as body habitus, other comorbid conditions, and concurrent injuries. Moreover, there are a sparse number of research regarding the mentioned technique, and more research need to be conducted to have a broader knowledge about the method.
In the current research, the most common mechanism of injury was MVA, contrary to other studies that demonstrated airborne activities to be the most common.[6],[11],[12] We attribute this to the increased prevalence of high-energy motor accidents in our region. In the current study, it was found that pelvic ring injuries were the most common associated injury (57%), followed by facial injuries (42%) and acetabular fractures (27%); similar results were shown in another research, showing pubic rami fractures to be prevalent in 89% of cases.[1] Neurological deficits have been associated with this type of fracture, with a percentage reaching up to 68%.[6] This study shows a 25% prevalence of neurological deficits; similar results have been observed in the literature. The average functional outcome of this study was 68%, slightly lower than the international scores. This can be explained by the nature of associated injuries, as acetabular fractures can often alter scores. Furthermore, physiotherapy adherence and follow-up remain an issue for our population, as many patients did not vigorously follow-up with regular physiotherapy sessions. Moreover, we acknowledge the lack of response (66% response rate), as it can alter the scores.
This study highlights the importance of surgical intervention and provides a guide for expected complications postoperatively. To the best of our knowledge, this is the first study that examines spinopelvic dissociation in the region, and it serves to present different patient population to the literature. We acknowledge the limitation of this study as it is a single-center study and the nature design of retrospective studies.
Conclusion Spinopelvic Dissociation injuries repreasent a variety of injuries that are commonly associated with high-energy trauma. Surgical intervention aids with regaining acceptable outcome, and the triangular fixation method has proven to be a stable construct in dealing with such injuries.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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