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8 Sacral Injuries

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Fig. 8.2 Type C3 injury; (a) CAT scan (b) CT 3D reconstruction

Fig. 8.3 Type C3 injury; the information was given by MRI (a) is less precise than the one pro- vided by the CT scan (b) which should guide the treatment algorithm

patients, delayed diagnosis of a sacral injury is common. The routine CAT scan clearly identies minor and major injuries, allowing the application of a classication system that can help the surgeon with the decision-making process (Fig.8.2). Magnetic resonance imaging (MRI) is rarely needed upon the admission of the patient in the ER although it may be helpful to evaluate nerve roots or in the case of pathological fractures (Fig.8.3).

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L. R. Vialle and E. N. Vialle

8.5 Classification

Traditionally, sacral fractures were included in the pelvic trauma classications, due to their frequent association. Few classications started to prioritize the sacrum, although none were inclusive nor validated. The AOSpine sacral classication offers a denitive tool for the correct understanding of the displacements resulting from the injury [1]. The analysis of the morphological alterations denes the degree of severity of the deformity and the associated amount of instability. A neurological evaluation at admission and the application of modiers help with the treatment algorithm. A detailed description can be found online [2] Appendix D highlights this classication. The correct interpretation of the injury allows the surgeon to differentiate between stable and unstable injury, to discard or conrm the spinopelvic involvement, and to suggest the best treatment option.

8.6 Differential Diagnosis

There is not a signicant differential diagnosis to keep in mind although an adequate assessment of the amount of instability is of paramount importance. The analysis of high-quality images and a correct application of the classication are needed to rule out complex spinopelvic dissociation. Not displaced Type C0 fractures are potentially unstable, and without proper identication, a secondary displacement can occur. The small signs of a more severe injury must always be on the surgeon’s mind, as the minor L5 transverse process avulsion may be a warning sign for vertical instability.

8.7 Treatment Options

1. Conservative treatment: This is an option applicable to all stable injuries, without

joint disruption or pelvic ring dissociation. It consists of bed rest and progressive mobilization without full weight-bearing. The patients must be regularly followed with weekly radiographs so that any misdiagnosis or minor displacement could be promptly identied. The treatment option should then be reevaluated.

2. Surgical treatment: This option is indicated when there is uncontrolled pain,

instability, or gross displacement and xation or reduction is deemed necessary [3]. As a rule of thumb, it is important to reduce and x the sacrum rst and then

to extend the instrumentation if needed (Video 8.3). The options are: (a) Cement injection for pathological fractures is effective to control pain. (b) Percutaneous iliosacral screws for trans-alar fractures, mainly Type B inju-

ries (Fig.8.1c).

According to the clinical status, the anatomy of the injury, and the amount of displacement, the goal of treatment is to reduce and stabilize the injury with a sound xation; not infrequently, this means spinopelvic instrumentation from L4 to the iliac ala (uni or bilateral) (Fig.8.4c, d).

8 Sacral Injuries

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Fig. 8.4 Type C3 injury; (a, b) CT scan showing displacement and instability; (c, d) surgical treat- ment with spinopelvic bilateral xation and additional posterior plate

8.8 Expected Outcomes

Outcomes depend on the severity of the injury. In Type A injuries, the return to normal daily life activities is possible in about 2months while complete recovery from a severe sacral injury implies a long-term rehabilitation program.

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L. R. Vialle and E. N. Vialle

8.9 Potential Complications

Patients must be aware of the potential complications such as neural decits, residual deformity, lower limb discrepancy, pseudoarthrosis, and postoperative infection (not uncommon; perineum close to the surgical approach). The initial treatment must consider all these issues, and the surgeon must use all resources to achieve the best possible reduction and xation.

8.10 What Should Patient andFamily Know?

The consequences of such injury must be stressed to patients and families before starting any treatment. It may be a life-threatening situation in the ER, a demanding procedure at the operating room with numerous potential postoperative complications and risks; all potential complications should be carefully explained and detailed. Last but not the least, patients and family should be prepared for a longterm rehabilitation process.

Further Readings

1. Vaccaro A, Schroeder G, Divi S, Kepler C, etal. Description and reliability of the AOSpine

sacral classication system. J Bone Joint Surg Am. 2020;102:1454–63.

2. Spine, trauma, sacral fractures, classication. www.aosurgeryreference.com

3. Bellabarba C, Schildhauer TA, Vaccaro AR, Chapman JR. Complications associated with

surgical stabilization of high-grade sacral fracture dislocations with spino-pelvic instability.

Spine. 2006;31(11 Suppl):S80–8.

Spinal Cord Injury andRelated

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Conditions

PaulaValerieter Wengel andF.CumhurÖner

9.1 Definition

Traumatic spinal cord injury (tSCI) is dened as neurologic dysfunction as a consequence of spinal trauma. Its incidence ranges between 10 and 84 cases per million per year, with wide variations between countries. The cervical spinal cord is the most commonly affected level, followed by the thoracic and lumbar spinal cord. The severity of the injury is generally categorized according to the American Spine Injury Association (ASIA; Appendix G) Impairment Scale (AIS: AIS A-E). Around 30% to 55% of patients with tSCI will present with complete neurological injury (AIS A).

9.2 Natural History

The severity of initial neurological injury negatively affects the neurological outcome, where patients with complete tSCI AIS A and incomplete AIS D are less likely to recover neurologically compared to incomplete AIS B and C patients. One year after trauma, approximately 70% to 85% of AIS A patients and 85–88% of AIS D patients will not recover in AIS grade. In contrast to AIS B and C patients, patients with less severe incomplete tSCI (AIS D) are also less likely to recover

Supplementary Information The online version contains supplementary material available at [https://doi.org/10.1007/978- 3- 030- 80356- 8_9].

P. V. ter Wengel Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands e-mail: v.ter.wengel@haaglandenmc.nl

F. C. Öner (*) Department of Orthopaedics, University Medical Center Utrecht, Utrecht, Netherlands e-mail: F.C.Oner@umcutrecht.nl

https://doi.org/10.1007/978-3-030-80356-8_9

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neurologically. Injuries at the cauda equina level, in general, have a better potential for substantial recovery.

P. V. ter Wengel and F. C. Öner

9.3 Physical Examination

When feasible, patients should be evaluated neurologically according to the International Standards for Neurological Classication of Spinal Cord Injury (ISNCSCI). This systematic neurological examination is used to determine the motor, sensory impairment, severity, and level of tSCI (Video 9.4). The severity of the neurological injury is classied in AIS grades, where AIS A is sensorimotor complete tSCI and AIS B-D refer to incomplete tSCI.AIS B describes motor complete lesions with preserved sensation below the level of injury, which at least should include the lower sacral segments. AIS C describes motor incomplete lesions ranging from only the presence of voluntary anal contraction to preservation of some motor function below the level of injury, where at least half of the key muscles have less than antigravity function (<MRC 3). AIS D refers to incomplete motor lesions where at least half of the key muscles have antigravity function (≥MRC 3). When there is a disproportionately greater motor decit in the upper extremities compared to the lower, this is dened as a central cord–type injury (TCCI). While TCCI is the most frequent incomplete tSCI, there are still inconsistencies in the denition and treatment of TCCI patients. Some argue that TCCI patients have a more favorable prognosis compared to incomplete tSCI.However, the initial severity of the injury, as categorized by the AIS grade, plays a more important role in neurological recovery potential rather than having a TCCIlike injury.

9.4 Radiographic Examination

Imaging should start with a high-quality CT scan with multiplanar reconstructions. In cases with tSCI, an MRI should be obtained even if there are no injuries seen on CT scans. MRI should be preferentially performed preoperatively to adequately assess the extent of spinal cord compression, hemorrhage, traumatic disc herniation, epidural hematoma, or ligamentous injury.

9.5 Differential Diagnosis

Complete spinal cord injury can be difcult to distinguish initially from spinal shock. Spinal shock is characterized by the temporary reduction or loss of reexes, motor, and sensory function following tSCI and can last from hours to weeks. Spinal shock is more pronounced in severe spinal cord injury and at higher neurological levels of injury. There is debate regarding the end of the spinal shock phase; usually,

9 Spinal Cord Injury andRelated Conditions

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it starts with the gradual return of reexes. While it can be difcult to distinguish in the acute phase, only about 3% of patients with complete cervical tSCI will show some spontaneous neurological recovery within a week indicating recovering spinal shock.

9.6 Neurogenic Shock

Injuries above T6 can cause sudden loss of autonomic tone. This can cause a lifethreatening distributive shock with hypotension, bradycardia, and peripheral vasodilatation. In the acute phase, hypovolemic shock should be ruled out. In contrast to hypovolemic shock, patients with neurogenic shock will have bradycardia due to the loss of sympathetic innervation instead of tachycardia.

9.7 Treatment Options

Surgery aims at restoring the spinal alignment and stability while decompressing the injured spinal cord; early treatment increases the chances of recovery. Lifethreatening injuries should be managed rst. When there is ongoing spinal cord compression, it should be decompressed to prevent further damage to the spinal cord and enhance potential neurological recovery. Dislocation injuries can be treated by promptly closed reduction, while other compressive injuries should be treated operatively. There is debate on the optimal surgical timing. While surgical decompression within 24h from trauma has been shown to increase the chances of neurological recovery and to prevent secondary deterioration, the effect of earlier timeframes (less than 8 to 12h) is still under investigation though early treatment increases the chances of recovery. The surgical plan depends on the type of injury and the compression of the spinal cord. Nonetheless, laminectomy appears to have a greater potential to adequately decompress the spinal cord than anterior surgery only.

9.8 Expected Outcome

The neurological outcome is dependent on the level and severity of the injury as well as the surgical timing. When surgical decompression is performed within 24h, patients with complete cervical tSCI (AIS A) appear to have a signicantly greater likelihood to improve ≥2 AIS grades compared to surgery performed thereafter, namely, 22.6% versus 10.4%. About 27.2% of patients with cervical tSCI (AIS A-D) will recover ≥2 AIS grades or recover to normal when surgery is performed within 24h, compared to 26.5% when surgery is performed later. For thoracic and thoracolumbar tSCI, this is 42% when surgery is performed within 24h, compared to 27.3% when it is performed later (Tables 9.1, 9.2, 9.3, and 9.4).

first author of study

total nr of

nr of patients

percentage

lower

Fehlings Levi Umerani

Newton Randle

Randle Liu Benzel

Bourassa–Moreau Papadopoulos Jug Mattiassich Hansebout Grassner

Early surgery

Late surger

higher

95%CI

first author of study

total nr of

nr of patients

percentage

lower

Fehlings

Umerani

Fehlings

Umerani

Newton

Randle

Liu

Benzel

Papadopoulos

Jug

Mattiassich

Grassner

Early surgery

Late surger

higher

95%CI

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P. V. ter Wengel and F. C. Öner

Table 9.1 The impact of surgical timing on >2 ASIA grade improvement in the complete cervical tSCI

patients

with improvement

44 22 12 24 20 14 38 26 20 14 14

248

27 14 20 12 66 35

174

8 5 3 7 3 4 8 4 5 4 5

3 4 2 1 8 0

0102030%40 50 60

improvement

21.7

22.7

23.0

23.7

21.7

23.4

22.4

21.5

23.0

23.3

24.2

22.6

10.6

11.9

10.5

10.8

9.2

10.4

95%CI

14.2

14.9

14.3

16.0

12.7

15.1

15.2

12.8

15.0

15.1

16.0

16.6

5.3

5.9

5.2

5.1

5.7

3.5

5.6

29.3

31.8

34.3

34.8

30.0

35.5

30.5

29.4

33.0

34.2

37.4

28.7

17.1

21.8

17.1

17.2

16.3

15.1

15.8

Table 9.2 The impact of surgical timing on >2 ASIA grade improvement in the incomplete cervical tSCI

patients

with improvement

improvement

95%CI

217

251

419

138

0102030%40 50 60

33.4

35.6

32.5

26.4

38.3

30.7

20.3

30.4

28.8

25.3

38.6

34.0

37.9

32.5

25.1

22.1

18.8

13.6

23.6

18.9

5.7

19.8

19.0

13.8

22.9

28.6

27.4

21.4

43.2

53.9

49.6

38.3

59.5

44.2

35.2

41.6

38.2

36.4

59.7

39.6

50.8

45.8

first author of study

total nr of

nr of patients

percentage

lower

Cengiz

Bourassa

Rahimi

Payer

Dobran

Early surgery

Late surger

higher

95%CI

first author of study

total nr of

nr of patients

percentage

lower

Cengiz

Rahimi

Rath

Rahimi

Clohisy

Wang

Payer

Clohisy

Dobran

Early surgery

Late surgery

higher

95%CI

9 Spinal Cord Injury andRelated Conditions

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Table 9.3 The impact of surgical timing on >1 ASIA grade improvement in the complete thoracic/thoracolumbar tSCI

patients

Table 9.4 The impact of surgical timing on >1 ASIA grade improvement in the incomplete thoracic/thoracolumbar tSCI

patients

331

386

380

445

with improvement

170

217

158

201

0103020 40%50 60 70 80 10090

improvement

58.4

19.5

22.1

69.3

37.6

40.0

18.7

23.6

16.5

63.5

21.6

27.4

improvement

87.8

51.9

88.6

78.5

83.5

80.7

81.3

45.6

41.8

67.5

66.3

53.0

80.4

60.2

95%CI

25.1

7.0

3.3

34.6

17.6

11.2

2.3

5.4

2.1

34.7

4.7

4.8

95%CI

65.9

46.3

67.9

54.7

52.9

60.3

62.1

62.2

18.3

37.0

49.6

41.1

26.9

57.7

36.4

89.4

36.1

51.8

95.4

60.1

79.4

47.2

49.7

40.7

87.8

46.7

61.9

99.2

57.3

99.2

94.9

94.8

97.5

94.0

94.3

73.8

46.9

83.2

87.6

78.1

96.4

82.6

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P. V. ter Wengel and F. C. Öner

The severity of the injury not only affects the functional outcome in tSCI patients but also negatively affects the lifelong incidence of long-term complications such as pulmonary, urogenital complications, pain, and pressure ulcers. These complications can lead to frequent re-hospitalization and are the cause of morbidity and even mortality.

9.9 Potential Complications

Early surgery does not lead to a higher postoperative complication rate nor mortality compared to delayed surgery. On the contrary, early surgical management appears to decrease the overall complication rate during the acute hospital phase. Nevertheless, there is a chance that a patient can deteriorate neurologically after surgery independently from surgical timing. After the acute phase, late complications due to tSCI can occur and are essentially related to the severity of the injury. These late complications include bowel, bladder, and pulmonary dysfunction, pressure ulcers, pain, spasticity, sexual dysfunction, and even increased mortality.

9.10 What Should Patient andFamily Know?

The severity of the initial injury directly affects the neurological outcome. There is growing evidence that early decompression within 24h has a positive effect on neurological recovery. An additional benecial effect of an ultra-early intervention is not clear and yet to be elucidated. Not only is the severity of injury related to the ability to improve neurologically, but it is also related to the prevalence of long-term complications which can cause great morbidity and even mortality.