Anterior Lumbosacral Dislocation: Case report and review of the literature

doi:10.1016/S0090-3019(98)00009-3

Surgical Neurology

Volume 50, Issue 1, July 1998, Pages 11-16

https://doi.org/10.1016/S0090-3019(98)00009-3 Get rights and content

Abstract

Background

Anterior lumbosacral dislocation is a rare traumatic anterior spondylolisthesis.

Methods

We report a new case surgically treated and review the eight cases previously reported.

Results

The mechanism of injury is hyperflexion-distraction. Neurological signs are inconsistent. Indirect radiological signs such as bilateral multiple transverse process fractures are strongly suggestive of the diagnosis. This complete soft tissue injury induces a definitive instability and requires an open reduction with posterior fixation.

Conclusions

Suspicion of lumbosacral dislocation requires a computed tomography scan exploration with multiplanar reconstructions. Early reduction is associated with neurologic recovery. However, prognosis is correlated with the initial neurologic status and the severity of other associated injuries.

Section snippets

Case Report

A 25-year-old man was admitted to the hospital after a motorcycle crash during a competition. The exact circumstances of the injury were not determined because of a head trauma with initial loss of consciousness. He experienced severe lumbosacral and abdominal pain. Physical examination disclosed diffuse tenderness of the lumbosacral region with a left side echymosis and no open wounds. Neurological examination revealed an incomplete cauda equina syndrome, including the left side, S1 sensory

Discussion

The facet joints and the supraspinous ligament play a crucial role in the stability of the lumbosacral junction whereas the interspinous and yellow ligaments play a minor role at this level. In case of LD, soft-tissue disruption not only involves the posterior ligament complex but also the posterior longitudinal ligament and the annulus fibrosus 20, 24.

The mechanism of injury is complex and a subject of controversy. Watson-Jones [23]was the first to hypothesize that dislocations were caused by

Conclusion

Lumbosacral dislocation should be suspected in case of bilateral multiple transverse process fractures occuring after a severe spinal injury. This feature should lead one to perform a CT scan of the lumbosacral spine. Definitive compromised stability requires an open reduction with internal fusion. Prognosis is dictated by the initial neurologic status and other associated injuries. [25]

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Cited by (31)

Single-stage treatment of lumbar fracture-dislocation using a combined anterior and posterior approach
2012, Journal of Orthopaedic Science
A rare case of spinal injury: Bilateral facet dislocation without fracture at the lumbosacral joint
2012, Journal of Orthopaedic Science
Lumbosacral dislocations are rare disorders; since they were first reported by Watson-Jones [1], only 100 cases have appeared in the literature [2]. A traumatic bilateral lumbosacral dislocation is even rarer, with a mere 10 cases reported [3]. Because of its low incidence and atypical location, the lesion may often go unnoticed on initial clinical assessment [4]. Surgical treatment modalities are not defined, but open reduction and internal fixation are often necessary because of a three-column involvement [5]. In this paper, we report on an initially misdiagnosed case of lumbosacral dislocation treated with open reduction and internal fixation.
Lumbosacral dislocation: A review of the literature and current aspects of management
2010, Injury
Citation Excerpt :
Pulmonary, abdominal, chest, vascular and brain injuries are frequently present and sometimes require immediate surgical care or resuscitation, so that lumbosacral dislocations can be missed due to poor quality X-rays and/or lack of awarenes.3,18,44,66,50 Fractures of transverse processes are described as sentinel fractures.26,36,50,54,66 Although they can be inconstant, these sentinels should lead to an investigation of the lumbosacral transition.
Lumbosacral fracture dislocation is a very rare lesion and was first described by Watson-Jones in 1940. Two anatomical classifications are described in the literature, all other reports are case presentations.
This fracture type is characterised by an antero- or retrolisthesis or a lateral translation of the 5th lumbar vertebra in relation to the sacrum. Biomechanics are discussed controversially. Most patients suffer from a high energy trauma with concomitant severe injuries. There is a high rate of additional neurological deficits. Fractures of the transverse process are thought to be sentinel fractures. MRI and CT scans are essential to detect the whole extent of the lesion. Circumferential fusion is recommended by several authors to regain stability at the lumbosacral junction.
A Noncontiguous 2-Level Spinal Injury in a Young Female Driver Due to a 3-Point Seat Belt Restraint
2009, Journal of Manipulative and Physiological Therapeutics
The purpose of this case is to describe noncontiguous fracture and dislocations of the thoracolumbosacral spine in a 23-year-old female driver with a 3-point seat belt restraint.
A 23-year-old woman presented to us after a motor vehicle accident while driving with a 3-point seat belt restraint. She was neurologically intact except for loss of motor function in the distribution of the L5 nerve root in the right lower limb. Computed tomography and magnetic resonance imaging showed fracture and dislocation of T3 with considerable retrolisthesis and complete anterolisthesis of L5 over the sacrum.
Both fractures were reduced and fixed with bone graft and instrumentation. She was discharged a month later without any further neurologic deterioration.
To our knowledge, this case is the first report in the literature of a seat belt safety restraint causing 2 noncontiguous fracture dislocations of the spine. Although the consensus is that seat belts can prevent most spine injuries, this case shows that the seat belt can be a contributor to spine injury. It shows that the shoulder-lap restraint can act as 2 fulcrums at the upper and lower bands causing 2 separate fracture dislocations. A thorough radiologic evaluation of the spine with respect to the clinical findings is mandatory in seat belt–restrained road traffic accidents cases.
Traumatic lumbosacral fracture dislocation: A case report and review of the literature
2007, Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur
Les luxations lombosacrées sont rares. Nous rapportons le cas d’une femme âgée de 33 ans, victime d’un accident de la voie publique (piéton heurtée par une voiture). L’impact postérieur avait entraîné un traumatisme lombaire, avec une douleur lombaire diffuse plus intense au niveau de la charnière lombosacrée ; une traînée ecchymotique de l’ensemble de la région lombaire associée à une fluctuation traduisait la présence d’un hématome sous-cutané. L’examen neurologique a mis en évidence une paraplégie incomplète de niveau L5. Le bilan radiologique standard a montré un spondylolisthésis L5-S1 avec une fracture de l’apophyse épineuse de L5 ainsi qu’une fracture étagée des apophyses transverses de L3, L4, et L5. L’examen tomodensitométrique a montré une fracture luxation biarticulaire L5-S1, et surtout une volumineuse hernie discale L5-S1.
La patiente a été opérée en urgence. L’abord chirurgical a trouvé un décollement sous-aponévrotique allant de D4 jusqu’à S1 et des pyramides iliaques chauves.
Après une laminectomie L5 et l’extraction d’une volumineuse hernie discale, une réduction de la luxation a été réalisée et stabilisée par un montage court constitué par des vis pédiculaires en L5 et en S1 des deux côtés et deux tiges, associé à une autogreffe iliaque postéro-latérale.
L’évolution s’est faite vers une récupération neurologique quasi complète, la patiente n’a gardé qu’une parésie des releveurs.
À travers ce cas et une revue de la littérature nous essayerons d’étudier l’aspect physiopathologique, clinique, radiologique et thérapeutique des fractures luxations lombosacrées.
Lumbosacral dislocation is uncommon. We report a case of traumatic lumbosacral dislocation which occurred in a 33year-old pedestrian traffic accident victim. The posterior impact produced lumbar injury with diffuse pain exacerbated at the lumbosacral junction. Ecchymotic diffusion involving the entire lumbar region fluctuated due to the presence of a subcutaneous hematoma. The neurological examination revealed incomplete L5 paraplegia. Standard x-rays revealed L5-S1 spondylolisthesis and fracture of the L5 spinous process as well as fractures of the L3, L4, and L5 transverse processes. Computed tomography disclosed biarticular L5-S1 fracture dislocation and a voluminous herniation of the L5-S1 disc.
Emergency surgery was performed and revealed subaponeurotic detachement from T4 to S1 and bald iliac pyramids. After L5 laminectomy and extraction of the voluminous herniation of the L5-S1 disc, a short L5-S1 posteriolateral fusion was achieved using pedicular screws and two rods on either side as well as a posterolateral iliac autograft. The clinical course was satisfactory with nearly complete neurological recovery (persistent levator ani paresis).
This clinical case and a review of the literature illustrate the pathogenic, clinical, radiological and therapeutic aspects of lumbosacral fracture dislocation.
Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy
2007, Injury
Citation Excerpt :
IB: bilateral facet joint dislocation with lateral displacement (patient 11). Mechanism of injury seems to be hyperflexion associated with a lateral translational force.2,13,33,38 In this type of injury (lateral subluxation) and even without anterior displacement of the L5 vertebra, severe disc lesions may be found.
Purpose of the study: Traumatic lumbosacral dislocation is a rare lesion often characterised by a fracture dislocation of L5-S1 articular facets associated with anterior L5 slipping. Because of its rarity, the surgical strategy of lumbosacral traumatic dislocation remains controversial. We report the most important series of traumatic lumbosacral dislocation. The cases of six men and five women are presented. We discuss the diagnosis and surgical treatment options regarding the different type of lesions.
A moderate anterior slipping of L5 over S1 was present in eight cases. The lesion was a bilateral lumbosacral fracture dislocation in eight cases, a pure lateral dislocation in two cases and a unilateral rotatory dislocation in one case. Patients were multiple-trauma patients in eight cases. A radicular deficit was present in two cases. All patients were treated surgically with a posterior osteosynthesis and fusion. A circumferential fusion was made in six cases. In four cases, the anterior fusion was made during the posterior approach.
The postoperative course was favorable in all the cases. One patient necessitated secondarily an iterative posterior lumbosacral fixation and anterior fibular bone graft because of a lumbosacral pseudarthrosis.
Traumatic dislocation of the lumbosacral junction is a rare and severe spinal fracture which occurs in patients after high energy trauma and could be initially misdiagnosed. We devised a new classification based on anatomical lesions. Treatment is always surgical, requiring reduction, osteosynthesis, and fusion. In case of L5 anterior slipping, it is crucial to assess the L5S1 disc by MRI or surgical exploration for disc disruption. In such case, we recommend to perform circumferential fusion to prevent lumbosacral pseudarthrodesis.

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Original ArticlesAnterior Lumbosacral Dislocation: Case report and review of the literature

Abstract

Section snippets

Case Report

Discussion

Conclusion

Surg Neurol

Injury

Am J Surg

Anterolateral dislocation of the lumbosacral junction. Case report

Can Assoc Radiol J

Unilateral lumbosacral facet fracture-dislocation

Spine

Traumatic retrolisthesis of the lumbosacral junction. A case report

Spine

Lumbosacral fracture-dislocations. A report of four cases

J Bone Jt Surg

Bilateral facet dislocation at the lumbosacral joint. A report of a case and review of literature

Spine

The three column spine and its significance in the classification of acute thoracolumbar spine injuries

Spine

Fracture-dislocation of the lumbosacral spine with cauda equina lesion. Report of two cases

J Bone Jt Surg

CT of bilateral lumbosacral facet dislocation

AJNR

Traumatic posterior fracture-dislocation of the lumbo-sacral joint

J Trauma

Original Articles
Anterior Lumbosacral Dislocation: Case report and review of the literature