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Neurological damage in pelvic injuries: a continuous prospective series of 50 pelvic injuries treated with an iliosacral lag screw - 06/05/08

Doi : RCOE-04-2004-90-2-0035-1040-101019-200510470 

J. Tonetti [1],

C. Cazal [1],

A. Eid [1],

A. Badulescu [1],

T. Martinez [1],

H. Vouaillat [1],

P. Merloz [1]

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Abstract

Purpose of the study

The purpose of this study was to analyze lesions to the lumbosacral plexus related to pelvic injury and its treatment.

Material and methods

Forty-four patients presented 50 posterior osteoligamentary lesions of the pelvic girdle. All patients except eight had other injuries. Mean ISS was 27/75. Posterior lesions were: iliosacral disjunction (n = 23), extra-foraminal fracture of the sacrum (n = 4), transforaminal fracture (n = 22), intra-foraminal fracture (n = 1). Vertical posterior displacement was > 1 cm for 24 posterior lesions. Orthopedic reduction was performed at admission for all patients. Fluoroscopy-guided percutaneous lag screw fixation was performed in all cases, on the average eight days after the accident. Neurological involvement was evaluated at admission, after surgery, and at last follow-up. Data were recorded for skeletal muscles, lower limb dermatomes, tendon reflexes, and anal tone. Screw emplacement was checked on the CT-scan. Outcome was assessed subjectively with the Majeed score, a self-administered visual analog scale, and use of antalgesic drugs according to the WHO classification.

Results

The neurological examination could not be performed for ten patients at admission. Postoperatively, there was a neurological deficit associated with 26 osteoligamentary lesions (23 lesions of the lumbosacral trunk, 14 lesions of the S1 spinal nerve, 3 lesions of the pudendal nerve, 12 lesions of the superior gluteal nerve, and 10 lesions of the femoral nerve). Patients with neurological involvement had experienced more severe trauma. The iliosacral screw was partially extra-osseous in thirteen cases, with an associated iatrogenic neurological deficit in seven. At mean follow-up of 20 months (range 4-50) there persisted ten major sequelae including eight cases of hallux extensor deficit.

Discussion

Neurological involvement is underestimated during the acute phase of trauma. After recovery, only the manifestations of major injuries persist. The prognosis is poor in the event of a stretched lumbosacral trunk or gluteal nerve due to iliosacral disjunction. Prognosis is good for nerve contusion due to sacral fracture because of early reduction. The femoral nerve is generally injured by compression due to a peri-fracture hematoma; recovery is the rule. Iliosacral screwing requires rigorous technique by a skilled and experienced surgeon.

Conclusion

About 52% of posterior osteoligamentary injuries are associated with neurological symptoms. After recovery, permanent deficit persists in 21.7%. The most common sequelae are hallux extensor and gluteus medius palsy due to stretching of the lumbosacral trunk.

Keywords: Lumbosacral plexus , pelvic injuries , iliosacral screw


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© 2004 Elsevier Masson SAS. Tous droits réservés.
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Vol 90 - N° 2

P. 122-131 - avril 2004 Retour au numéro

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