CHAPTER
Thomas A. Schildhauer
135
Management and Surgical Treatment
of Fractures of the Lumbosacral
Region and the Sacrum
INTRODUCTION
Injuries to the sacrum and lumbosacral junction have histori-
cally been a largely overlooked entity within the realm of spine
trauma. Reasons for this are multifactorial, ranging from defi-
ciencies of diagnostic modalities available to the more limited
territorial interests of surgical subspecialties and the relatively
infrequent occurrence paired with a highly pleomorphic injury
presentation.
Fractures and fracturedislocations at the lumbosacral
region comprise injuries to the L5 vertebra as well as the
sacrum and pelvic ring. The evaluation and treatment of these
injuries must therefore take into consideration a number of
factors beyond those specific to the lumbar spine or the pelvic
ring. This includes concern for the anatomic complexity, chal-
lenges associated with fixation of the sacrum and posterior
pelvic ring, and the considerable biomechanical forces acting
upon this region to achieve and maintain a normal physio-
logic relationship across the lumbosacral junction. In the past,
a possible need for comprehensive neural element decom-
pression was frequently overshadowed by concern for removal
of bone and thus iatrogenic destabilization. Historically, there
was also a paucity of implants readily applicable for lum-
bosacral stabilization. Instead, devices primarily designed for
thoracolumbar deformity surgery or for extremity trauma
found rather improvisational applications to this complex
region. Not surprisingly, many of these constructs were unable
to counteract the multidirectional instabilities, which charac-
terize so many lumbosacral fracturedislocations. In review-
ing the medical literature of past decades, there appeared to
be a somewhat resigned approach toward these challenges in
light of very unclear neurologic outcomes of sacral injury
patients. The combination of unsatisfactory stabilization
methods and uncertainty about neural injury management
commonly resulted in a nonoperative treatment approach
along with need for long-term patient immobilization,
acceptance of residual sacral deformity, chronic pain, and
either unchanged or only mildly improved neurologic symp-
toms. Advances in imaging as well as operative stabilization
1460
LWBK836_Ch135_p1460-1473.indd 1460
Carlo Bellabarba
M.L. Chip Routt
Jens R. Chapman
techniques and implants, however, have opened the door for
a more standardized and biomechanically advantageous oper-
ative approach for patients afflicted with these potentially dev-
astating injuries.
Sacral fractures with functional instability of the lum-
bosacral junction occur commonly in two variants. In the first
scenario, a unilateral vertical sacral fracture, which constitutes
the posterior component of a pelvic ring injury, extends ros-
trally into or medial to the S1 superior facet, therefore disar-
ticulating the L5-S1 facet from the stable sacral fracture frag-
ment. In the second circumstance, a multiplanar sacral
fracture composed of bilateral, often transforaminal, longitu-
dinal fractures, and a transverse sacral fracture component
separates the upper central sacrum and remainder of the
spine from the peripheral sacrum and attached pelvis. The
end result of this fracture pattern and its variants is dissocia-
tion of the lumbar spine from the pelvic ring and functional
lumbosacral instability. These injuries are usually the result of
high-energy trauma, but may also occur with low-energy
mechanisms or insufficiency fractures in osteoporotic bone.
They are frequently associated with neurologic deficits rang-
ing from lower extremity monoradiculopathies to complete
cauda equina deficits. Spinal canal or neuroforaminal com-
pression may be severe due to displacement of major fracture
fragments and the presence of loose bony fragments within
the spinal canal and neuroforamina. Depending upon the
onset of neural element compression, deficits of the lum-
bosacral or sacral plexus may occur acutely or in subacute
manifestation. From a structural perspective, these fractures
may also be associated with major pelvic ring disruption and
multidirectional instabilities. In addition to structural and
neurologic perspectives, general patient physiology and integ-
rity of the very thin posterior integument have to be pondered
prior to arriving at any definitive treatment recommendation.
Consequently, therefore, treatment of sacral injuries ideally is
conducted with a symbiotic utilization of conventional con-
cepts of spinal and pelvic surgery. In the following a rational
approach toward assessment and decision making combining
elements of traumatology and spine surgery is offered.
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 Chapter 135 Management and Surgical Treatment of Fractures of the Lumbosacral Region and the Sacrum
SURGICAL ANATOMY
The sacrum forms the interconnection between the spinal col-
umn and the posterior pelvic ring based on well-developed
ligamentous connections and an intricate osseous architecture.
Its integrity assures a physiologically functional lumbopelvic
alignment. The kyphotic sagittal sacral shape provides the basis
for physiologic lumbar lordosis with a 45 slope on average of
the S1 superior end plate with respect to the horizontal plane
(see Fig. 135.1). With its central location of this anatomic and
biomechanical transition zone, the angles of lumbar lordosis
and sacral inclination as well as integrity of the lumbosacral
facet joints are critical in determining the amount of shear
force acting upon the lumbosacral junction.11
Knowledge of the anatomy of the posterior elements of the
lower lumbar spine and of the ilia is essential for accurate pedi-
cle and iliac screw placement in lumbopelvic fixation tech-
niques. The typical medial angulation of the pedicle axis
increases from the rostral to the caudal lumbar vertebra,
increasing from approximately 15 at L3 to more than 20 at
L5. The average minimal pedicle diameter usually measures
8.5 mm at L3 compared with 10 mm at L5. There are usually
four large ventral neuroforamina at the junction of the sacral
body to the sacral ala and four associated smaller dorsal foram-
inae.11 In 10% to 15% of patients consideration for transitional
vertebra formation, either in form of lumbarization of the
upper sacral segment, or with assimilation of the caudal most
lumbar segment (sacralization) may be associated with altered
bony anatomy and anomalous level counts. Incomplete assimi-
lations, such as large L5 transverse processes may distort radio-
graphic landmarks further. The ilium, which articulates bilater-
ally with the lateral portions of S1, S2, and partially S3, provides
a continuous bony canal that extends between the posterior
superior iliac spine (PSIS) and the anterior inferior iliac spine
(AIIS).
Figure 135.1. (A and B) Sacral anatomy. The sacrum forms the
foundation for the spinal column. Its inclination and balanced com-
position have profound impact on alignment and force vectors of the
spinal column.
LWBK836_Ch135_p1460-1473.indd 1461
1461
Although a healthy sacrum provides excellent protection to
the neural elements crossing through and around it, disruption
of the bony sacrum can lead to a perplexing variety of injury
patterns. Understanding neural anatomy in its spatial relations
to its surrounding bony elements is a prerequisite to injury
assessment and surgical management. The sacral spinal canal
changes in cross-section from a capacious triangular shape at
the S1 segment to a flat and narrow structure at the lower sacral
segments. The lumbosacral plexus, with its L4, L5, and S1 roots
mainly provides lower extremity motor and sensory function,
whereas the sacral plexus (with its S2-5 roots) controls bowel
and bladder function, contributes to sexual function, and sup-
plies pudendal sensation.7,8 Sacral roots are encased by the
bony sacrum itself without the benefit of ligamentous cushion-
ing, whereas the L5 root shoulders the sacral ala in an oblique
trajectory from its emergence through the L5/S1 foramen
toward its lateral ventral surface. The cerebrospinal fluid-
containing dural sac usually ends at the S2 segment.
Sacral motor roots emerge through the ventral foramina to
their target organs. A relatively narrow channel is available for
passage of the S1 roots, which occupy approximately 30 to more
than 50% of their foramina. Each lower sacral root is of pro-
gressively smaller size and occupies a proportionally smaller
space within its foramen, with the S4 root occupying one sixth
of its ventral foraminal space.18 The cutaneous posterior rami
of the sacral roots pass through the posterior sacral foramina
prior to contributing to the cluneal nerves. The ventral rami of
the S2-S5 roots, with S3 as the main neural branch of the so-
called pudendal plexus, comprise the pelvic splanchnic nerves,
which provide parasympathetic control to the bladder and the
rectum. Sympathetic input to the inferior hypogastric plexus is
mainly derived from the sympathetic ganglia that are located
on the anterolateral aspect of the L5 and S1 vertebral bodies
and which run caudally along the ventral surface of the sacrum
just medial to the ventral S2-S4 foramina.
PATIENT EVALUATION AND
DIAGNOSTIC APPROACHES (Table 135.1)
CLINICAL EXAMINATION
As in any systematic patient evaluation, a patient history is the
desirable starting point. Lumbosacral fracturedislocations and
fractures at the lumbosacral junction with functional instability
result from high-energy trauma as in motor vehicle or motor-
cycle accidents, falls from a height, or industrial accidents with
crushing mechanism (see Fig. 135.2). In these injuries, the spi-
nal column typically creates a flexion or extension moment
arm on the posterior pelvic ring, often with associated axial
loading vector added. In contrast, complex insufficiency frac-
tures of the sacrum may occur in patients suffering from
osteopenic bone disorders as a result of low-impact or chronic
forces, or in presence of lumbosacral spinal instrumentation.
Physical examination follows the advanced trauma life sup-
port (ATLS) protocol with recording of vital signs and cogni-
tive status. During the initial sideways turning of patient with
formal logrolling allows for inspection and palpation of the
posterior integument. Sentinel examination findings include
tenderness, swelling, ballottable fluid, overt soft tissue disrup-
tion, crepitus, and atypical bony prominences or step-offs (see
Fig. 135.2). Formal neurologic function testing is preferably
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 1462 Section XII Trauma
TABLE 135.1 Evaluation Checklists
General Evaluation Checklist
Hemodynamic stability
Neurocognitive status
Pelvic ring disruption
Obvious signs of SCI
Dorsal soft tissue injury
Posterior pelvic ring/lower lumbar disruption
Specific Evaluation Checklist
CT pelvis with sagittal/coronal reformats
CT L-spine with reformats
Dedicated XRs/composite images: inlet/outlet/iliac oblique/
obturator oblique/sacrum lateral
Focused examination: palpation/mechanical stability/
neurologic status/anal sphincter (vaginal examination)
Urogenital pathway disruption
(Electrodiagnostic assessment)
Note: These checklists are provided as a general reference tool
only and do not attempt to identify specific diagnostic/treatment
pathways. It is incumbent upon the specific treating provider to
assess and treat a patient to the best of their knowledge under
recognition of the circumstances at hand.
CT, computed tomography; SCI, spinal cord injury.
performed and documented according to the principles sug-
gested by the American Spinal Injury Association (ASIA)
group.1 This includes rectal examination with specific assess-
ment of motor, reflex, and sensory components of the lum-
bosacral and sacral plexus, as well as screening for overt or
occult blood in meatus, rectal vault, and (in females) the vagi-
nal vault.
Figure 135.2. Soft tissue bruising and deglovement (Morel
Lavalle lesion). Systematic evaluation of patients with sacral fracture
is essential to assess overall injury severity and heavily influences treat-
ment decisions. Dorsal soft tissue contusion, ballotable fluid collec-
tion, and crepitus are all important clinical findings reflective of
injury severity.
LWBK836_Ch135_p1460-1473.indd 1462
IMAGING TECHNIQUES
Initial evaluation of trauma patients includes an anteroposte-
rior (AP) pelvic radiograph according to ATLS standard proto-
cols. This view may be helpful in identifying major fractures
and fracturedislocations at the lumbosacral junction but offers
a limited view of the sacrum due to its normal sagittal plane
inclination. Pelvic inlet and outlet views offer a meaningful
structural assessment of the posterior pelvic ring in case of sus-
pected posterior pelvic ring injury. Presence of any fracture
lines on any of these three radiographs, even as trivial as an L5
transverse process fracture should be taken seriously as a pos-
sible indicator of greater underlying trauma to this usually well-
protected area. Difficulty of visualizing the sacrum on an AP
pelvis view (paradoxical inlet) may imply presence of a com-
plex multiplanar sacral fracture (Figs. 135.3A and B). A lateral
radiograph of the sacrum (Fig. 135.3C) can be used as a rela-
tively simple method to identify transverse sacral fractures and
fracturedislocations otherwise not visible on the three stan-
dard pelvis plain radiographs.
The shortcomings of plain pelvic radiographs in identifying
lumbosacral injuries have been reported repeatedly.3,10
Computed tomography (CT), increasingly deployed as a rapid
acquisition helical torso scan for routine assessment of high-
grade trauma, has commonly supplanted plain radiographs as
the preferred method of imaging acute pelvic ring injuries.
Review of sagittal and coronal reformatted CT scan images adds
important elements to the understanding of the injury distribu-
tion. Three-dimensional reformats as a routine measure can be
visually compelling but have not been shown to be of general
relevance. Key parameters for sacral radiographic assessment
have been identified to consist of the following measures: sacral
inclination, alar vertical and sagittal distraction, midsagittal and
midcoronal spinal canal occlusion, as well as foraminal
stenosis.
Magnetic resonance imaging (MRI) plays secondary role in
acute lumbosacral injury assessment. However, presence of
unclear neurologic deficits or discrepancies of skeletal and
neurologic level of injury may merit further investigation with
MRI to identify occult spinal pathology, the level of spinal cord
injury, or the presence of spinal canal hematoma. Also, MRI
neurography sequences may aid in visualization of acute or
chronic lumbosacral plexus injuries. MRI has been recom-
mended for detection of insufficiency-type fractures. As an
alternative to MRI, technetium-99 bone scans have remained a
mainstay for the diagnosis of occult and pathologic fractures.
To the present date, the relative sensitivity and specificity of
either diagnostic modality for the assessment of insufficiency
fractures remains in dispute.
Other radiographic examinations to consider in lumbosacral
fracturedislocations and pelvic ring fractures with associated
spinal instability are plain AP radiographs with bladder contrast
to identify associated bladder and urethral disruptions (retro-
grade cystourethrogram), as well as a hypaque enema in case
an associated rectal injury is suspected.2
ELECTROPHYSIOLOGICAL EXAMINATION
Aside from conventional electromyography (EMG) and soma-
tosensory evoked potentials (SSEP) for assessment of the L5
and S1 roots, pudendal SSEP and anal sphincter EMG allow for
evaluation of the sacral roots caudal to the S1 level. This can
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 Chapter 135 Management and Surgical Treatment of Fractures of the Lumbosacral Region and the Sacrum 1463

Figure 135.3. (A) Pseudoinlet view on anteroposterior

(AP) pelvis radiograph. Note the visualization of the S1 seg-
ment in an axial plane on this level AP pelvis radiograph.
This image is nonphysiologic and only possible if the upper
sacrum has been disconnected from the remainder of the
pelvic ring. (B) Straight lateral cross table pelvis radio-
graphs are a simple and often overlooked modality to assess
for sagittal plane fracture displacement. (C) The sagittally
reformatted computed tomography of the patient depicted
under A and B shows a severely displaced fracture with
C
kyphotic fracture dislocation between S2 and S3 segments.

be useful in the diagnosis and management of cognitively CLASSIFICATIONS

impaired patients with lumbosacral fractures and for intraop-
erative monitoring.4 Furthermore, electrophysiological
recordings, in concert with the clinical examination, allow a
prognostic assessment of functional outcome and the objective
assessment of neurologic recovery. Electrodiagnostic evalua-
tion can be also used to identify upper motor neuron lesions
or spinal cord injury concurrent with sacral trauma or in dif-
ferentiating neurologic from visceral causes of bowel and blad-
der dysfunction. Urodynamic evaluations, including postvoid
residuals and cystometry, have been recommended for long-
term evaluation of patients with incomplete neurologic injury
and can help assess sacral root recovery. For patients with more
involved questions surrounding bladder function cystometry
can be performed in conjunction with bladder sphincter EMG.
Possible abnormal findings on sphincter EMG may include
detrusor areflexia, uninhibited sphincter relaxation, or out-
right denervation.7
Lumbosacral fracturedislocations and fractures at the lum-
bosacral junction with functional instability are most often
referred to in separate and dedicated sacral and pelvic ring
fracture classifications. In more descriptive terms, these are
either longitudinal sacral fractures, which extend into or medial
to the L5/S1 facet joint or bilateral vertical sacral fractures con-
nected by a transverse fracture line. This fracture pattern results
in a U-type fracture, or, if the vertical fracture lines extend and
exit caudal to the sacroiliac joint, in an H-type (bilateral pelvic
instability) and Y-type (unilateral pelvic instability) fracture. H-
and Y-type fracture patterns result in a disrupted posterior pel-
vic ring and an unstable pelvis. They are typically associated
with an anterior pelvic ring injury as well. Less commonly
encountered fracture patterns include L, T, and lambda types.
These informal classifications continue to provide a simple
but not clearly delineated conversation basis for care of these

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 1464 Section XII Trauma
fractures but are not suitable as a foundation for more formal
analysis of any sort.13
The Arbeitsgemeinschaft fr Osteosynthesefragen and
the Orthopaedic Trauma Association (AO/OTA) have pro-
vided the probably most encompassing fracture classification
system to date, which is the most commonly used fracture
classification in orthopedic and trauma surgery, describes ver-
tical sacral fractures as 61-C1.3, C2.3, C3.2, and C3.3 fractures
depending on overall pelvic ring stability in the horizontal
and vertical planes.6,12 The Denis classification of sacral frac-
tures correlates anatomic factors with neurologic injury risk
in a progressive severity scale (see Fig. 135.4).5 It differenti-
ates between alar fractures (zone I; 5.9% incidence of pre-
dominately L5 root injuries), transforaminal fractures (zone
II; 28.4% incidence of mainly L5/S1 root injuries), and cen-
tral fractures, which include any fracture extending into the
spinal canal (zone III; 56.7% incidence of neurologic injury
mostly consisting of sacral plexus dysfunction). However, this
classification system fails to take injury displacement or lum-
bosacral stability into account. Isler9 provided the most
insightful lumbosacral injury classification to date. He differ-
entiated vertical sacral fractures, which extend lateral to,
through, or medial to the L5-S1 facet. Fractures that involve
or extend medial to the L5/S1 facet result in lumbosacral
instability.
U- and H-type fracturedislocations at the lumbosacral
junction are summarized in AO/OTA type 61-C3.3 pelvic
fractures. According to the Denis classification, these fracture
dislocations are zone III injuries, since they all involve the sacral
canal. Unfortunately, these classifications do not take into
II
I III
Figure 135.4. Classification according to Denis et al.5 This simple
three-zone classification is grouped according to the most medial
excursion of the fracture. Zone I injuries are basically posterior pelvic
ring injuries, zone II injuries are transforaminal and have an increased
lumbosacral plexus injury risk, and zone III injuries extend into the
spinal canal and have been reported to have a risk of bowel and
bladder compromise in more than 50% of patients.
LWBK836_Ch135_p1460-1473.indd 1464
account the mechanism of injury, nor the type, magnitude, or
direction of displacement. Roy-Camille et al14 have added a
helpful subclassification system of Denis zone III injuries and
lumbosacral fracturedislocations, describing three types of
transverse sacral fractures that are classified according to injury
severity and presumed likelihood of neurologic injury. In this
subclassification, type 1 injuries consist of a simple flexion
deformity of the sacrum and are thought to be the result of
axial loading injury with the spine in flexion; type 2 injuries are
characterized by flexion and posterior translation of the upper
sacrum, also presumably caused by axial loading injury with a
flexed spine; and type 3 injuries demonstrate complete ante-
rior translation of the upper sacrum, typically caused by an
axial loading force in extension. A type 4 injury was later added
by Strange-Vognsen and Lebech,21 consisting of a segmental
comminuted S1 vertebral body caused by axial implosion of the
lumbar spine into the upper sacrum. These injury types are
caused by indirect force acting upon the lumbosacral junction.
A direct impact force as in impalement or gunshot injuries can
result in a completely disrupted sacrum with lumbosacral
instability. These injuries may be classified as type 5 injuries
(Fig. 135.5). Unfortunately, the level of the transverse compo-
nent of the sacral body fracture is not specified by this, or most
other sacral classification systems. The added information of
the sacral segment involved (high equaling S1-S2, low equal-
ing S3-5 and coccyx) may add to the understanding of the type
of neurologic injury commonly involved in these complex inju-
ries. Isolated low injuries can also usually be considered as
biomechanically stable.20,22
The high likelihood and variable grade of neurologic
impairment in lumbosacral fractures are not accounted for in
any of the above classification systems. In light of an absence of
any spinal cord injury classification system (such as the one
proposed by the ASIA group) addressing the sacral plexus
injuries, Gibbons suggested a differentiation based on motor,
sensory, and bowel/bladder control. He subdivided patients
into those having no injury, lower extremity paresthesias only,
lower extremity motor deficit with intact bowel and bladder
function, or impaired bowel and/or bladder control.7 This
classification systemwhile simpleunfortunately does not
address incomplete injuries or takes sexual function into con-
sideration. Despite its imperfections it remains the most useful
tool to date to describe neurologic injury in a sacral fracture
patient.
BIOMECHANICS
Lumbosacral fracturedislocations are characterized by a mul-
tidirectional instability, although they mainly fail acutely as well
as secondarily in flexion/extension, anterior translation, and
vertical shortening, as described in Roy-Camille fracture types
1, 2, and 3.17 The center of rotation for the flexion deformity
(being the major deforming force) is located in the anterior
part of the S1/S2 vertebral bodies, which is important to be
realized for the understanding of failure modes of various
operative stabilization techniques. In addition, the forces gen-
erated by the upper body are transferred across the fracture
site toward the pelvic wings and lower extremities. Based on
largely anecdotal experiences from oncologic surgery it can
usually be expected that an intact S1 segment with intact sur-
rounding ligamentous structures is capable of adequate stress
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 Chapter 135 Management and Surgical Treatment of Fractures of the Lumbosacral Region and the Sacrum
Figure 135.5. The Roy-Camille
subclassification of zone III injuries
allows for some further differentiation
of injury severity by description of
injury type and displacement.14 Type 1
injuries have a simple compressive flex-
ion deformity, type 2 injuries are flexed
and translated, and type 3 injuries are
dislocated and extended. Type 4 inju-
ries were added later by Strange-
Vognsen and Lebech21 and are
segmentally comminuted; type 5
injures are segmental fractures
described by Schildhauer et al.15
transfer of the trunk to the lower extremities.8 An operative
fixation of such fractures compromising this area, therefore,
needs to counteract all these multiple directed forces and
requires a bony anchor stable enough to allow immediate
patient mobilization and early full weight bearing. Within the
sacrum itself, biomechanically effective screw fixation is usually
limited to the S1 segment. The sacrum from S2 through S4 and
the sacral alae allow for very limited fixation due to thin sur-
rounding osseous shell referred to as compacta and poor can-
cellous bone core even in patients with healthy bone metabolism.
Unfortunately, the S1 segment itself is commonly frequently
fractured and subject to toggle loosening even with perfect
bicortical screw placement due to the very high biomechanical
forces acting upon it.
The considerable flexion forces acting upon a sacral frac-
ture can be most reliably counteracted mechanically by a
strong vertically oriented fixation, as offered by lumbopelvic
stabilization techniques. This stabilization technique was pio-
neered in spinal deformity surgery in form of the Galveston-
technique with bent rods pushed into the iliac intertable
space. Screw fixation in the intact pedicle of L4 or L5 as well as
long screws across the ilium between the PSIS and the AIIS
provides a biomechanically much stronger and far more versa-
tile anchor between cortical bone densities. In such a con-
struct, the fixed-angle connection between the longitudinal
connecting rods and the anchor screws counteract the flexion
deformity. The long ilium screw provides a strong anchor away
from the center of rotation for flexion.17 Thus the weight and
moment arm of the upper body are directly transferred to the
pelvic ring bypassing the fracture through the lumbopelvic
implants. However, a two-point-fixation between the L5 pedicle
and the ilium alone could allow for splaying of the fracture
site. Therefore, such a fixation assembly may require addi-
tional horizontal fixation, for instance, in the form of bilateral
iliosacral screws or a crossconnector system connecting the
bilateral longitudinal connecting rods. A third point of vertical
fixation, for example, in the pedicle of L4 may achieve the
same goal.
Other stabilization techniques present with a variety of
mechanical shortcomings in comparison, however, may be indi-
cated for other reasons, such as soft tissue impairment. Local
LWBK836_Ch135_p1460-1473.indd 1465
1465
plate osteosynthesis techniques with small fragment plates
across the sacrum are anchored only in sacral cancellous bone
and provide weak fracture stabilization in highly unstable
situations as well as in insufficiency fractures with osteoporotic
bone. Bridging plate osteosynthesis with a horizontally ori-
ented plate across the bilateral PSISs applies mainly a compres-
sion force on the posterior pelvic ring and poorly withstands
the high flexion forces caused by upper body motion and
weight. Bilateral iliosacral screw fixation techniques, as they
are described for Roy-Camille type 1 lumbosacral fractures
without neurologic symptoms, provide mainly a horizontal
compression force on the posterior pelvic ring.12,13 In addi-
tion, the horizontally placed screws within the S1 vertebral
body are positioned close to the center of rotation for second-
ary fracture displacement in a flexion direction. External fixa-
tion techniques for injuries involving the posterior pelvic ring
are commonly insufficient for achieving meaningful neutral-
ization of this anatomy and therefore mainly serve in an emer-
gent splinting technique or in an adjunct capacity to posterior
internal fixation techniques.
TREATMENT OPTIONS (Table 135.2)
GENERAL CONSIDERATIONS
Treatment options must be tailored to two distinct patient
groups. Priorities and treatment challenges differ considerably
between patients with high-energy injuries, patients present
either with vertical sacral fractures and involvement of the L5/
S1 facet joint or with acute lumbosacral fracturedislocations as
compared to patients with a chronic metabolic bone disorder
who ultimately will suffer from a sacral insufficiency U- or
H-type fracturedislocation.
For acutely traumatized patients, emergent resuscitation is
the indisputable initial priority. The Advanced Trauma Live
Support (ATLS) algorithm provides a well-tested and reproduc-
ible blue print. Patients with lumbosacral fracturedislocations
and associated AP compression-type pelvic ring injuries or
patients with vertically unstable sacral fractures with involve-
ment of the lumbosacral junction may benefit from urgent
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 1466 Section XII Trauma

TABLE 135.2 Decision-Making and Checklists

General Decision-Making Checklist
Primarily bony injury/ligamentous injury/mixed
Boney displacement?
Stability prediction: stable/unstable/unclear
Neurologic status: intact/incomplete/complete/unclear
Dorsal soft tissues: Intact/contused degloved/open
General Treatment Pathways
Acute
Hemodynamically unstable?
Open book pelvissheet/C-clamp/external fixateur to close pelvic ring  resuscitation  angiography (embolization)
Lumbosacral dislocation: consider for early open reduction internal fixation
Vertically displaced hemipelvis: closed reduction with skeletal traction, external fixateur
Open sacral fractures: consider colostomy, Ob-Gyn consult, throughandthrough washout, temporary anterior external fixation or
minimally invasive internal fixation, antibiotic bead spacers, planned second washout, definitive stabilization when circumstances permit,
appropriate IV antibiotics
Nonoperative (simple)
Closed single-system injury
Stable injury pattern
Neurologically intact
Braceable (body habitus/soft tissues)
Pain after mobilization
Nonoperative (complex)
Complex primarily bony injury
No major trunk trauma
Intact soft tissue continuity
Suitable for
chemical anticoagulation
skeletal traction or restrictive bracing (pantaloon, hip spica, etc.)
Surgical Treatment Options
Laminotomy/foraminotomy/ventral disimpaction  ORIF)
Anterior ring fixation: plate, screws, temporary external fixateur
Percutaneous posterior fixation: SI screw (single, double, bilateral, compression, static)
Open reduction, lumbopelvic fixation (SI arthrodesis)
Classification Based on General Treatment Algorithm
Isler I: nonoperative simple or complex, percutaneous SI-screws
Isler II: nonoperative complex, or segmental lumbopelvic fixation
Isler III: likely segmental lumbopelvic fixation  SI screws
Denis zone I: nonoperative (simple/complex) or SI screws
Denis zone II: nonoperative (complex), SI screws*/lumbopelvic fixation  decompression for neural compromise
Denis III: nonoperative (complex), SI screws (minimally displaced, neuro intact), segmental lumbopelvic fixation  SI screw fixation 
decompression for neural compromise

*Less preferable for vertically displaced subtype.

Note: These checklists are provided as a general reference tool only and do not attempt to identify specific diagnostic/treatment pathways.
It is incumbent upon the specific treating provider to assess and treat a patient to the best of their knowledge under recognition of the
circumstances at hand.
ORIF, open reduction internal fixation; SI, sacroiliac.

intervention during the intervention phase. Application of a
circumferential pelvic antishock sheet or anterior external fix-
ator can reduce the volume of the lesser pelvic cavity and pro-
vide provisional pelvic stability as well as aid resuscitation efforts
by containing blood loss in the retroperitoneal peripelvic space
(see Fig. 135.6).19 Detailed examination of the patient and doc-
umentation is an essential component of the secondary survey
since cauda equina deficits, presence of an open or highly dis-
placed fracture, and severe soft tissue injury are important fac-
tors in the decision-making process as to influencing decisions
toward emergent or urgent intervention.
The chronic nature of pathologic insufficiency fractures
allows a more deliberate approach to formulating a treatment
plan. It requires added emphasis on addressing any causative
or preexisting pathologic condition. Again patients with a pre-
cipitous onset of a dense cauda equina deficit may benefit from
urgent surgical intervention.10
Goals of treatment include union of the fracture in physio-
logic alignment while optimizing the potential for recovery of
neurologic deficits and minimizing potential complications
associated with prolonged recumbence. Pursuit of these goals
may require any combination of open fracture reduction,
neural decompression, fracture stabilization with instrumenta-
tion, and possibly early mobilization and weight bearing.
Conversely, nonoperative treatment may be selected as the
most favorable method, as long as an acceptable alignment can

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 Chapter 135 Management and Surgical Treatment of Fractures of the Lumbosacral Region and the Sacrum
C the pelvic ring usually has a supplemental temporizing role at best but
be achieved and long-term immobilization appears physiologi-
cally tolerable.6
Neurologic improvement after sacral fracturedislocations
has been reported to approach 80%, regardless of operative or
nonoperative treatment. In one of the rare comparison studies,
a 73% incidence of neurologic improvement with nonopera-
tive care in patients with sacral fractures and neurologic defi-
cits, compared with an 87% incidence of improvement with
surgical care.7,15 However, a wide variability in injury types, sur-
gical treatments, and inconsistent reporting of improvement
and outcome criteria has lessened the significance and reliabil-
ity of reported recovery rates. Several series with small cohorts
have described better neurologic outcome with surgical treat-
ment, particularly in patients with bowel and bladder impair-
ment. These studies, however, have significant shortcomings.
Aside from small cohort sizes and selection bias, type and sever-
ity of neural encroachment in nonoperatively treated patients
LWBK836_Ch135_p1460-1473.indd 1467
1467
Figure 135.6. Temporary fixation in polytrauma. This 34-year-old
woman was severely injured in a high-speed car crash. She sustained
bilateral femur fractures, a right zone II, left zone sacral fracture,
along with a number of other abdominal injuries. (A and B) She
received closed reduction of the posterior pelvic ring in the operating
room before undergoing intramedullary rod fixation of her femur
fractures and later received bilateral sacroiliac screw fixation of her
posterior pelvic ring and sacrum fractures. (C) External fixation for
serves a valuable role as reduction aid of the pelvic ring.
was not reported. Persistent pelvic instability was not consid-
ered. Surgical technique and timing of intervention were highly
variable and frequently not outlined. Adequacy of decompres-
sion and quality of reduction were not evaluated with postop-
erative imaging, and the type of pelvic stabilization was not con-
sistently described. Furthermore, widely heterogeneous Denis
zones I to III injuries were often collectively evaluated as a sin-
gle group.
Adding to the complexity of predicting neural recovery,
patients with predominantly neuropraxic-type single root
lesions without significant bony encroachment of neural ele-
ments can be expected to experience spontaneous neurologic
improvement over time. Conversely, surgical intervention for
neurologic improvement may be futile in patients with trau-
matically transected sacral roots or in patients whose neural ele-
ments have been exposed to significant traction or shear injury.
Schildhauer et al15 identified 18 patients with high-grade sacral
8/25/11 10:17:23 PM
 1468 Section XII Trauma
fractures and impaired bowel and bladder control who had
undergone comprehensive neural element decompression and
structural realignment and stabilization with segmental lum-
bopelvic fixation. The authors noted an overall neurologic
improvement rate of 83%. The recovery rate was significantly
higher for patients with incomplete lumbosacral injury com-
pared to patients with an established complete injury. Also,
complete recovery of cauda equina function was more likely in
patients with continuity of all sacral roots (86% vs. 0%) and
incomplete deficits (100% vs. 20%).
Because of the violent nature of sacral trauma with substan-
tial initial fracture displacement and resulting large zone of
injury, surgical root end-to-end repair or reconstruction with
interposition graft is rarely feasible. In general, traction injuries
to peripheral nerves have a worse prognosis than do compres-
sion injuries. Traction injuries to the lumbosacral plexus and
sacral roots in the presence of trauma generally occur in con-
junction with significant posterior pelvic ring disruption.
Surgical intervention under such circumstances is primarily
aimed at establishing a stable fracture reduction for structural
purposes, with the hope for neurologic recovery being a more
secondary goal. Unfortunately, current neuroimaging and elec-
trophysiological tests do not allow for conclusive preoperative
identification of sacral root transection or avulsion. Preoperative
determination of the type of neurologic injury remains a mat-
ter of clinical judgment paired with consideration of available
studies. An important argument in favor of aggressive interven-
tion to maximize patient outcome can be made by the observa-
tion that restoration of even unilateral sacral root function may
lead to a return of voluntary continence.
Timing of surgical intervention should be determined
according to the patients traumatic and medical comorbidities
with an effort made at balancing the overall injury burden and
expected physiologic tolerances.2 Although patients are
thought to benefit from the concept of early mobilization/
weight bearing and decompression of compromised neural
elements provided by early surgical intervention, these benefits
must be weighed against the considerable risk factors associ-
ated with surgery. Emergent operative intervention is clearly
recommended for patients with open fractures, lumbodorsal
presacral soft tissue compromise caused by displaced fracture
fragments, and patients with a deteriorating neurologic exami-
nation. Late surgical intervention, arbitrarily defined as taking
place later than 14 days following injury, seems to result in
decreased neurologic recovery and increased occurrence of
permanent radicular pain and dysesthesia in presence of con-
current bony encroachment and concordant neurologic defi-
cit. Other than in cases requiring emergent intervention, the
timing of surgical intervention should be optimized to the
patients physiologic status and is preferably performed between
48 hours and 2 weeks after injury.
NONOPERATIVE TREATMENT
There are two major outcomes that can be expected from non-
operative treatment of sacral fractures in a majority of cases:
(1) fracture union with potential for tolerable bony deformity
and (2) unchanged or partially improved neurologic deficits.
Analysis of long-term functional outcomes of sacral fractures,
though, has shown a high frequency of fair and poor results,
which are thought to be unrelated to the quality of reduction
and are largely due to pain and persistent neurologic deficits.
LWBK836_Ch135_p1460-1473.indd 1468
In general terms, nonsurgical care of sacral fractures can be
grouped into simple and complex care categories. The prior
usually consists of some form of protected mobilization with or
without brace, the other requires some degree of bed rest with
attempt at postural reduction and injury healing while address-
ing cardiopulmonary, thromboembolic, and integumentary con-
cerns associated with prolonged recumbence. Nonoperative
treatment usually attempts to minimize bed rest by providing
some meaningful external immobilization with protected weight
bearing of the injured side in unilateral sacral fractures. More
complex nonsurgical treatment, however, includes skeletal trac-
tion, suspension slings, and external immobilization afforded by
a brace or spica cast. Of course, this treatment category requires
application of comprehensive thromboembolic and respiratory
preventative measures over a period of typically 3 to 12 weeks
depending upon the type of injury encountered. Because of the
complexities and expenses of prolonged recumbent nonsurgical
care most nonsurgical care is rendered in the form of a short
period of bed rest followed by early mobilization with or without
an orthosis. This scenario usually has been recommended in
acute trauma patients with intact neurologic function and mini-
mally displaced or angulated fractures without major ligamen-
tous component and with predominately single-system injuries.
A reliable indicator of adequacy of this treatment is recurrence
of increased lumbosacral pain with mobilization. Usually patients
with sufficient pelvic stability will not complain of significant
increase in pain with mobilization. Obviously repeat radiographs
with postmobilization images, including lateral sacral images are
helpful in assessing maintenance of an acceptable alignment.
SURGICAL TREATMENT
Historically, surgical treatment consisted of sacral laminectomy
and neural/nerve root decompression with and without
fracture reduction procedures. Challenges of surgical care
commonly revolved around blood loss, exposure-related soft
tissue compromise, and traditionally inadequate fixation options
for the sacrum, due to factors such as severe comminution,
regional osteopenia of the sacral alae, and instrumentation not
well suited to this region. Other factors include obesity, atypical
anatomy, and common comorbidities typically found in a multi-
ply injured patient. These factors may have influenced general
preference for nonoperative care over many years.
The evolution of pelvic osteosynthesis techniques, with con-
cepts such as transiliac bolts, bridging plate fixation, local plat-
ing, and iliosacral screw placement for posterior pelvic ring insta-
bilities lead to increasing reports on their use in treating
lumbosacral fractures (see Fig. 135.7).12 However, these fracture
stabilization techniques did not address the combined nature of
injuries affecting both spinal column and pelvic ring and, there-
fore, were not stable enough to prevent secondary loss of reduc-
tion or to allow early mobilization with early weight bearing. An
approach addressing spinal and posterior pelvic ring injury using
lumbosacral fixation techniques allows a more selective treat-
ment approach, including neural decompression, fracture
reduction, and stable lumbopelvic fracture fixation with the
ready potential for early mobilization with full weight bearing.
Some degree of neural element decompression can usually
be accomplished by indirect fracture reduction, provided inter-
vention is applied before the fracture hematoma fully congeals
and fibrous contractions take place. Direct neural decompres-
sion can be performed through anterior or posterior approaches.
8/25/11 10:17:24 PM
 Chapter 135 Management and Surgical Treatment of Fractures of the Lumbosacral Region and the Sacrum 1469

D E

Figure 135.7. This 28-year-old woman was injured in a motorcycle crash and sustained a Denis III, Roy-
Camille type 1 injury with American Spinal Injury Association grade E, Motor score of 100 neurologic status.
Despite encroachment of the right S1 foramen by 50% she had no radicular symptoms on either leg (A and
B). She received best possible closed reduction and percutaneous fixation with bilateral sacroiliac screws
(C and D). She was mobilized with a reclining back wheelchair for 6 weeks and placed on toe-touch weight
bearing. She maintained an acceptable alignment and achieved solid fracture healing. (E) Closed reduction
and percutaneous reduction remain a very appealing option for surgical stabilization of sacral fractures but is
limited in reduction capacity.

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 1470 Section XII Trauma

The anterior approach is rarely indicated with exception of ante-
rior sacral ala fragments impinging on the L5 nerve root. In
these rare circumstances, an ilioinguinal approach, described as
Olerud window may allow for repositioning of the elevated alar
fragment and direct decompression of the L5 root. Otherwise,
neural decompression for the entire sacral plexus can be
achieved through a posterior midline approach. Single bony
fragments that encroach on a nerve root can be removed by
focal laminotomy. For complex sacral fractures with complex dis-
ruption of the sacral spinal canal, a comprehensive sacral lamine-
ctomy is necessary. Ventral canal decompression can be accom-
plished by freeing the sacral roots in the injury zone from their
epidural venous cuff and then proceeding with ventral disimpac-
tion or direct removal of protruding bone fragments. Ventral
disimpaction may also be facilitated by placing an elevator into
the fracture as a lever or by using an impactor to directly manipu-
late the dorsal wall of the injured sacral vertebral bodies and thus
correct the neural impingement. It is helpful to perform sacral
decompression surgery under lateral C-arm control for orienta-
tion purposes and to help assess sacral alignment and confirm
decompression of the spinal canal.
In the case of associated pelvic ring involvement, it is gener-
ally preferable to stabilize the anterior pelvic ring first. Anterior
pelvic ring fixation aids in indirect reduction of the posterior
pelvic ring and provides partial pelvic stability. Anterior pelvic
stabilization may involve plating of the symphysis or antero-
grade and retrograde superior pubic ramus screw fixation.13 If
an acceptable posterior pelvic ring reduction can be achieved
in the initial treatment phase and if the first sacral vertebral
body is intact, then percutaneous iliosacral screw fixation can
be performed. This has the advantage of providing early pelvic
ring stabilization, an important factor in the initial resuscita-
tion of the patient. Iliosacral screw fixation can be augmented
with lumbopelvic fixation if there is considerable fracture insta-
bility or unfavorable biomechanical loading circumstances are
anticipated once an affected patients overall condition allows
for a more extensive open posterior pelvic ring surgery. This
surgery is carried out with the patient prone on a radiolucent
operating table through a relatively atraumatic straight midline
exposure. Prior to neural decompression, lumbopelvic fixation
is prepared with insertion of pedicle screws in L5, as well as
long (up to 130 mm) 7- or 8-mm iliac screws inserted between
the medial part of the PSIS and the AIIS. Ilium screw applica-
tion is performed under C-arm visualization, using primarily
the lateral pelvic view and the combined obturator oblique-
outlet view (see Fig. 135.8). With greater degrees of instability,
supplementary S1 pedicle screw fixation should be considered.
In highly unstable situations, lumbopelvic fixation may have to
be extended to the L4 pedicles and may have to include two
long iliac screws bilaterally. After the application of lumbopel-
vic fixation, the vertical connecting rods should be compressed
toward each other by one or two transversely placed rods for

A B

Figure 135.8. Segmental lumbopelvic fixation technique. (A) Insertion of segmental lumbopelvic fixation
can be accomplished from a straight midline incision under identification of the posterior superior iliac
spinous processes. Drilling from the posterior superior iliac spinous process to the anterior inferior iliac
spinous process in plane with the outer iliac table can allow for safe screw placement of up to 130 mm in
men and 120 mm in women. (B) Final assembly of a segmental lumbopelvic construct allows for immediate
full weight bearing without brace. For unstable sacral fractures two-point fixation above the lesion, in exam-
ple at L5, S1 (if intact)or L4 and L5is recommended to assure adequate stability. Single or double iliac
screws on either side can be chosen based on bone quality.

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 Chapter 135 Management and Surgical Treatment of Fractures of the Lumbosacral Region and the Sacrum
better overall stability and to reestablish posterior pelvic ring
alignment. Care should be taken to ensure that this horizontal
compression does not compromise the sacral neuroforamina.
Since soft tissue coverage and viability is a constant concern in
these injuries, care should be taken to ensure to avoid promi-
nence of the iliac screws in particular. It is advisable to recessing
the iliac screws by preparing a bony window at the insertion
point selected over the posterior superior iliac spinous process.
Figure 135.8 presents variations of lumbopelvic fixation
technique in an acute fracture dislocation as well as in a patho-
logic insufficiency fracture.
In unilateral sacral fractures with rostral extension into and
medial to the L5/S1 facet, the so-called triangular osteosynthe-
sis, consisting of lumbopelvic fixation between the pedicle of
L5 and the ilium associated with ipsilateral iliosacral screw fixa-
tion, has been shown to result in stable fracture fixation allow-
ing early weight bearing.16
Local bone graft from the sacral laminectomy and the medial
wall of the rostral upper end of the ilium is then applied to the
decorticated posterolateral elements of the most rostral instru-
mented lumbar vertebra to the sacral ala. The pelvis and poste-
rior ilium, however, are not included in the arthrodesis. Usually,
no formal attempt at iliosacral joint arthrodesis is made with this
technique to minimize the risk of further traumatizing the iliac
crest with decortication attempts necessary for an arthrodesis.
Segmental lumbopelvic fixation holds the potential for full
weight bearing without brace wear unless precluded by other
injuries. Elective lumbopelvic hardware removal between 6 to
12 months postoperatively has been recommended in case of
local hardware prominence or if hardware breakage, most likely
induced by micromotion across the nonfused iliosacral joints, is
a concern.16 To date, the question of adding a formal arthrode-
sis of the sacroiliac joint at the cost of longer operating time and
greater blood loss, or bridging the sacroiliac joints without a for-
mal arthrodesis at the expense of an occasional hardware break-
age and possible elective hardware removal has not been
addressed and remains a matter of individual preference.3
PEDIATRIC INJURIES
Fortunately, pediatric posterior pelvic injuries are a rare occur-
rence. Most of these fractures are treated nonoperatively. How-
ever, in case of neurologic involvement or severe disruption of
the posterior pelvic ring and lumbosacral junction, the same
measures and indications for surgery apply as in the adult
patient. Because of the age-dependant smaller scale of anat-
omy, implant dimensions may have to be adjusted accordingly.
Size-appropriate pedicle and cannulated percutaneous sacroil-
iac screws have become available. Placement of long iliac
anchoring screws following the intertable course between the
PSIS and the AIIS may not be possible due to pelvic fossa
curvature and greater bone density. Even presence of a more
modest-sized iliac screw with purchase in the iliac cortex is of
no problem in a skeletally immature population due to the
much greater bone density. Care has to be taken, however, to
avoid excessive screw penetrationespecially of the medial
kindto avoid iatrogenic injury to adjacent structures.
For skeletally immature patients with lumbopelvic instability
and subsequent internal fixation hardware removal after solid
bony healing is generally recommended to minimize risk of
bony overgrowth.
LWBK836_Ch135_p1460-1473.indd 1471
1471
COMPLICATIONS
Fractures and fracturedislocations at the lumbosacral junction
are severe injuries, which are often associated with compro-
mised soft tissue, expansile hematoma, MorelLavalle lesions,
or open wounds. Extensive surgery in this area of physiologi-
cally thin soft tissue coverage over the bony prominences of the
posterior pelvic ring may bear an increased risk of postopera-
tive infection and wound healing problems. A retrospective
analysis of patients with high-grade sacral fracturedislocations
treated with lumbopelvic stabilization techniques, revealed a
16% incidence of postoperative class 2 infections. Such patients
may require surgical wound debridement, placement of antibi-
otic beads, and adjuvant intravenous antibiotics for 6 weeks.
Supplemental nutritional support and minimization of supine
positioning should be pursued.3,24
Development of a decubitus ulcer may be related to a prom-
inent iliac screw at the PSIS. Cachexia may contribute to that
problem. Therefore, precautions, such as appropriate skin care
measures and recessed screw positioning at the PSIS are help-
ful considerations. Should hardware around the posterior pel-
vic ring become symptomatic despite best efforts, selective
hardware removal on an elective basis may be necessary after
healing of the injury site.
Seroma and pseudomeningocele formation has been
described in operatively treated high-grade sacral fracture
dislocations. Typically, this complication occurs in situations
with concurrent traumatic dural tears. Timely surgical reex-
ploration is recommended to diminish the risk of sinus tract
formation or complex infection.
Neurological deterioration following surgical treatment is a
known complication in any severe trauma to the spine. It may
also occur following sacral laminectomy, foraminotomy, indi-
rect fracture reduction, and direct removal of bony fragments
but has fortunately been an infrequent occurrence. Aside from
intraoperative manipulation of traumatically compromised
neural elements postprimary deterioration may result from
postoperative fluid collections, such as postoperative epidural
hematoma, meningocele, or infection, as well as due to loss of
fracture reduction or implant dislodgement. In general sacral
decompression surgery may indeed benefit from intraoperative
use of a C-arm as well as intraoperative EMG and SSEP moni-
toring. In case of postoperative neurological deterioration,
neuroimaging such as CT or MRI can be helpful in identifying
underlying reasons and to discuss and plan revision surgery.
Absence of posttraumatic neurologic recovery is most com-
monly due to sacral root transection. Presence of even unilat-
eral sacral root transection has been associated with meaning-
ful neurologic recovery, thus reinforcing the suggestion to
maximize chances for recovery by surgical exploration, decom-
pression where necessary, and stabilization even if in doubt.
Hardware failure may occur before fracture healing or at a
later follow-up examination. Hardware failure has been
described in up to 30% of patients. In that study, broken hard-
ware was always found after fracture healing and was related to
persistent toggle motion of the iliosacral articulation in case
there was no bridging callus formation of the posterolateral
arthrodesis mass to the ilium. Rod breakage was not associated
with clinical complaints and was identified incidentally on rou-
tine follow-up radiographs. Nevertheless, early hardware
removal after fracture healing at 6 to 12 months may be
indicated to prevent late hardware failure and to preclude
8/25/11 10:17:26 PM
 1472 Section XII Trauma

symptoms caused by prominent hardware under the skin.
Development of a fracture pseudarthrosis and premature hard-
ware failure was not described in that study.
Loss of reduction has so far not been observed with segmen-
tal lumbopelvic stabilization techniques in lumbopelvic
fracturedislocations. Malreduction, however, does occur in
these severe injuries. It may be the reason for persistent neuro-
logic symptoms, if bone at the fracture site still encroaches on
neural elements. Also, reduction of the lumbar spine to the pel-
vis, and thereby restoration of the sacral kyphosis, is determining
compensatory lumbar lordosis. Malreduction and increased
sacral forward tilting or buckling after fracture healing may
cause chronic low back pain due to muscular imbalance at the
lumbopelvic junction.
Persistent pain after healing of the fracture is predominantly
revolving around persistent neurologic deficits (see Fig.
135.9).22,23 A Visual Analog Score (VAS) analysis of patients
with lumbopelvic stabilization techniques after lumbosacral
fracturedislocations demonstrated without exception the
worst results in patients with persistent sexual dysfunction or

C D

Figure 135.9. (A) Pelvis anteroposterior image of a 48-year-old man status post high-speed motor vehicle
crash. He had sustained zone III sacral fracture with complex bilateral pelvic fractures and initially unknown
neurologic status. After resuscitation the patient received combined open reduction and internal fixation
with open reduction of posterior iliac wing fractures and open reduction of the sacral fracture using lum-
bopelvic fixation. (B) Final image 1 year postoperative. The patient is fully weight bearing without major
pain. He had maintained erectile function and bowelbladder control. (C and D) Final postoperative com-
puted tomography-myelogram 1 year postoperative. This study confirmed anatomic healing of the sacrum,
but identified new onset spinal stenosis at the L4/5 segment. This condition is being treated nonsurgically.

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 Chapter 135 Management and Surgical Treatment of Fractures of the Lumbosacral Region and the Sacrum
lumbosacral plexus dysesthesias. The predominant influence
of urogenital function and neurologic injury on eventual out-
comes scores for patients with sacral fractures has since been
validated in generalized outcomes studies, which did not
address matters of treatment technique and quality of injury
reduction.
SUMMARY
Evaluation and treatment of lumbosacral fracturedislocations
and complex sacral fractures with resultant instability has
evolved considerably with improved imaging standards and the
availability of newer implantation systems and fracture stabiliza-
tion concepts and techniques. A more consistent use of injury
classification systems based upon proper lumbopelvic imaging
may help in the decision-making process but certainly can
advance our attempts at comparing treatment results. In the
past, conservative treatmentprovided in an era of perhaps
greater acceptance of posttraumatic neurologic deficit and
bony deformitymay have been used more due to necessity
rather than choice in light of relatively high morbidity rates
and mostly improvisational fixation techniques. Neural decom-
pression associated with more standardized and effective lum-
bopelvic fixation may offer a more consistent approach toward
even complex injuries compromising the lumbosacral junction
and allow for more consistent reporting of outcomes in the
future. Any enthusiasm geared toward greater utilization of
operative treatment has to be weighed against possible periop-
erative pitfalls and complications such as malposition of
hardware, infection, hematoma, iatrogenic nerve injury, pseu-
darthrosis, and hardware failure. More sophisticated outcomes
analyses are necessary to aid in our decision-making process
toward timing and type of preferred treatment.
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