- Division of Neurosurgery, Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts, USA
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
Correspondence Address:
Erica F. Bisson
Division of Neurosurgery, Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts, USA
Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
DOI:10.4103/2152-7806.77278
© 2011 Schirmer CM This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.How to cite this article: Schirmer CM, Bisson EF. Management of distraction injury of the lumbosacral junction with unilateral perched facet. Surg Neurol Int 03-Mar-2011;2:26
How to cite this URL: Schirmer CM, Bisson EF. Management of distraction injury of the lumbosacral junction with unilateral perched facet. Surg Neurol Int 03-Mar-2011;2:26. Available from: http://sni.wpengine.com/surgicalint_articles/management-of-distraction-injury-of-the-lumbosacral-junction-with-unilateral-perched-facet/
Abstract
Background:Traumatic unilateral facet dislocation without fracture is an uncommon injury of the lumbosacral junction. We describe a case of a unilateral perched L5–S1 facet causing axial back pain and radiculopathy provoked by motion.
Case Description:The patient underwent reduction with complete facetectomy followed by internal fixation at L5–S1, facilitating decompression of the S1 nerve root. Postoperatively, the patient reported improvement in her pain.
Conclusions:This injury can be recognized using subtle clues, such as transverse process fractures and/or widened posterior elements. Despite its rarity, when identified, this injury can be characterized using the new TLICS system for thoracolumbar fractures and should be managed accordingly.
Keywords: Facet dislocation, operative management, trauma
INTRODUCTION
Traumatic unilateral or bilateral facet dislocations without fracture of the cervical spine are common injuries, indicative of injury of the stabilizing ligaments, and are routinely managed with reduction and operative fixation. In contrast, facet dislocations without fracture of the lumbar spine are rare. The superior articular process may be partially or completely dislocated, and the dislocations may involve either one or both articular processes.[
CASE DESCRIPTION
A 46-year-old woman presented in transfer from a community hospital after sustaining injuries from a motor-vehicle accident in which she was a restrained driver. During evaluation at the community hospital, no gross signs of internal or external injuries and no neurologic deficit were noted; however, the patient complained of significant pain and spasms in the lower back, worsened by an upright position. She also complained of right leg pain with a sharp quality when she would change position. Lumbar radiographs showed a potential widening of one of the L5–S1 neuroforamina [
Surgical intervention was undertaken because of the presence of clinical instability and her TLICS score. We found obvious disruption of the posterior tension band, including the interspinous ligaments between L4, L5, and S1 with associated soft tissue hematoma. After subperiosteal dissection, the naked superior articular process of S1 was visible, with the most caudal aspect of the inferior articular process of L5 lying cephalad and ventral to it, causing a clockwise rotation of L5. Reduction was accomplished with a complete facetectomy on the right followed by internal fixation with interbody graft and pedicle screw instrumentation at the L5–S1 level, facilitating complete decompression of the S1 nerve root [
DISCUSSION
Trauma to the lumbar spine typically results in injuries at the thoracolumbar junction. In a large series more than half of all fractures involved T12 or L1.[
The diagnosis of lumbosacral dislocation may be missed because radiographs taken as part of a trauma evaluation may be inadequate to visualize an abnormal relationship of the lumbosacral facets. The presence of transverse process fractures, as seen in our case, should alert the medical team to the possibility of a more serious injury.[
For subacute dislocation, surgical treatment is complex. The reported cases treated conservatively had excellent clinical outcomes.[
Although our patient was neurologically intact without canal compromise, with a score of 8 on the TLICS system, optimal management of this lesion is operative reduction and fixation.[
Lumbosacral dislocations are usually associated with high-energy trauma, and patients often suffer from associated visceral lesions, extraspinal fractures, and secondary spine fractures, including transverse process fractures in the majority.[
In a review of the literature on lumbosacral dislocations, we found 93 cases that were previously reported [
In young children, this injury has been managed successfully by cast immobilization[
Unlike the lumbar facets with a relative sagittal orientation, the L5–S1 facet has a more coronal alignment.[
The management of these rare injuries is still controversial. Boldin and coworkers[
CONCLUSIONS
A unilateral lumbosacral facet dislocation is a rare injury that has been managed both conservatively and surgically. Transverse process fractures may point to the diagnosis of this injury, which otherwise may be missed on routine evaluation. Despite its rarity, this injury pattern fits into the categories of the Thoracolumbar Injury Classification and Severity Score (TLICS) system for thoracolumbar fractures and can be managed accordingly. Open reduction and fixation is safe and efficacious.
This report alerts neurosurgeons to the need for careful analysis of diagnostic radiographs when a patient has been involved in a potentially high-impact injury to the spine. The authors point out that transverse process fractures, in part, directed them to the unilateral dislocation at the lumbosacral junction. However, such dislocations may occur without other fractures[
The authors of this report made use of the Thoracolumbar Injury Classification and Severity Scale – TLICSS, originally proposed by The Spine Trauma Study Group as reported by Vaccaro et al. in 2005, in helping to make the decision to surgically treat this dislocation. Spine surgeons should familiarize themselves with this classification, which has been verified in a number of reports[
Commentary
- Department of Neurosurgery, University of Illinois, Chicago 900 Westmoreland, Suite LL50, Lake Forest, Chicago, IL, USA. E-mail:
ron@pawl.com
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