No Time Lost Results in Optimal Results for Transverse Sacral Fractures
Physicians at trauma centers must be prepared for the weird, the unusual, and the rare cases of everything because they see everything in all three of these categories. This case presentation of an extremely rare sacral fracture in a 13-year-old demonstrates this point very well.
The girl fell from a second-story building and came to the trauma center with the main symptom of low back pain. She didn't have paralysis but without knowing it, she did have an injury to the lower part of her spinal cord called the cauda equina. The result was a loss of sensation in the groin area called the perineum and a loss of bowel and bladder function. She had no sensation that her bladder was full or that she had to empty her bladder (urinate) or have a bowel movement.
The physician who examined her was careful to conduct some special tests that revealed the cauda equina lesion. X-rays confirmed a transverse fracture (transverse means through the sacral bone), which had then shifted so that the two pieces of the sacrum were overlapping one another.
She was sent to surgery right away in order to take the pressure off the cauda equina before the bowel and bladder problems became permanent. The surgeon removed a portion of the sacrum that was pressing on the nerve tissue. This procedure is called a decompression surgery. The fracture couldn't be reduced (bone fragments put back together) without a metal plate to hold it together. She was put in a lumbosacral orthosis (LSO) (type of rigid back brace) to stabilize the low back and sacrum.
Her sensation and bowel and bladder function came back very gradually over a six-month period of time. The doctors credit the fast action between arrival at the trauma center, diagnosis, and surgery (a total of four and a half hours) for that good result. That's why they wrote this case up for publication -- to help other physicians know how to recognize these rare (only nine ever reported) and very serious cases.
Although the fracture in this case was obvious on plain X-rays, these fractures can be very subtle and easily missed on X-rays and CT scans. MRIs are really the best way to diagnose sacral fractures. Likewise, the fact that the patient had not gone to the bathroom and was unaware of the need to do so (an important neurologic sign) can be overlooked.
Surgery isn't always required with transverse sacral fractures. If the fracture isn't displaced (separated) and the patient doesn't have any neurologic damage, then conservative (nonoperative) care may be all that's needed. But severe fractures with displacement, bony malalignment, and/or any sign of neurologic compromise warrants an immediate surgical procedure.
Some experts suggest that surgery can be preventive in a way. If the fracture looks stable but develops a large bone callus during the healing phase that presses on nerve tissue, then it would have been better to operate early on. The same thing applies if the bone fragments move after the imaging study showed they were lined up and stable.
These cases are so rare, no one knows how to predict when those complications might occur and prevent them in any other way than by doing early surgery. This is especially true when you consider that these fractures are difficult to treat and displacement of the bones only makes it that much harder to realign and stabilize them.
This case also helps physicians know that they can reassure patients with neurologic problems from a transverse sacral fracture that it takes quite a long time to recover after surgery. Reviewing the results of the other nine cases, it looks like complete neurologic recovery is more likely with surgery -- another reason to support early surgical decompression and stabilization for this condition.
Ashwin Avadhani, MS(Orth), DNB(Orth), et al. Pediatric Transverse Sacral Fracture with Cauda Equina Syndrome. In The Spine Journal. February 2010. Vol. 10. No. 2. Pp. E10-E13.