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Traumatic Lumbosacral Dislocation Treated by Stand-Alone Anterior Approach

1David M. Neils, MD; 2Stylianos K Rammos, MD; 3 J. Kevin Paulsen, MD; 1Daniel Fassett, MD, MBA
1Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine, Peoria, Illinois; 2Arkansas Neurologic Institute, Little Rock, Arkansas; 3Department of Surgery, University of Illinois College of Medicine, Peoria, Illinois

Correspondence should be addressed to: 
David Neils, M.D. 
Department of Neurosurgery
Illinois Neurological Institute
530 NE Glen Oak
Peoria, IL 61637
Phone: 309-655-2700
Fax: 309-655-4728
Email:  HYPERLINK "mailto:dmneils@yahoo.com" dmneils@yahoo.com
Abstract:
Background: Lumbosacral dislocation is a rare injury associated with a substantial force of impact which often leads to significant neurological injury.  The treatment of these unstable fractures is typically via a posterior arthrodesis or combined anterior and posterior surgery.  In this case report, a lumbosacral dislocation with bilateral jumped facets successfully treated with an anterior-only approach is described. 
Methods/Results: We present a case of a 29-year-old female who was struck by an automobile and dragged for several blocks beneath the vehicle. On her initial evaluation, she was noted to have bilateral jumped facets with anterolisthesis of L5 upon S1. Additional injuries included a 30% body surface area second-degree burn involving her entire back prohibiting a posterior approach for reduction and internal fixation of the dislocation.  As a result, an anterior stand-alone approach was utilized to reduce and stabilize the dislocation. After diskectomy, the facets were unlocked with distraction within the interspace and reduction maneuvers were able to realign the dislocated segment. Stand-alone instrumented anterior lumbar interbody fusion (ALIF) was subsequently used to stabilize the segment.  Her abrasions were successfully treated at a burn center with skin grafting.  At 4-month follow-up, the patient was pain free and neurologically intact. On final one-year follow-up, computed tomography (CT) imaging demonstrated normal alignment and solid bridging bone across the lumbosacral junction. 
Conclusion:  In summary, stand-alone anterior approach is a viable alternative for reduction and stabilization of traumatic lumbosacral dislocations. Extensive distraction within the interspace may be required to facilitate unlocking of the facets to allow for reduction of the dislocation.  Although posterior approaches may be favored for the treatment of many of these injuries, this case demonstrates the feasibility of an anterior-only approach when circumstances prohibit a posterior approach. 

Key Words: Lumbosacral distraction; jumped facets; neurological injury; ALIF
Abbreviations:  
ALIF = anterior lumbar interbody fusion 
CT = computed tomography
ASIA = American Spinal Injury Association
CSF = cerebrospinal fluid
BMP = bone morphogenic protein
GCS = Glasgow coma scaleIntroduction
	Traumatic unilateral facet dislocation or traumatic spondylolisthesis of the lumbosacral spine is an uncommon injury typically related to a high energy mechanism..  Reported cases of this injury pattern typically occur at the lumbosacral junction although the injury has been reported in the higher lumbar spine as well [1-7].8 Often times, due to the high energy nature of the injury, patients have additional significant traumatic injuries. The treatment of the dislocation is typically operative with reduction and stabilization of the injury via a posterior approach. With a posterior approach, the superior articular process of the sacrum can be removed facilitating realignment of the inferior facet of L5 and reduction of the spondylolisthesis. After spinal realignment, these injuries are typically stabilized with instrumented arthrodesis utilizing pedicle screws.  Although not previously described in the lumbar spine, anterior-only approaches have been utilized to reduce and stabilize bilateral jumped facets within the cervical spine.  This is the first reported case of a successful reduction of traumatic lumbosacral facet dislocation with an anterior approach.

Case Presentation
A 29-year-old female was involved in a pedestrian versus motor vehicle accident on the day of admission. She was dragged beneath the vehicle for approximately three blocks after being struck by a car.  She was noted to have second-degree burns encompassing 30% of her body surface area including the entire back, shoulders, and posterior scalp.  Her presenting neurological examination was a Glasgow Coma Scale (GCS) 15 with 5/5 strength in all American Spinal Injury Association (ASIA) muscle groups with the exception of bilateral 4+/5 strength in bilateral extensor hallucis longus and plantar flexion. She was also noted to have a dislocation of L5 and S1 on plain radiographs and computed tomography (CT) demonstrated bilateral jumped facets at L5/S1 (Fig. 1).  Further workup revealed small apical pneumothoracices requiring no treatment and additional studies did not reveal other injuries.
	Given the extensive posterior cutaneous injury, a posterior approach was not viable due to concerns for wound healing with the further tissue disruption occurring with posterior spinal exposure. For this reason, a stand-alone anterior approach was utilized to reduce and stabilize the dislocation. Retroperitoneal exposure of the L5-S1 disk space was performed followed by thorough diskectomy of the disrupted disk. During diskectomy, a preexisting disruption of the posterior longitudinal ligament and dura was found with cerebrospinal fluid (CSF) leakage into the surgical site. The dural defect was repaired with onlay patching utilizing a commercially available collagen dural patch. 
	Under fluoroscopic visualization, the interspace was distracted to unlock the subluxed facet joints. Attempt was first made with standard anterior lumbar interbody fusion (ALIF) distractors which distract up to a length of 20 mm, but it was found that this provided insufficient distraction to reduce the facets.  A graft impactor (dimensions 14 mm x 26 mm) was then placed into the interspace and carefully rotated to distract the interspace to 26 mm which unlocked the facet joints (Fig. 2A).  A bone tamp was used on the ventral surface of the L5 vertebral body to push L5 vertebra posteriorly and realign the facet joints (Fig. 2B). After reduction of the subluxation, the level was stabilized with a femoral ring interbody graft packed with two bone-morphogenic-protein (BMP) sponges. Anterior plating was performed with a Depuy Aegis plate spanning the L5-S1 interspace with 28 mm screws into L5 and 32 mm screws into S1.  Postoperatively the patient was kept on flat bedrest for 48 hours to treat the CSF leak. She did well with improvement in lower extremity strength and no complications related to the procedure.  A CT obtained postoperatively demonstrated complete reduction of the facet dislocation and a normal posterior spinal line (Fig. 3). The patient was subsequently transferred to a burn center on postoperative day one for treatment of her skin injuries.  At four-month follow-up, the patient was ambulating without deficits or pain. A CT scan demonstrated maintenance of normal alignment with solid bridging bone across the L5-S1 interspace indicating solid fusion (Fig.  4). Fracture of both S1 screws was found, but the spinal alignment was maintained and fusion was achieved despite this hardware breakage.    

Discussion:
Traumatic spondylolisthesis with lumbosacral locked facet and dislocation is a rare entity described primarily in case reports [1-7].  In this case and the others reviewed, the mechanism of injury typically has a high force of impact such as being struck by a car.  Lumbosacral dislocation is typically associated with multiple other injuries including additional spinal fractures, nerve root injury, dural laceration, and visceral injury.  Most cases of lumbosacral dislocation described in the literature have utilized a posterior approach for reduction and stabilization [1-7]. A posterior approach allows for direct visualization of the disrupted facet joint to facilitate reduction of the dislocation, an avenue for repair of any dural violations, and a method for internal stabilization with pedicle screws.  The posterior approach appears to afford adequate functional and radiological outcomes.  
Recently Vaille, et al. reported the largest series of L5-S1 traumatic dislocation [8].  In this series of traumatic dislocation, all patients received transpedicle fixation, four patients had lumbosacral interbody arthrodesis at the same time, two other patients had staged anterior discectomy and fusions. Vaille, et al. reported subtotal resection of the L5-S1 articular processes to facilitate reduction in 10 of their 11 cases, highlighting the advantage of the posterior approach for direct reduction [8]. There was a single pseudoarthrosis requiring revision in this series of 11 patients.
The ALIF technique allows for a thorough exploration of the disc space and offers a direct means of access to any pathology therein.  Biomechanically, the ALIF technique has been studied extensively under physiologic loading conditions [9]. Simply placing a femoral ring allograft into the interspace significantly reduces motion in flexion and extension in these cadaveric models. This is further reduced by the use of anterior plating systems or pedicle screw plating systems with pedicle screws providing more rigid fixation than anterior plating.  Traditional long-term successful fusion rates for ALIF with anterior plating in the setting of degenerative pathology have reported fusion rates of 92% at 6 to 9 months [10].  
Reduction of a traumatic spondylolisthesis with an anterior lumbar technique is not without potential shortcomings.  In the present case, a posterior approach was prohibited due to the patient�s associated second degree burns encompassing the entirety of her back.  Although an anterior retroperitoneal approach allowed for reduction of the subluxation, it is important to note that superphysiologic amounts of distraction were required to reduce the facet joints.  In this particular case, the rotating interbody distractors available in the ALIF set only allowed for 20 mm of interbody distraction which was found to be insufficient. Thus, a graft impactor instrument was utilized similar to a rotating interbody distractor within the interspace to allow for 26 mm of distraction between L5 and S1 to unlock the facet joints. There is a concern that this amount of distraction may lead to stretching of the L5 nerve roots and potential for postoperative root deficits may exist.  In this particular case, the patient�s minor preoperative neurological deficits improved after surgery.  
In addition, dural injuries along with additional lumbar fractures are commonly noted in the setting of lumbosacral dislocation. A transdiscal approach offers limited avenues for the repair of dural injuries.  Fortunately onlay dural grafting and postoperative recumbence was successfully utilized in this case.
	In summary, we report a previously-unreported case of traumatic lumbosacral dislocation with unilateral locked facet treated via a novel anterior approach.  An anterior approach allowed us to effectively treat a CSF leak, reduce the dislocation, and obtain a stable instrumented arthrodesis in this patient.  In conclusion, the ALIF procedure offers a biomechanically viable, safe, and effective alternative for lumbosacral dislocation reduction and fusion in the setting of musculocutaneous disruption.  
Acknowledgement: 
	The authors wish to acknowledge Mrs. JoAnna Fleckenstein for her editorial assistance with the manuscript. References: 
1.	Aihara T, Takahashi K, Yamagata M, Moriya H: Fracture-dislocation of the fifth lumbar vertebra. A new classification. J Bone Joint Surg Br 80:840-845, 1998. 
2.	Arnold PM, Malone DG, Han PP: Bilateral locked facets of the lumbosacral spine: treatment with open reduction and transpedicular fixation. J Spinal Cord Med 27:269-272, 2004
3.	Boger DC, Chandler RW, Pearce JG, Balciunas A: Unilateral facet dislocation at the lumbosacral junction. Case report and literature review. J Bone Joint Surg AM 65:1174-1178, 1983
4.	Carl A, Blair B: Unilateral lumbosacral facet fracture-dislocation. Spine 16:218-221, 1991
5.	Connolly PJ, Esses SI, Heggeness MH, Cook SS: Unilateral facet dislocation of the lumbosacral junction. Spine 17:1244-1248, 1992
6.	Herreon LD, Williams RC: Fracture-dislocation of the lumbosacral spine. Report of a case and review of the literature. Clin Orthop Relat Res 186:205-211, 1984
7.	Reddy SJ, Al-Holou WN, Leveque J-C, Marca FL, Park P: Traumatic lateral spondylolisthesis of the lumbar spine with a unilateral locked facet: description of an unusual injury, probable mechanism, and management. J Neurosurg Spine 9:576-580, 2008
8.	Vialle R, Charosky S, Rillardon L, Levassor N, Court C: Traumatic dislocation of the lumbosacral junction diagnosis, anatomical classification and surgical strategy. Injury 38:169-181, 2007

9.	Tzermiadianos MN, Mekhail A, Voronov LI, Zook J, Havey RM, Renner SM, et al: Enhancing the stability of anterior lumbar interbody fusion: A biomechanical comparison of anterior plate versus posterior transpedicular instrumentation. Spine 33(2):E38-E43, 2008
10.	Freudenberger C, Lindley EM, Beard DW, Reckling C, Williams A, Burger EL, et al:  Posterior versus anterior lumbar interbody fusion with anterior tension band plating: tretrospective analysis. Orthopedics 32(7):492, 2009

Figure Legend: 
Figure 1: 	Presenting CT Scan showing A) Right Facet , B) Midline, C) Left Facet, D) and E) 3D Reconstructions.
Figure 2: 	Intraoperative fluoroscopy showing A) distraction with graft impactor and B) the final construct.
Figure 3: 	Immediate postoperative CT scan showing A) Right Facet, B) Midline, and C) Left Facet Alignment.
Figure 4: 	Showing stable alignment and osseous fusion at 1 year follow-up.








Traumatic Lumbosacral Dislocation		Neils and Fassett    PAGE 12



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