Direct anterior decompression of L4 and L5 nerve root in sacral fractures using the pararectus approach: a technical note
- 3 Downloads
To describe a new surgical technique for neurolysis and decompression of L4 and L5 nerve root entrapment after vertical sacral fractures via the pararectus approach for acetabular fractures, and to present four case examples.
Patients and methods
We retrospectively evaluated four patients suffering radiculopathy from entrapment of the L4 or L5 nerve root in vertical sacral fractures between January and December 2016. The mean follow-up period after surgery was 18 (range 7–27) months. All patients underwent direct decompression and neurolysis of the L4 and L5 nerve roots via the single-incision, intrapelvic, extraperitoneal pararectus approach.
In all patients, the L4 and L5 nerve root was successfully visualized and decompressed, proving feasibility of the pararectus approach for this indication. No patient presented with a neural tear. Complete neurologic recovery was present in one patient at last follow-up; two patients had incomplete recovery of their radiculopathy; and one patient had no improvement after nerve root decompression.
The pararectus approach allows for sufficient visualisation and direct decompression and neurolysis of the L4 and L5 nerve root entrapped in vertical sacral fractures. Although neurologic recovery was not achieved in all patients in this small case series, the approach may be a suitable alternative to posterior approaches and other anterior approaches such as the lateral window of the ilioinguinal approach.
KeywordsVertical sacral fractures Nerve root entrapment Radiculopathy Neurolysis Pararectus approach L4-nerve root injury L5 nerve root injury Anterior approach lumbar plexus
There is no funding source.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
- 1.Schnaid E, Eisenstein SM, Drummond-Webb J (2019) Delayed post-traumatic cauda equina compression syndrome. J Trauma 25(11):1099–1101. https://www.ncbi.nlm.nih.gov/pubmed/4057302. Accessed 23 May 2019
- 2.Denis F, Davis S, Comfort T (1988) Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 227:67–81. https://www.ncbi.nlm.nih.gov/pubmed/3338224. Accessed 10 Sep 2018
- 3.Roy-Camille R, Saillant G, Gagna G, Mazel C (1985) Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine (Phila Pa 1976) 10(9):838–845. https://www.ncbi.nlm.nih.gov/pubmed/4089659. Accessed 23 May 2019
- 4.Bydon M, Fredrickson V, De la Garza-Ramos R, Li Y, Lehman RA, Trost GR et al (2014) Sacral fractures. Neurosurg Focus 37(1):E12. https://www.ncbi.nlm.nih.gov/pubmed/24981900. Accessed 27 Dec 2018
- 7.Garozzo D, Zollino G, Ferraresi S (2014) In lumbosacral plexus injuries can we identify indicators that predict spontaneous recovery or the need for surgical treatment? Results from a clinical study on 72 patients. J Brachial Plex Peripher Nerve Inj 9(1):1. https://www.ncbi.nlm.nih.gov/pubmed/24410760. Accessed 28 Dec 2018
- 8.Horn A, Thomas A, Dunn R (2019) Debilitating sciatica following a sacral fracture: a case report. SA Orthop J 15(2):35–37. https://ref.scielo.org/k87pnh. Accessed 13 Jan 2019
- 9.Bellabarba C, Schildhauer TA, Vaccaro AR, Chapman JR (2019) Complications associated with surgical stabilization of high-grade sacral fracture dislocations with spino-pelvic instability. Spine (Phila Pa 1976) 31(11 Suppl.):S80–S88. https://insights.ovid.com/crossref?an=00007632-200605151-00014. Accessed 20 Jan 2019 (discussion S104)
- 10.Jones CB, Sietsema DL, Hoffmann MF (2012) Can lumbopelvic fixation salvage unstable complex sacral fractures? Clin Orthop Relat Res 470(8):2132–2141. https://doi.org/10.1007/s11999-012-2273-z
- 11.Vaccaro AR, Kim DH, Brodke DS, Harris M, Chapman JR, Schildhauer T et al (2004) Diagnosis and management of sacral spine fractures. Instr Course Lect 53:375–385. https://www.ncbi.nlm.nih.gov/pubmed/15116628. Accessed 23 May 2019
- 12.Bellabarba C, Nork S, Pohlemann T, David Stephen D, Case M, Stephen D et al (2006) The debate: how to treat sacral fractures with nerve injuries? https://www.aofoundation.org/Documents/debate.pdf. Accessed 23 Dec 2018
- 14.Dumont CE, Keel MJ, Djonov V, Haefeli PC, Schmid T, Olariu R et al (2017) The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest. Injury 48(10):2169–2173. https://www.ncbi.nlm.nih.gov/pubmed/28823386. Accessed 20 Jan 2019
- 15.Medical Research Council (1976) Aids to the examination of the peripheral nervous system. Her Majesty’s Stationery Office, London. https://mrc.ukri.org/documents/pdf/aids-to-the-examination-of-the-peripheral-nervous-system-mrc-memorandum-no-45-superseding-war-memorandum-no-7/. Accessed 13 Jan 2019
- 17.Khan JM, Marquez-Lara A, Miller AN (2017) Relationship of sacral fractures to nerve injury. J Orthop Trauma 31(4):181–184. https://insights.ovid.com/crossref?an=00005131-201704000-00001. Accessed 23 Dec 2018
- 19.Zelle BA, Gruen GS, Hunt T, Speth SR (2004) Sacral fractures with neurological injury: is early decompression beneficial? Int Orthop 28(4):244–251. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456939/pdf/264_2004_Article_557.pdf. Accessed 12 Jan 2019
- 21.Mehta S, Auerbach JD, Born CT, Chin KR (2006) Sacral fractures. J Am Acad Orthop Surg 14(12):656–665. https://www.ncbi.nlm.nih.gov/pubmed/17077338. Accessed 27 Dec 2018
- 22.Reilly MC, Zinar DM, Matta JM (1996) Neurologic injuries in pelvic ring fractures. Clin Orthop Relat Res 329:28–36. https://journals.lww.com/corr/Abstract/1996/08000/Neurologic_Injuries_in_Pelvic_Ring_Fractures_.5.aspx. Accessed 27 Jan 2019
- 24.Tonetti J, Cazal C, Eid A, Badulescu A, Martinez T, Vouaillat H et al (2004) Neurological damage in pelvic injuries: a continuous prospective series of 50 pelvic injuries treated with an iliosacral lag screw. Rev Chir Orthop Reparatrice Appar Mot 90(2):122–131. https://www.ncbi.nlm.nih.gov/pubmed/15107699. Accessed 27 Jan 2019
- 26.Keel MJB, Siebenrock KA, Tannast M, Bastian JD (2018) The pararectus approach. JBJS Essent Surg Tech 8(3):e21. https://www.ncbi.nlm.nih.gov/pubmed/30588366. Accessed 28 Dec 2018
- 27.Sharma H, Lee SWJ, Cole AA (2012) The management of weakness caused by lumbar and lumbosacral nerve root compression. SPINE J Bone Jt Surg Br 94(11):1442–1447. https://doi.org/10.1302/0301-620X.94B11.29148
- 28.Baker Susan P, O’Neill B, Haddon W, Long W (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Trauma-Injury Infect Crit Care 14(3):187–196. https://journals.lww.com/jtrauma/Citation/1974/03000/The_Injury_Severity_Score__A_Method_for_Describing.1.aspx. Accessed 13 Jan 2019