Lumbopelvic fixation for high-grade sacral fracture-dislocations with different injury mechanisms: a two-case report

Introduction and importance: High-grade sacral fracture-dislocations associated with spinopelvic dissociation are mostly high-energy traumatic injuries, whereas a minority represent low-energy sacral insufficiency fracture-dislocations. Although lumbopelvic fixation (LPF) is an established treatment, most published data concern traumatic injuries. In the two cases reported here, we describe the outcomes and management considerations of LPF applied to injuries with different energy mechanisms, which may be of educational value and may provide comparative surgical observations. Presentation of the case: Two patients with high-grade sacral fracture-dislocations of different etiologies underwent LPF. A 48-year-old man presented with bilateral lower-extremity weakness and urinary retention after a fall from a height; a 70-year-old woman presented with lumbosacral pain after minor trauma. In both patients, conservative management and isolated sacroiliac screw fixation were considered as alternatives. LPF was performed to restore spinopelvic stability, permit early mobilization, and support neurological recovery. The patient with a traumatic injury recovered neurological function and returned to daily life after fracture union and hardware removal. The elderly patient mobilized early but subsequently developed implant exposure and a surgical-site infection after prolonged bed rest. Clinical discussion: In these two patients, LPF appeared to stabilize both fracture subtypes. Traumatic fractures may require early fixation with either direct or indirect neural decompression, whereas optimized screw placement combined with cement augmentation may improve purchase in fragility fractures. In the elderly patient reported here, the decision regarding implant removal was individualized. These observations are hypothesis-generating only and will require confirmation in larger cohorts. Conclusion: In the two patients reported here, LPF was associated with restoration of spinopelvic stability and a favorable short-term course. Management was individualized according to injury characteristics. Three considerations emerged from these cases: differing therapeutic goals for distinct injury patterns; tailored neural decompression and augmented iliac screw fixation; and individualized decision-making regarding implant removal. Whether these observations can be generalized cannot be determined from two cases.