J Korean Fract Soc.  2017 Jan;30(1):24-28. 10.12671/jkfs.2017.30.1.24.

Decompressive Sacral Foraminotomy for Nerve Root Injury during Conservative Treatment of Sacral Fracture: A Case Report

• Lee JG
• Shin JH
• Kim K
• Choi SM
• Park MS
• Chang HG

• KMID: 2367349
• DOI: http://doi.org/10.12671/jkfs.2017.30.1.24

Abstract

A 35-year-old woman visited the emergency department for a pedestrian traffic accident. Severe tenderness was noted at the posterior sacrum area, without open wound or initial neurologic deficit. Fracture of the left sacral ala extended to the S1 foramen, anterior acetabulum, and pubic ramus. Two weeks after the injury, she presented aggravating radiculopathy with the weakness of the left great toe plantar flexion. The S1 nerve root was compressed by the fracture fragments in the left S1 foramen. Decompressive S1 foraminotomy was performed. The postoperative follow-up computed tomography scan showed successful decompression of the encroachment, and the patient recovered well from the radiculopathy with motor weakness. She was able to resume her daily routine activity. We suggest that early decompressive sacral foraminotomy could be a useful additional procedure in selective sacral zone II fractures that are accompanied by radiculopathy with a motor deficit.

Keyword

Fractures; Bone; Sacrum; Radiculopathy; Foraminotomy

MeSH Terms

Accidents, Traffic
Acetabulum
Adult
Decompression
Emergency Service, Hospital
Female
Follow-Up Studies
Foraminotomy*
Humans
Neurologic Manifestations
Radiculopathy
Sacrum
Toes
Wounds and Injuries

Figure

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  Fig. 1 This schematic drawing of the sacrum shows a classification of sacral fractures according to Denis et al.1) 1: Zone I-ala region; 2: Zone II-foramina region; 3: Zone III-central sacral canal region.

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  Fig. 2 A, B) Anteroposterior pelvic radiograph and 3-dimensional computed tomography (CT) shows a fracture at the left sacral ala, sacral foramina (white arrows) anterior acetabulum, and pubic ramus. Coronal (C), and axial (D) view of the CT image show S1 left foraminal encroachment by the fracture fragment (arrows).

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  Fig. 3 (A, B) T2-weighted axial images show an enlarged S1 nerve root with increased signal intensity, suggesting nerve root injury (arrow heads and arrow).

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  Fig. 4 (A-C) Decompressive S1 foraminotomy was performed. The S1 foramen was explored under an image intensifier with a penfield probe. We used a Kerrison punch (2 mm, 3 mm) in the foraminotomy, under a loupe magnification. The foraminal encroachment and nerve root release were identified with a nerve hook probe.

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  Fig. 5 (A) Postoperative computed tomography images demonstrate decompression by S1 foraminotomy (arrow head). (B) Postoperative 4 months follow-up image shows union and remodeling processes of the fracture around the S1 neural foramen.

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