Journal of Spine

Journal of Spine

Christian, et al., J Spine 2014, 3:4 http://dx.doi.org/10.4172/2165-7939.1000174

Case Report

Open Access

A Modified Gaines Approach for Lumbosacral Traumatic Spondyloptosis: A Historical Review and Case Illustration Eisha Christian1*, Christina Huang1, Christina Yen4, Frank A Acosta1,3, Thomas C Chen1,3, John C Liu C Hsieh1,3

1,3,

Mark Spoonamore2,3, Jeffrey C Wang2,3 and Patrick

1Department

of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA

2Department

of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA

3USC

Spine Center, Keck Medical Center of USC, Los Angeles, California, USA

4Keck

School of Medicine, Los Angeles, California, USA

*Corresponding

author: Eisha Christian, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300 Los Angeles, CA 90033, USA, Tel: 323.226.7421; Fax: 323.226.7833; E-mail: [email protected]

Rec date: Jun 10, 2014, Acc date: Jul 28, 2014, Pub date: Aug 01, 2014 Copyright: © 2014 Christian E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract Spondyloptosis is defined as greater than 100% subluxation of one vertebra over another; it most commonly develops due to dysplastic spondyloslisthesis but can also develop as a result of traumatic fracture-dislocations. In the past, given the significant force associated with this injury, most patients did not survive the initial trauma and resuscitation. However, as early care of patients with multiple traumatic injuries continues to improve, a larger number of patients with traumatic spondyloptosis will require treatment. In general, the goals of surgical intervention are to treat symptoms, preserve and improve neurologic status, restore and maintain sagittal balance, and obtain a solid arthrodesis while fusing as few segments as possible. There is, however, considerable controversy about specific surgical management in achieving these goals. We present a case of traumatic spondyloptosis including a discussion of our surgical approach, which is a modified Gaines procedure with a corpectomy, interbody fusion, and posterior spinal decompression and fusion. Alternate approaches are also discussed from both our institutional experience and from a review of the current literature.

Keywords: Spondyloptosis; Traumatic fracture-dislocation; Gaines procedure; Lumbar trauma

Introduction Spondyloptosis, or Grade V spondylolisthesis, is defined as greater than 100% subluxation of one vertebra over another in the coronal or sagittal plane. Spondyloptosis (ptosis is Greek for falling down or off) was first described by Neugebauer in 1882 as a complete tilting of the L5 vertebral body over the sacrum but this term has evolved to include greater than 100% subluxation at any level [1]. L5/S1 spondyloptosis is usually the final result of developmental dysplastic spondylolisthesis that has progressed with time, and a younger age and history of high (Grade III and IV) slips usually precede its development. While rare, spondyloptosis can also develop secondary to trauma, and this injury is most frequently incurred from falls from significant heights, high speed motor vehicle accidents, or vehicular collisions with pedestrians. Given the extreme force that is required to disassociate the lumbar spine from the pelvis, most patients frequently do not survive initial resuscitation. Unlike dysplastic spondyloptosis, traumatic spondyloptosis can be associated with variable neurologic deficits and is oftentimes complicated by polytrauma due to the high impact force of the injury. Even if there is no neurological deficit secondary to spondyloptosis, patients eventually have difficulty maintaining their sagittal balance, and further verticalization of the sacrum leads to difficulty with gait and maintaining posture (hyperlordosis). Given these implications, the current trend is to surgically intervene and treat these fracture dislocations.

J Spine ISSN:2165-7939 JSP, an open access journal

The natural history of traumatic spondyloptosis is unknown given its rare clinical manifestation. In addition, the clinical picture is not uniform where some patients are almost asymptomatic whereas others have severe functional disability from posture and gait imbalances and others are complete ASIA A spinal cord injuries. Given such a variable clinical presentation, there is considerable controversy about surgical management of spondyloptosis. In general, the goals of management are to treat symptoms, preserve and improve neurologic status, restore and maintain sagittal balance, and obtain a solid arthrodesis while fusing as few segments as possible. We present a case of traumatic spondyloptosis including a validation of our surgical approach, which is a modified Gaines procedure with a corpectomy, subsequent cage insertion and interbody fusion, and posterior spinal decompression and fusion. Alternative approaches are also discussed from both our experience and from case reports in the literature.

Case Presentation We present a 44 year old male with a past medical history significant for diabetes mellitus, alcoholism, and depression who jumped 100 feet from the coastal cliffs in what was believed to be a suicide attempt. He was brought via ambulance to an outside Level 1 trauma facility where he was treated for multiple orthopedic injuries that included significant and numerous bilateral lower extremity fractures in addition to a skull fracture with underlying traumatic subarachnoid hemorrhage and an epidural hematoma. His lumbar spine imaging (Figure 1) showed L5 on S1 spondyloptosis with complete displacement of the L5 vertebral body on S1 with corresponding bilateral L5 pars interarticularis fractures and severe

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Citation:

Christian E, Huang C, Yen C, Acosta FA, Chen TC, et al. (2014) A Modified Gaines Approach for Lumbosacral Traumatic Spondyloptosis: A Historical Review and Case Illustration. J Spine 3: 174. doi:10.4172/2165-7939.1000174

Page 2 of 7 narrowing of bilateral L5-S1 neural foramina. He was evaluated by a neurosurgeon and was placed in a lumbosacral orthosis at this outside facility. Per neurosurgical notes at this facility, he was full strength with no bowel or bladder deficits. He was then transferred to our facility 2 months after his injury. On initial presentation at our institution, the patient was awake and fully oriented. He was able to move his toes bilaterally with 4/5 strength but his bilateral extremities were circumferentially splinted and bandaged. He had an unreliable motor exam in his gastrocnemius and anterior tibialis due to bilateral ankle fractures. He had normal rectal tone with normal perianal sensation and had no urinary retention. He did complain of debilitating lower back pain even at rest and was not able to sit upright in bed. He had a fixed deformity on supine flat and extension films (Figure 1c). Given that he was non-weightbearing for his lower extremity fractures, we were not able to obtain full scoliosis x-rays to assess his sagittal balance. Given his severe pain, deformity, and nerve compression, we offered the patient surgery. We planned our surgical treatment with a modified Gaines procedure, including an anterior approach for L5 corpectomy followed by posterior reduction of spondyloptosis with L2-pelvis posterior spinal fusion as well as subsequent staged L4-S1 interbody fusion with cage insertion.

severe step-off deformity was noted. Osteotomies were performed for the L5 corpectomy with L4-5 and L5-S1 discectomies after which the L5 nerve roots were bilaterally exposed and were noted to be scarred down in the foramen and tethered to the surrounding tissues at L5-S1 interspace and S1 alar. We decompressed the bilateral L5 nerve roots circumferentially from the foramen to the retroperitoneal space at S1. We de-tethered them by performing neurolysis around bilateral L5 nerve roots until we reached the sacral alar and visualized the connection to the S1 nerve root to form the lumbosacral plexus. The roots were de-tethered to avoid the potential for stretch injury during the correction and reduction of the spondyloptosis. Once the L5 nerve roots were freed, multiple attempts were made to reduce the L4-S1 alignment with anterior distraction and applied extension to the lumbosacral junction. However, despite the L5 corpectomy, the L4-S1 alignment remained fixed and non-mobile. The fixed deformity was felt to be related to partial fusion and post-traumatic fibrosis from the delay in treatment. The decision was made then to close anteriorly and proceed with posterior release with reduction and correction of his deformity with L2-pelvis fusion posteriorly (Figure 2).

Figure 2: Stage 1 Anterior retroperitoneal approach for L5 corpectomy

Stage 2: Posterior spinal decompression, internal reduction and fusion

Figure 1: Pre-operative Imaging (a): Pre-operative sagittal lumbar MRI demonstrating anterior spondyloptosis of L5 on S1. (b): Pre operative sagittal lumbar CT demonstrating anterior spondyloptosis of L5 on S1. (c): Pre-operative lateral supine and extension x-rays.

Stage I: Anterior retroperitoneal approach for L5 corpectomy Vascular surgery assisted with the anterior exposure and they noted severe distortion of the vascular anatomy and significant adhesions. The left common iliac artery and vein and ureter were mobilized to expose L4-5. The left iliolumbar vein was ligated for L4-5 exposure and the middle sacral vessels were ligated to expose L5-S1 at which a


The second segment of the case involved a posterior approach with bilateral pedicle screws placed at L2-4 and S1. Two traditional iliac screws (Medtronic Vertex System) were placed bilaterally. AP and lateral radiographs confirmed placement and each screw was also stimulated with no response at 10 mAmps. Upon completion of the hardware placement, a L4-S1 laminectomy was performed. There were multiple fractured bony fragments identified that were embedded in dura. The dura had a wide laceration between L4-5 with a pseudomeningocele. CSF leak was noted with the laminectomy to decompress the canal with opening of the pseudomeningocele. The dura was repaired primarily with dural substitute graft and covered with DuraGen and DuraSeal. Bilateral 6.0 mm cobalt chrome rods were placed and secured to the iliac and S1 screws with appropriate lordosis contoured into the rods. Sequential reduction was performed with reduction towers placed at L2-4 pedicle screws bilaterally to reduce the L4 body posteriorly to center over S1. Correction of deformity with appropriate alignment was confirmed with radiographs. Local autograft mixed with DBM and allograft were

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Page 3 of 7 placed along the posterior lateral gutters from L2-S1 for posterolateral arthrodesis. A cross-link was then placed to interconnect the bilateral rods. Radiographs were performed to verify reduction, alignment, and screw placement. There was a decrease in the MEP amplitude on the right foot to 50% of baseline during the correction that improved back to baseline with elevation of blood pressure to MAP >85 mmHg. Due to the extended length of the case, the patient remained intubated post-operatively and he was taken back to the ICU to recover (Figure 3).

Figure 4: Stage 3 Anterior L4-S1 Interbody fusion

Figure 3: Stage 2 Posterior spinal decompression, internal reduction and fusion

Stage 3: L4-S1 interbody fusion and cage insertion (Figure 4) The following morning, anterior access was achieved through the previous abdominal incision with the same retroperitoneal approach performed to access the site of the L5 corpectomy. A 22x25mm Stryker V-lift expandable cage with 30 degree lordosis was used for the L4-S1 interbody arthrodesis. The cage was packed with demineralized bone matrix and allograft prior to insertion. A stand-alone anterior screw with a buttress washer was placed into L4 to secure the cage in place (Figure 5).

Post-operative course Postoperatively, the patient did well. His motor exam remained unchanged. He remained non-weight-bearing in his lower extremities during the course of his hospitalization secondary to his tibial plateau and talus fractures. He remained hospitalized in our psychiatric ward for several months postoperatively but was able to sit up independently for all transfers and also demonstrated resolution of his severe back pain. Two months post operatively, AP and lateral lumbar radiographs were obtained demonstrating preservation of normal lordosis, an intact construct, and initiation of boney fusion (Figure 6).


Figure 5: Post-operative CT Lumbar Spine demonstrating placement of the cage

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Page 4 of 7 of their time, hesitant to operate due to the poor condition of the patient’s skin and soft tissue. In their second case, open decompression was completed. However, complete facetectomy was required for anatomic reduction, and they, therefore, did not proceed with it because they felt that it was unsafe given the lack of adequate instrumentation to achieve stabilization [2]. In 1988, a case of a 39 year old male with L5/S1 spondyloptosis was treated initially with closed reduction and traction which failed. The author then performed an open anterior fixation via a transperitoneal approach using autologous iliac bone graft bridging the space between the L5 vertebral body and the sacrum and internal fixation with 2 Knowles pins. The patient retained full neurological function.

Figure 6: Upright AP and lateral lumbar radiographs two months post operatively demonstrating the entire construct with preservation of normal lordosis

Discussion One of the earliest descriptions of traumatic spondyloptosis was published by Dewey and Browne in 1968 who presented two cases of fracture-dislocation at the L5-S1 level. Prior to this time, few patients with severe traumatic lumbosacral dislocations survived their initial injuries. In addition, for those who survived such trauma, surgeons were reluctant to operate due to lack of adequate instrumentation and poor skin and soft tissue conditions thereby leading to difficulties with primary closure. In their first case, they attempted closed reduction, which was unsuccessful after 2 weeks. They were, like other surgeons

Hanley et al., presented a patient who had a similar mechanism of injury as our patient. His group did a posterior reduction and fusion using iliac plating and lumbar pedicle screws. This two-point fixation on the pelvis enabled adequate reduction. This case was also complicated by wound healing and CSF leak ultimately requiring a free latissimus dorsi flap [5]. Several additional cases were reported using 2 or 3 staged approaches with both posterior and anterior decompression and fusion (Table 1) [1,4-26].

Author

Year

# of Pre Ptnts Exam

Dewey [2]

1968

2

ASIA B

NR

L5/S1

1 - Closed reduction; failed 2 - Open reduction; failed

Samberg [25]

1975

1

ASIA E

NR

L5/S1

Open reduction and posterior spinal fusion

Jackson [17]

1979

1

ASIA E

7 days

L5/S1

ORIF (wires); fusion

Griffin [15]

1980

1

ASIA A

NR

L5/S1

Posterior decompression and dural repair

Grabe [14]

1988

1

ASIA E

NR

L5/S1

Failed traction, in situ anterior L5/S1 fusion and fixation

Cohn [8]

1989

1

ASIA A

NR

L5/S1

Failed traction, posterior ORIF and fusion

Gertzbein [12]

1990

1

ASIA A

hours

L5/S1

Posterior ORIF and L5/S1 fusion with instrumentation

Van Savage [28]

1992

1

ASIA A

7 days

L5/S1

Posterior lumbo-pelvic fusion (rods, wires, hockey stick),

Hanley [5]

1993

1

ASIA D

5 days

L5/S1

Poster reduction/instrumentation

Hilibrand [16]

1995

1

ASIA A

11 days

L5/S1

2 Stage: posterior reduction-fusion, second anterior fusion

Carlson [7]

1999

1

ASIA C

NR

L5/S1

2 Stage: posterior reduction-fusion, second anterior fusion

Kaplan [19]

1999

1

ASIA A

NR

L5/S1

3 Stage: anterior release/posterior reduction, reduction/fusion, anterior fusion

Meneghini [20]

2003

1

ASIA C

6 days

L5/S1

Posterior reduction, decompression, L4-S1 fusion

Robertson [32]

2005

1

ASIA D

8.5 mo

L5/S1

2 Stage: anterior release, posterior fusion


Op Time to Injury Surgery

During this same time period, Herron and Williams endorsed good results after treatment of traumatic spondylolisthesis with open reduction and internal fixation via a posterior only approach [3]. Van Savage, in 1992, described another case of traumatic spondyloptosis with posterior approach for open reduction and internal fixation which was however complicated by wound infection and cerebrospinal fluid leak (CSF) leak. In his discussion, he noted that as early care of patients with multiple traumatic injuries continued to improve, we would see a larger number of surviving patients with severe lumbosacral fracture dislocations and therefore would need to improve on methods of fusion, instrumentation and surgical decompression [4].

Approach

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Page 5 of 7

Emel [10]

2006

1

ASIA E

14 yrs

L5/S1

2 Stage: anterior/posterior: fibular graft through L5 body into S1

Saiki [21]

2006

1

ASIA C

1 day

L5/S1

Posterior reduction, fusion

Bellew [6]

2007

1

ASIA A

3 wks

L5/S1

T11-S1 posterior fusion only

Yadla [23]

2008

5

4 ASIA A 1 ASIA C

NR

L5/S1 L5/S1

2 posterior fusion, 1 posterior fusion with anterior corpectomy, 1 posterior fusion with anterior fusion and corpectomy Posterior fusion with partial L1/2 corpectomy

Daniels [9]

2009

1

ASIA E

12 hrs

L5/S1

2 Stage: posterior reduction/fusion, anterior fusion

Verhelst [4]

2009

1

ASIA A

6yrs

L4/5