Traumatic unilateral lumbosacral jumped facet without fracture in a child – presentation of a safe treatment strategy for a rare injury
© Szentirmai et al; licensee BioMed Central Ltd. 2008
Received: 03 September 2008
Accepted: 10 November 2008
Published: 10 November 2008
The vast majority of pediatric lumbosacral spondylolisthesis have developmental etiology. Of the very rare type of pediatric lumbosacral facet dislocations, there are only three reported cases of a pediatric unilateral jumped facet injury. All of these cases are associated with fracture dislocation of L5-S1. Hyperflexion with rotation is thought to provoke this uncommon type of spine injury.
The authors report the first pediatric patient reported in literature to date with a traumatic unilateral jumped facet at the lumbosacral joint without fracture. The presentation, surgical treatment, hospital course, outcome and management options with the review of the literature is summarized.
Unilateral jumped (or locked) facet injuries are consequences of massive forces with a rotational component in the setting of hyperflexion. Most patients suffer minor or no neurologic injury. Unilateral lumbosacral facet dislocation injuries are infrequent and are often associated with fractures at L5-S1 and other segments of the spinal column. We found a total of approximately 50 traumatic lumbosacral facet dislocation cases reported in the literature. 21 cases are unilateral lumbosacral injuries. 3 of these cases are pediatric and are described as unilateral fracture-dislocations [1–5]. To our knowledge, this is the first case reported in the PubMed literature database with an L5-S1 unilateral jumped facet injury with anterolisthesis but without associated L5-S1 fracture.
Sporadic early case reports initially suggested conservative management with cast immobilization as a viable treatment option. More recent reports advocate anterior and/or posterior surgical reduction with instrumentation. Here we report our own experience with stand alone open posterior reduction and instrumentation with iliac crest bone grafting that resulted in excellent clinical outcome.
Traumatic unilateral facet dislocations decrease in frequency towards the caudal spinal column. Watson-Jones proposed hyperextension as the underlying cause of lumbo-sacral fracture-dislocations in the 1940s. Dewey and Browne further explained that spondylolisthesis is secondary to anterior vector forces while Samberg provided the most compelling explanation of rotational forces with hyperflexion as the major underlying mechanism. With only a handful of similar cases published in the literature, it is only proper to correlate the conclusion drawn from sporadic clinical experiences with the results of controlled experiments in animal and cadaver models on the forces involved to elicit these types of spinal column injuries. There are only twelve published case review papers on unilateral lumbosacral fracture-dislocations (21 total cases). Thoracolumbar and cervical unilateral facet dislocations are more common [9–12]. Pediatric sacroiliac unilateral jumped facet injuries are rare with only three published cases to date, all involving fracture at the level of the jumped facet. Management recommendations in this age group are not well established. Isolated ligamentous injury associated with jumped facet and without fracture, as presented in this manuscript, has not been published in the pediatric literature. Instability of all three vertebral columns necessitates surgical reduction with instrumentation. There are numerous case reports and review series on bilateral facet dislocations with recommendations for CT scanning of the spine, early reduction with lumbosacral arthrodesis and posterolateral bone grafting with instrumentation[4, 13, 14]. In bilateral facet injuries careful assessment for possible intervertebral disc herniation leading to cauda equina syndrome is warranted with MRI imaging and possible canal exploration. The high energy forces leading to a lumbosacral unilateral spondylolisthesis is likely to cause other injuries. In our patient we found a large paraspinous hematoma, multiple lumbar transverse process fractures, an iliac wing fracture and a T1 compression fracture. Many of these associated injuries can go undetected without a thorough workup. Less than one third of the patients in the reported lumbosacral dislocation cases presented with impaired neurologic function, suggesting that nerve root evulsion or severe canal compromise is infrequent in this type of spine injury. Our case suggests that there might be a higher incidence of associated injuries than previously published in similar traumatic pathologies of the lumbosacral spine.
Although some authors have advocated anterior or anterior-posterior 360 degree spinal fusion with instrumentation[14, 16–18], in this case we achieved good results with only posterior-lateral fusion with instrumentation. This was deemed appropriate at the time of surgery based on a stable reduction with near anatomic re-approximation of the left L5-S1 jumped facet. The integrity of the L5-S1 disc was considered, but thought to provide adequate anterior column support in combination with satisfactory pedicle screw placement. Long term follow up will be important as this patient ages to assess the natural history of the disc and possible sequelae of not removing this at the time of surgery.
The rotational deformity was quite significant (approximately 30 degrees) and thus the patient was not expected to do well with only cast or brace treatment. The difficulty of surgical reduction also implied that closed reduction, though not attempted, would not have been successful. The difficulty of maintaining the achieved reduction of the L5-S1 jumped facet intra-operatively argues for the inclusion of a reduction device or spondylolisthesis reduction screws in the pre-operative surgical plan.
In summary, based on the available literature and our experience, stand alone posterior instrumentation with arthrodesis can provide excellent clinical outcome following unilateral spondylolisthesis in a pediatric patient.
Stand alone posterior instrumentation with arthrodesis is a safe treatment in a pediatric patient. This approach avoids the inherent risks associated with anterior exposure of the lumbosacral junction.
Written informed consent for publication of this case report was obtained from the patient's legal representative.
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