Classifications in Brief: The Denis Classification of Sacral Fractures

Rizkalla, James; Lines, Tanner; Nimmons, Scott J. B.

doi:10.1097/corr.0000000000000861

Cited by 17 publications

(9 citation statements)

References 16 publications

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“…Sacral fractures were characterized by the Denis zone and were defined as incomplete or complete based on whether the fracture extended through the posterior cortex on a CT scan 26 . Superior ramus fractures were classified according to the Nakatani system (root, mid-ramus, or parasymphyseal) and by fracture characteristics (transverse, oblique, comminuted, or segmental) 27 .…”

Section: Methodsmentioning

confidence: 99%

Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable

DeKeyser

Kellam

Haller

et al. 2021

Journal of Bone and Joint Surgery

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Background: Occult instability of lateral compression type-1 (LC1) pelvic ring injuries may be determined with a fluoroscopic stress examination under anesthesia (EUA) performed in the operating room. We hypothesized that LC1 injuries, similar to some fractures of the extremities, could be radiographically stressed for stability in the emergency department (ED). Our primary objective was to determine if stress examination of LC1 fractures could be safely and accurately performed in the ED and could be tolerated by patients.Methods: A prospective, consecutive series of 70 patients with minimally displaced LC1 pelvic injuries (<10-mm displacement on presentation) underwent stress examinations performed by the on-call orthopaedic resident in the ED radiology suite. The stress examination series included static 40°inlet, internal rotation stress inlet, and external rotation stress inlet views. Pelvic fractures that had positive stress results ( ‡10 mm of overlap of the rami) were indicated for a surgical procedure. These fractures also underwent EUA in order for the 2 techniques to be compared.Results: All patients tolerated the ED stress examination without general anesthetic or hemodynamic instability. Fiftyseven patients (81%) had negative stress results and were allowed to bear weight. All patients with negative stress results who had 3-month follow-up went on to radiographic union without substantial displacement. For the patients with a positive stress result in the ED, the mean displacement was 15.15 mm (95% confidence interval [CI], 10.8 to 19.4 mm) for the ED stress test and 15.60 mm (95% CI, 11.7 to 19.4 mm) for the EUA (p = 0.86). Two patients with a negative ED stress test did not mobilize during their hospitalization and underwent EUA and conversion to a surgical procedure. Thus, a total of 11 patients underwent both stress testing in the ED and EUA; no patient had a positive result on one test but a negative result on the other.Conclusions: ED stress examination of LC1 injuries is a safe and reliable method to determine pelvic ring stability. The displacement measured in the ED stress examination is similar to the displacement measured under general anesthesia. Furthermore, a negative ED stress examination predicts successful nonoperative treatment. Given the results of this study, we encourage the use of stress examination in the ED for LC1-type injuries involving complete sacral fractures only. Widescale adoption of this streamlined protocol may substantially diminish cost, anesthetic risk, and potential operations for patients.Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. Lateral compression type-1 (LC1) fractures are common injuries, accounting for approximately 50% of all pelvic ring injuries 1-3 . They occur secondary to a lateral compressive force on the pelvis causing medialization and internal rotation of the hemipelvis 1,3,4 . These injuries have historically been treated nonoperatively, but current surgical indications a...

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Section: Methodsmentioning

confidence: 99%

Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable

DeKeyser

Kellam

Haller

et al. 2021

Journal of Bone and Joint Surgery

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“…72 Operative stabilization promoted healing and earlier mobilization, but was associated with a 13% postoperative infection rate, with both Rizkalla et al and Zelle et al warning of the need to weigh this perioperative risk against the potential operative difficulty encountered when correcting delayed posttraumatic deformity. 73,74 The distinguishing final feature of the AO system is its synthesis and integration of historical pelvic and sacral classification systems. It has been interrogated by Schroeder et al and proven robust, with 86.90% of 474 surgeons agreeing with the progressive arrangement of categories, with moderate reproducibility and interobserver agreement.…”

Section: Discussionmentioning

confidence: 99%

Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic review

Kweh

Tee

Öner

et al. 2022

Journal of Neurosurgery: Spine

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OBJECTIVE The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems. METHODS A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems. RESULTS A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable “U-type” fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date. CONCLUSIONS The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries.

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“…The etiologies of spinal sacral nerve injury are not rare but common and expansive, such as spinal bifida 6 , tethered cord syndrome 7 , anterior sacral meningocele 8 , 9 , sacral canal cyst and sacral fractures 10 – 12 . Compared with other nerve injuries that usually cause motor dysfunction, the spinal sacral nerve is a mixed nerve comprising motor, sensory and autonomic nerves (parasympathetic nerves) 13 that mainly innervate the bladder and bowel 5 , 14 , 15 .…”

Section: Introductionmentioning

confidence: 99%

Functional, morphological and molecular characteristics in a novel rat model of spinal sacral nerve injury-surgical approach, pathological process and clinical relevance

Wang

et al. 2022

Sci Rep

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Spinal sacral nerve injury represents one of the most serious conditions associated with many diseases such as sacral fracture, tethered cord syndrome and sacral canal tumor. Spinal sacral nerve injury could cause bladder denervation and detrusor underactivity. There is limited clinical experience resolving spinal sacral nerve injury associated detrusor underactivity patients, and thus the treatment options are also scarce. In this study, we established a spinal sacral nerve injury animal model for deeper understanding and further researching of this disease. Forty 8 w (week) old Sprague Dawley rats were included and equally divided into sham (n = 20) and crush group (n = 20). Bilateral spinal sacral nerves of rats were crushed in crush group, and sham group received same procedure without nerve crush. Comprehensive evaluations at three time points (1 w, 4 w and 6 w) were performed to comprehend the nature process of this disease. According to urodynamic test, ultrasonography and retrograde urography, we could demonstrate severe bladder dysfunction after spinal sacral nerve injury along the observation period compared with sham group. These functional changes were further reflected by histological examination (hematoxylin-eosin and Masson’s trichrome staining) of microstructure of nerves and bladders. Immunostaining of nerve/bladder revealed schwann cell death, axon degeneration and collagen remodeling of bladder. Polymerase Chain Reaction results revealed vigorous nerve inflammation and bladder fibrosis 1 week after injury and inflammation/fibrosis returned to normal at 4 w. The CatWalk gait analysis was performed and there was no obvious difference between two groups. In conclusion, we established a reliable and reproducible model for spinal sacral nerve injury, this model provided an approach to evaluate the treatment strategies and to understand the pathological process of spinal sacral nerve injuries. It allowed us to understand how nerve degeneration and bladder fibrosis changed following spinal sacral nerve injury and how recovery could be facilitated by therapeutic options for further research.

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Classifications in Brief: The Denis Classification of Sacral Fractures

Cited by 17 publications

References 16 publications

Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable

Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable

Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic review

Functional, morphological and molecular characteristics in a novel rat model of spinal sacral nerve injury-surgical approach, pathological process and clinical relevance

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