Operative management of complex lumbosacral dissociations in combat injuries

Background Context: As war injury patterns have changed throughout Operations Iraqi and Enduring Freedom (OIF and OEF), a relative increase in the incidence of complex lumbosacral dissociation (LSD) injuries has been noted. Lumbosacral dissociation injuries are an anatomical separation of the spinal column from the pelvis, and represent a manifestation of severe, high-energy trauma. Purpose: This study aimed to assess the clinical outcomes of combat-related LSD injuries at a mean of 7 years following operative treatment. Study Design: This is a retrospective review. Patient Sample: We identified 20 patients with operatively managed LSDs. Outcome Measures: Time from injury to arrival in the United States, operative details, fixation methods, postoperative complications, time to retirement from military service, disability, and ambulatory status at latest follow-up. Methods: We performed a retrospective review of outcomes of all patients with operatively managed combat-related LSD from January 1, 2003 to December 31, 2011. Results: Twenty patients met inclusion criteria and were treated as follows: posterior spinal fusion (12, 60%), sacroiliac screw fixation (7, 35%), and combined anterior-posterior fusion for associated L3 burst fracture (1, 5%). The mean age was 28.2±6.4 years old. The most common mechanism of injury was mounted improvised explosive device (IED, 55%). On average, 2.2 spinal regions were injured per patient. Neurologic dysfunction was present in 15 patients. Three patients underwent operative stabilization of their injuries before evacuation to the United States. Four patients had a postoperative wound infection and two patients underwent reoperation. Mean follow-up was 85.9 months (range: 39.7–140.8 months). At most recent follow-up, seventeen patients were no longer on active duty military service. Eight patients had persistent bowel dysfunction and nine patients had persistent bladder dysfunction. Fifteen patients reported chronic low back pain. Seventeen were ambulating and five had documentation of running following surgery. Conclusions: This is the largest series of operatively managed LSD in patients currently reported. Our series suggests that combat-related LSD injuries frequently result in persistent, long-term neurologic dysfunction, disability, and chronic pain. Operative management carries a high postoperative risk of infection. However, a select group of patients are highly functional at latest follow-up.