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Case Report-Traumatic L5-S1 Instability: Are Upright Radiographs Potentially Dangerous?
Andrew B Rees1, Andrew J Croft1, Emil Varas-Rodrguez1
1Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Background:
Traumatic lumbosacral instability is a rare but potentially devastating injury. These injuries are frequently associated with neurologic injury and often result in long-term disability. Despite their severity, radiographic findings can be subtle, and multiple reports exist in which these injuries were not recognized on initial imaging. Transverse process fractures, high-energy mechanisms, and other injury features have been suggested as indications for advanced imaging, which has a high degree of sensitivity in detecting unstable injuries.
Case Presentation:
A 21-year-old man presented to our level I trauma center after being ejected in a rollover motor vehicle collision. He sustained multiple injuries, including multiple lumbar transverse process fractures and a unilateral superior articular facet fracture of S1.
Primary Outcomes:
Initial supine computed tomography (CT) images showed no displacement of the fracture and no listhesis or instability. Subsequent upright imaging in a brace, however, demonstrated significant displacement of the fracture with dislocation of the contralateral L5-S1 facet joint and significant anterolisthesis. The patient underwent open posterior reduction and stabilization of L4-S1 followed by L5-S1 anterior lumbar interbody fusion. The patient demonstrated excellent alignment on postoperative imaging. At 3 months postoperatively, he had returned to work, was ambulating without assistance, and reported minimal back discomfort and no lower extremity pain, numbness, or weakness.
Conclusion:
This case serves as a warning that supine CT imaging alone may not be sufficient to rule out unstable lumbar spine injuries, such as traumatic L5-S1 instability, and that upright radiographs in these potentially unstable injuries may represent a hazard to patients. Fractures involving the pedicle, pars, or facet joints as well as multiple transverse process fractures and/or a high-energy mechanism of injury should all raise suspicion of instability and warrant additional imaging.
Clinical Relevance:
This article provides guidance on approaching treatment for patients with potential traumatic lumbosacral instability.
