Lateral-rectus approach for treatment of pelvic and sacral fracture complicated with lumbosacral plexus injury

Objective To explore the lateral-rectus approach for surgical treatment of pelvic and sacral fracture with lum-bosacral plexus injury and its effect. Methods From January 2013 to January 2015, 9 patients had undergone internal fixation and decompression of the sacral nerve via the lateral-rectus approach. Classification of pelvic fracture included Tile B2 in 2 patients, Tile B3 in 1 patient, Tile C1 in 2 patients, Tile C2 in 1 patient, Tile C3 in 3 patients. According to Denis classification, 3 cases were type I and 6 were type II. Among them, 3 cases involved acetabular fracture, 5 cases complicated with limbs fracture and 5 cases had organ injury. The durations before operations were 7-59 days after the trauma. The fracture model was manufactured by 3D printing and fracture reduction was simulated on computer preoperatively. 5 of 9 patients underwent DSA to block the internal iliac artery 1 hour before surgery. The patient was in supine position, after general anesthesia, the sacroiliac joint was exposed via the lateral-rectus approach. Then S1 was approached between median sacral artery and lumbosacral trunk and internal iliac artery. After reduction of the sacral fracture and release of the sacral plexus nerve, the sacroiliac joint was fixed with a plate. Finally, the fracture of acetabulum and anterior ring of pelvis was repaired. Postoperative treatment included prevention of infection and thrombosis. Results All the 9 cases underwent the operation successfully. The average surgical time was 183 min (range, 125-224 min) and the mean blood loss was 1 150 ml (range, 440-2 760 ml). Postoperative X-ray and CT indicated an excellent reduction of fracture. No complication was observed. 5 of 6 patients with fresh fracture had recovery of neurologic function 3 months after operation and one was good. The neurological outcome of old fractures was good in two, unrecovered in one. Conclusion In surgical treatment of sacral fractures, the lateral-rectus approach provides adequate exposure of sacroiliac joint and the sacral plexus nerve could be well decompressed. A stable fixation could be achieved with a plate crossing the sacroiliac joint. Key words: Pelvis; Sacrum; Fractures, bone; Lumbosacral plexus