Lumbopelvic Fixation for Sacral Insufficiency Fracture Presenting with Sphincter Dysfunction

Sacral insufficiency fractures (SIFs) are common in the elderly. In patients with SIF, objective neurological abnormalities such as sphincter dysfunction or leg paresthesia are uncommon. We present a case of SIF accompanied by spinopelvic dissociation with late neurological compromise treated by spinopelvic fixation. A 61-year-old woman presented to our hospital with low back pain without obvious trauma history. She had a past history of eosinophilic granulomatosis with polyangiitis and treatment with steroids. Her low back pain became worse, and she started to have radiating left posterior thigh pain and motor weakness in the left ankle and both great toes with symptoms of stress urinary incontinence, constipation, and loss of anal sensation. Magnetic resonance imaging revealed an H-shaped sacrum fracture. We attributed the neurological symptoms to unstable SIF and performed lumbopelvic fixation. After the surgery, her leg pain and symptoms of stress urinary incontinence improved markedly, as did anal sensation. At a 6-month follow-up, the patient reported no low back pain and she was walking independently without pelvic complaints. CT showed bone union was achieved. Even minimally displaced SIF in patients with osteoporosis can be a cause of bowel and bladder disturbance. Lumbopelvic fixation is a treatment option for SIF with spinopelvic dissociation presenting neurological deficit.

Pudendal Afferents Mapping in Posterior Sacral Rhizotomies

BACKGROUND: The effectiveness of pudendal afferents mapping in posterior sacral rhizotomies needs to be reviewed. OBJECTIVE: To evaluate the effectiveness of pudendal afferents mapping for both the dorsal penile or clitoral nerve and the inferior anal nerve to decrease the risk of postoperative bowel and bladder dysfunction when the sacral nerve roots are candidates for rhizotomies. METHODS: A retrospective review of 101 Asian children who underwent functional posterior rhizotomies with pudendal afferents mapping for spastic paresis was performed. RESULTS: Pudendal mapping was successful in 75 of 81 patients. The highest activity of afferent fibers of the dorsal penile or clitoral nerve was demonstrated at the S1 roots in 13.3%, at the S2 in 79.3%, and at the S3-5 in 7.3%. Considerable activity of the dorsal penile or clitoral nerve was recorded at 40% of the S1 roots, at 99.3% of the S2 roots, and at 52% of the S3-5 roots. The highest activity of afferent fibers of the inferior anal nerve was demonstrated at S2 roots in 42% and at S3-5 roots in 58%. Considerable activity of the inferior anal nerve was recorded at 10.7% of S1 roots, at 89.3% of S2 roots, and at 76.7% of S3-5 roots. The pathological S1 roots were divided into 3 to 4 rootlets, and the rootlets with significant afferent activity were preserved. None of the 75 patients experienced long-term bowel or bladder complications. CONCLUSION: Pudendal afferent mapping identified the sacral rootlets involved with genital and anal sensation. The preservation of such rootlets in sacral rhizotomies is considered to be important for minimizing postoperative bladder and bowel dysfunction.

Sequestered Intradural Lumbar Disc

A 42-year-old farmer was lifting a hay bale and experienced a sudden onset of sharp pain radiating down his left leg. Over the ensuing week, the pain became less pronounced, but was replaced with a progressive left greater than right leg numbness, foot weakness, and urinary hesitancy. He presented to his local hospital, where he was initially managed conservatively, and then transferred to our institution for consultation after an MR lumbar spine was completed. On physical exam, he had grade 1/5 weakness of left and right dorsi- and plantar flexion. Sensory testing showed a moderate decrease in pinprick sensation in his left leg from L1 to S1 dermatomes. He was symmetrically hyporeflexic with grade 1 knee reflexes and absent ankle jerks. Peri-anal sensation was intact, but there was moderately reduced rectal tone. The remainder of his neurological exam was normal.