Acute traumatic spondyloptosis (ATS) is a rare injury resulting from high-energy impact creating an unstable injury which requires surgical reconstruction and stabilization. Although rarely described in clinical practice this injury needs to be emphasized due to severe clinical manifestations and poor prognosis. Purpose of this study is to provide the educational insight into the management of the rare injury along with reduction technique for managing such spinal dislocations.

A 34-year-old female presented to us in emergency department with trauma due to a landslide and complaint of multiple injuries over her back and pelvis. Patient had laceration over the sacrum with open sacral fracture along with right sided acetabular central fracture dislocation and ATS of L2/L3 which was diagnosed on X-ray and computed tomography (CT) scan of pelvis and spine (Fig. 1). Focused assessment with sonography in trauma showed no free fluid in pericardial, Morrison’s pouch, supra pubic and splenorenal pouch. On neurological examination, the patient had paraplegia with bowel and bladder involvement. Sensations were intact till L4. Patient had a heart rate of 100/min and blood pressure of 80/60. Four units of whole blood were transfused along with one liter of ringer lactate. Patient was stabilized and blood pressure of 110/80 along with heart rate of 78 was achieved. The severity of spinal injury was graded according to American spinal injury association (ASIA) grading scale as grade A. CT angiography showed no trauma to vessels in front of lumbar spine and in pelvis.

Operative procedure and follow-up

After stabilizing the patient, debridement of the open sacral fracture was done; however, we could not get anesthesia clearance to fix spine simultaneously. As the patient was kept Prone for the debridement with blood pressure on the lower side, simultaneous spine fixation was not possible due to deterioration while debriding the patient. Hence, the decision was taken to stabilize the patient first as the chances of neurological recovery were very less but saving the life of the patient was priority. The patient was again taken for surgery 2 days after the debridement of sacral wound for spine fixation. However, to decrease the blood loss during surgery and duration of the surgery, it was decided to do MIS posterior instrumentation of spine from L1 to L5 without fusion. We were able to achieve reduction at L2-L3 preoperatively by hyperextension and traction maneuver in supine position (Fig. 2); however, the reduction was partially lost when patient was positioned in prone during surgery. Pedicle screws were inserted two levels above and below L3 under C-ARM guidance. Reduction was easily achieved using reduction screws (Figs. 3 and 4). No CSF leak was encountered during surgery. Her pelvic injury was treated conservatively.

Six months postoperatively, the patient regained bowel sensation but there was no motor recovery in bilateral lower limbs. At 1 year follow-up, the status is the same.

The most common site of spondyloptosis is the lumbosacral joint. This type of injury is extremely rare. Thoracolumbar vertebral fractures most commonly affect thoracolumbar junction (T11-L2). Spondyloptosis is associated with severe neurological deficit with 80% of cases leading to complete paraplegia. Usually, higher energy traumas cause traumatic spondyloptosis with multi system collateral damage where multidisciplinary intervention becomes essential. We searched for strings, lumbar spondyloptosis/traumatic spondyloptosis/spondyloptosis, in PUBMED and found 28 cases of lumbar spondyloptosis reported before our case report. All of those cases along with junctional (lumbosacral and thoracolumbar) spondyloptosis are included in Table 1.

The fractures of bilateral pedicles and posterior elements reduce the threat of cord compromise in patients with spondyloptosis. However, prolonged dislocation may result in stasis of blood flow within the vertebral arteries leading to thrombus formation, and subsequent reduction may restore the blood flow and dislodge thrombus leading to ischemic events. We were able to reduce the dislocation preoperatively by hyperextending the lumbar spine. This was achieved by placing a small bolster below the lower back of the patient in supine position. The patient was taken for spine fixation 2 days after the injury.

Various reduction techniques have been suggested by different authors. Tang et al. ^[1] reported traumatic lumbosacral spondyloptosis with locked inferior articular process of L5 in a 33 year old man presenting with ASIA grade C which improved to ASIA grade D, 6 months postoperatively. Authors suggest removing the bilateral inferior articular processes if found locked preoperatively on radiology and then perform reduction during surgery. Li et al. ^[2] have published operative technique to reduce spondylosis in which they stated that operative strategies have usually employed open posterior approaches using distraction between pedicle screws in the sagittal plane and cantilevering anteriorly dislocated vertebrae back into alignment by applying reducers to screw heads, as well as intradiscal distraction with spreaders have also been described. Maneuvers such as manual abdominal pressure have proved effective in selected cases. Corpectomy through either the trans pedicular or thoracotomy route has also been utilized especially if initial reduction maneuvers fail. Despite these strategies, complete realignment could not be achieved in approximately 25% of cases. Transversely oriented rods have been employed for fracture reduction thoracolumbar junction but not in context of spondyloptosis or within the rigid thoracic spine. The technique of multiple horizontal rods placed in parallel to enable additional surgeon recruitment has relatively high success rates of both closed and open reduction of cervical fracture dislocations whether approached anteriorly or posteriorly the same is not true for thoracic dislocations, due to the remoteness of potential proximal and distal fixation points for traction and difficulties directly assessing the thoracic spine from ventrolateral approaches. However, in our case, we used reduction screws and distraction to reduce L2-3 spondyloptosis. Halder et al. ^[3] reported a case of spondyloptosis at L1-L2 in a 33 year old male patient following a road traffic accident with paraparesis who developed abdominal distension vomiting and gardening on day 4 of injury. Contrast-enhanced computed tomography of abdomen and pelvis revealed tethering of proximal jejunal loop between interface of translated L1-L2 vertebrae and resultant dilation of stomach and duodenum with splenic injury and hemoperitoneum. Patient was managed by doing exploratory laparotomy during which the jejunal loops were successfully freed and resection and anastomosis of the involved segment was done. However, the patient developed septic shock with acute respiratory distress syndrome and succumbed to it on day 14. In our case, we did not find any associated vascular and bowel injury. However, our patient had associated open pelvi-acetabular injury.

ATS of lumbar spine is rare and unstable Injury. About 50% of these patients present with complete neurologic injury. However, the aim of surgery should be to stabilize the spine and to decompress the neural structures as early as possible without risking injury to other vital structures. However, it is also essential to give priority to associated life threatening injuries that need multidisciplinary intervention.

Managing spondyloptosis is challenging as intensive care with comprehensive team of trauma is required. Reducing spondyloptosis is difficult but achievable with proper technique.