Clinical Anatomy And Application Study Of Modified Pararectus Incision Approach For Sacral Fractures

Backgrounds:Traumatic sacral fractures often result in injuries to the posterior pelvic ring and multiple fractures of the pelvis,leading to malformations of the pelvic ring in multiple directions.Even today,the treatment of such fractures remains a challenge.Clinical studies have shown that conservative treatment of sacral fractures with obvious displacement often leaves serious complications,including neurological abnormalities,sexual dysfunction,bowel and urine dysfunction,abnormal gait,posture imbalance,and so on,with the clinical prognosis being worrying.Currently,surgical treatment remains the gold standard for these fractures.Reduction and fixation of fractures can not only reduce internal bleeding,reduce mortality,prevent malunion and allow early removal of fractures,but also provide a good recovery environment for injured nerves and significantly improve the long-term prognosis of patients.The traditional surgical method is the combination of anterior and posterior fracture reduction and fixation,which is complicated and traumatic,and requires the change of intraoperative position,resulting in a high incidence of complications.It has been reported that sacroiliac joint dislocation has been successfully treated by anterior surgery with satisfactory results.However,the anatomical study and clinical application of anterior approach in the treatment of sacrum are still blank.Objectives:1.To pinpoint the anatomical characteristics of the modified pararectus incision approach for sacral fracture,and to evaluate the safety and feasibility of the approach.2.To investigate the clinical effect of anterior sacral plate fixation for sacral fracture through modified pararectus incision approach,hoping to provide clinical basis for treatment.Methods:1.The fresh human species were investigated,with gross anatomy being performed on the side subject to modified pararectus incision approach to familiarize with the anatomical characteristics and path and make clear the exposure areas.Then the vertical distance of the lumbosacral trunk nerve from the sacral alar in the state of traction was measured and recorded.The other side of the pelvis was operated according to actual surgical standards,and the safety and feasibility of the approach were verified.2.A retrospective analysis was carried out on patients with modified pararectus incisions and anterior sacral fixation between 2016 and 2020,and the length of surgical incision,surgical duration,intraoperative blood loss and iatrogenic injury were observed.Postoperative fracture reduction was evaluated with Matta and Mears,and functional recovery was evaluated with VAS pain and Majeed score in the last follow-up.Results:1.Anatomical results:① exposure area:posterior pelvic:The lateral margin of the S1 vertebral body can be exposed medially,the L5 vertebral body can be exposed cephalally,and the S1 foramen can be exposed in the true pelvis;lateral exposure is the same as a traditional parabdominis approach;anterior pelvis:to the contralateral ramus of the pubis;② The lumbosacral plexus nerves(L4 to S1)can be explored and decompressed by the modified approach under direct vision,which is safe and effective.③There is a safe surgical operation area in front of L5 and S1,and the vertical distances between L4 and L5 nerve roots and the posterior edge of the sacral alar,the leading edge of the sacral alar and the midpoint between them are as follows:Right:12.01mm,Left:11.86;Right:13.82mm,Left:14.19;Right:13.91mm,Left:15.43 mm;2.Clinical results:all patients were followed up,with an average incision length of 7.7cm(6.5-10.5cm),an average blood loss of 660ml,an average operation duration of 142 min,and an average follow-up time of 51 months.The excellent and good rates of Matta,Mears and Majeed were 85.2%,88.9%and 92.6%,respectively,and the average VAS score was 0.67.All patients achieved bone union without internal fixation failure or infection.Conclusions:1.The results of anatomical and clinical application showed that the modified pararectus incision approach with anterior sacral plate fixation for the treatment of sacral fracture is characterized with a safe operation space,safe and feasible methods.2.The incision of the approach is small,and the operation from the muscle and peritoneal space is minimally invasive,with less intraoperative blood loss and low complications.The fracture can be reduced and fixed under direct vision,and the clinical effect is satisfactory,which provides a new idea for the selection of the approach and internal fixation of sacral fracture.