Spinal-Pelvic Dissociation in Pregnancy: Surgical Fixation o
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A 33-year-old gravid female from Pakistan presented to the Emergency Department with persistent, intractable low back pain and neuropathic left L5 leg pain, associated with a left foot drop. There was a notable history of weight loss for 1 year. Investigations revealed a large collection in the right posterior paraspinal muscles tracking from a large bony defect in the right half of her sacrum extending into the pelvis. The collection was suggestive of an abscess and underwent US-guided aspiration.

Culture, PCR examination, and bone biopsy were culture-negative for tuberculosis (TB). Samples taken from the placenta showed two small granulomata in the chorionic villi only. A multidisciplinary approach commenced with the initiation of empirical TB treatment and attempted normal vaginal delivery. An urgent cesarean section for the delivery of the baby was required for failure to proceed. Spinal-pelvic stabilization in two stages was performed for the unstable fracture pattern, followed by pharmacotherapy and physiotherapy rehabilitation.

At 12-month follow-up, the patient showed resolving TB and eradication of the paraspinal abscess. There were bony union and stability of the spinal-pelvic reconstruction. Back pain and sciatica can be common in pregnancy. However, this case highlights a rare occurrence of culture-negative extrapulmonary TB leading to an unstable spinal-pelvic fracture requiring a multidisciplinary approach for careful obstetric and orthopedic treatment with empirical treatment by the infectious disease team and microbiology.

This is the first case report of surgical stabilization of a highly unstable spinal-pelvic fracture dissociation due to an extrapulmonary tuberculous spinopelvic destructive skeletal lesion in a gravid female. Imaging is important to delineate the fracture pattern, and MRI and CT both have a role, despite fetal radiation safety. Empirical ATT must be considered early as there is a high risk of a culture-negative TB diagnosis. Normal delivery can be attempted, but in our case, there was a failure to proceed with SGA, and an emergent cesarean section was performed safely.

The orthopedic intervention was for gross instability, and an anterior Stoppa approach was used to access and stabilize the pelvic ring by open reduction and internal fixation. A second stage posterior approach was required to stabilize the spinopelvic dissociation using pedicle screws and iliac bolts. This case highlights the importance of maintaining a high level of suspicion for extrapulmonary tuberculosis for intractable back pain for a gravid female from the subcontinent.

Source:https://www.hindawi.com/journals/crior/2020/9769076/
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