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Noma M, Sato Y, Hara N, Yu J, Fukuhara H, Fukushima M, Nishizawa M, Komatsu N, Oshima Y. Treatment Outcomes of Lower Urinary Tract Symptoms due to Fragility Sacral Fractures: A Review of Eight Patients and Literature. World Neurosurg 2024; 188:e278-e287. [PMID: 38777323 DOI: 10.1016/j.wneu.2024.05.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Sacral fractures can cause lower urinary tract symptoms (LUTS) due to damage to the cauda equina. While several studies have reported on sacral fractures due to high-energy trauma, those due to fragility fractures have only been reported in case reports and their clinical differences are not well known. This study aimed to investigate the clinical characteristics of LUTS caused by fragility sacral fractures and propose a novel treatment strategy. METHODS This study is retrospective, uncontrolled, clinical case series. The inclusion criteria were sole sacral fractures due to low-energy trauma and appearance of LUTS after injury. Patients with additional spinal fractures or combined abdominal or pelvic organ injuries that could cause LUTS were excluded. Improvement in LUTS, period from onset to improvement, and imaging findings were recorded. RESULTS Eight patients met the inclusion criteria (4 surgical and 4 conservative treatment cases). Six patients showed improvement in LUTS. In surgical cases, the mean period from onset of LUTS to surgery and from onset of LUTS to improvement was 14.5 and 21.5 days, respectively. Intraoperative rupture or laceration of the dural sac was not observed. In 2 conservatively improved cases, the period from onset to improvement of LUTS was 14 and 17 days. CONCLUSIONS LUTS can improve even with conservative treatment and should be utilized as the primary choice. LUTS caused by severe sacral canal deformity and stenosis can be reversible, and the decision to perform surgical treatment is still timely if LUTS do not improve with conservative treatment for several weeks.
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Affiliation(s)
- Michita Noma
- Department of Orthopedic Surgery, Musashino Red Cross Hospital, Tokyo, Japan; Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yusuke Sato
- Department of Orthopedic Surgery, Musashino Red Cross Hospital, Tokyo, Japan; Department of Spine and Orthopedic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan.
| | - Nobuhiro Hara
- Department of Orthopedic Surgery, Musashino Red Cross Hospital, Tokyo, Japan
| | - Jim Yu
- Department of Orthopedic Surgery, Musashino Red Cross Hospital, Tokyo, Japan
| | - Hiroki Fukuhara
- Faculty of Medicine, Department of Urology, Yamagata University, Yamagata, Japan
| | | | - Mitsuhiro Nishizawa
- Department of Spine and Orthopedic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Naoto Komatsu
- Department of Orthopedic and Spine Surgery, Yokohama Rosai Hospital, Yokohama, Kanagawa, Japan
| | - Yasushi Oshima
- Department of Orthopedic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Sarigul B, Ogrenci A, Yilmaz M, Koban O, Mammadov M, Dalbayrak S. Sacral insufficiency fracture: a single-center experience of 185 patients with a minimum 5-year follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1511-1517. [PMID: 37955749 DOI: 10.1007/s00586-023-08027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/29/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE Sacral insufficiency fracture (SIF) is a commonly underdiagnosed etiology of back pain, especially in the geriatric and osteoporotic population. In this clinical study, we present our experience of 185 patients who were diagnosed with SIF and managed either with conservative or surgical treatment with a minimum 5-year follow-up. MATERIALS AND METHOD Patients who were diagnosed with SIF, managed either conservatively or surgically, and had a minimum 5-year follow-up medical record were included in this study. CT scans and MR imaging including coronal STIR sequence were obtained from all. Bone densitometry (DEXA) was performed to detect accompanying osteopenia or osteoporosis. Patients were treated either conservatively or surgically. VAS and ODI scores were evaluated prior to the treatment and 1st day, 10th day, 3rd month, and 1st year postoperatively. RESULTS The mean age of 185 patients was 69.2 and the mean follow-up period was 7.23 years (range: 5-11 years). 46 (24.9%) patients had a previous spinal or spinopelvic surgery and spinal instrumentation was implemented in 22(11.89%) of them. The time interval between the fusion surgery and the diagnosis of SIF was approximately 9.48 weeks. The fracture line could be detected with the MRI in 164 patients and with the CT in 177 patients. The fracture was bilateral in 120 (64.8%) patients. 102 patients were treated conservatively, and 83 received sacroplasty. VAS and ODI scores showed better improvement in pain and functionality in the surgical management group than in the conservative management group. CONCLUSION SIF should be considered in the differential diagnosis of back and pelvic pain, especially in elderly and osteoporotic patients. MRI with coronal STIR imaging should be a standard protocol for patients with a risk of SIF. Our results show that sacroplasty provides better and faster pain relief and recovery than conservative management.
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Affiliation(s)
- Buse Sarigul
- Department of Neurosurgery, Medicana International Atasehir Hospital, Istanbul, Turkey.
| | - Ahmet Ogrenci
- Department of Neurosurgery, Medicana International Atasehir Hospital, Istanbul, Turkey
| | - Mesut Yilmaz
- Department of Neurosurgery, Neurospinal Academy, Istanbul, Turkey
| | - Orkun Koban
- Department of Neurosurgery, Lokman Hekim Hospital, Istanbul, Turkey
| | - Mazhar Mammadov
- Department of Neurosurgery, Lokman Hekim Hospital, Istanbul, Turkey
| | - Sedat Dalbayrak
- Department of Neurosurgery, Medicana International Atasehir Hospital, Istanbul, Turkey
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Singh M, Balmaceno-Criss M, Knebel A, Kuharski M, Sakr I, Daher M, McDonald CL, Diebo BG, Czerwein JK, Daniels AH. Sacroplasty for Sacral Insufficiency Fractures: Narrative Literature Review on Patient Selection, Technical Approaches, and Outcomes. J Clin Med 2024; 13:1101. [PMID: 38398413 PMCID: PMC10889545 DOI: 10.3390/jcm13041101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Sacral insufficiency fractures commonly affect elderly women with osteoporosis and can cause debilitating lower back pain. First line management is often with conservative measures such as early mobilization, multimodal pain management, and osteoporosis management. If non-operative management fails, sacroplasty is a minimally invasive intervention that may be pursued. Candidates for sacroplasty are patients with persistent pain, inability to tolerate immobilization, or patients with low bone mineral density. Before undergoing sacroplasty, patients' bone health should be optimized with pharmacotherapy. Anabolic agents prior to or in conjunction with sacroplasty have been shown to improve patient outcomes. Sacroplasty can be safely performed through a number of techniques: short-axis, long-axis, coaxial, transiliac, interpedicular, and balloon-assisted. The procedure has been demonstrated to rapidly and durably reduce pain and improve mobility, with little risk of complications. This article aims to provide a narrative literature review of sacroplasty including, patient selection and optimization, the various technical approaches, and short and long-term outcomes.
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Affiliation(s)
- Manjot Singh
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Mariah Balmaceno-Criss
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Ashley Knebel
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Michael Kuharski
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Itala Sakr
- Department of Orthopedic Surgery, Hotel Dieu de France, Beirut 166830, Lebanon
| | - Mohammad Daher
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Christopher L. McDonald
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Bassel G. Diebo
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - John K. Czerwein
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Alan H. Daniels
- Department of Orthopedic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
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Luo HE, Yu WQ, Su XP, He CY, Lu ZX, Zhang DW, Tan XY. Bilateral insufficiency fracture of coracoid process: A rare case report. SAGE Open Med Case Rep 2023; 11:2050313X231187977. [PMID: 37529077 PMCID: PMC10387672 DOI: 10.1177/2050313x231187977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
A 69-year-old man was admitted to the hospital for a left femoral neck fracture. A preliminary chest computed tomography scan showed no coracoid process fracture. The patient had no history of trauma during his hospitalization. However, subsequent in-hospital computed tomography scan revealed bilateral coracoid process fracture. The patient underwent hip replacement surgery for femoral neck fracture, while conservative treatment was administered for the bilateral coracoid process fracture. After 1-year follow-up, the patient was diagnosed with bilateral insufficiency fracture of coracoid process after ruling out other types of fractures. The fractures did not heal while functions in both shoulders were adequate. Insufficiency fracture should be considered when fractures occur without trauma, especially in the presence of associated risk factors such as chronic renal failure and osteoporosis. For bilateral insufficiency fracture of coracoid process, conservative treatment is acceptable.
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Affiliation(s)
- Hai-En Luo
- Department of Orthopedic Surgery, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, Hunan Province, China
| | - Wen-Qi Yu
- Department of Orthopedic Surgery, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, Hunan Province, China
| | - Xin-Ping Su
- Department of Orthopedic Surgery, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, Hunan Province, China
| | - Can-Yu He
- Department of Orthopedic Surgery, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, Hunan Province, China
| | - Zhen-Xiang Lu
- Department of Orthopedic Surgery, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, Hunan Province, China
| | - Dao-Wei Zhang
- Department of Orthopedic Surgery, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, Hunan Province, China
| | - Xu-Yi Tan
- Department of Orthopedic Surgery, Hunan Academy of Chinese Medicine Affiliated Hospital, Changsha, Hunan Province, China
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Arthur RY, Johnson JP. Surgical treatment of sacral nonunions. Injury 2023:S0020-1383(23)00406-0. [PMID: 37179204 DOI: 10.1016/j.injury.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
Sacral fractures are complex injuries that follow a bimodal distribution, typically involving acute high energy trauma in young adults and low energy trauma in older adults (> 65 years old). Nonunion is a rare but debilitating potential complication of undiagnosed or improperly managed sacral fractures. Various surgical techniques, including open reduction and internal fixation, sacroplasty, and percutaneous screw fixation, have been used to manage these fracture nonunions. In addition to reviewing the initial management of sacral fractures and the risk factors for fracture nonunion, this article describes techniques, specific cases and outcomes of these treatment strategies.
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Affiliation(s)
- Rodney Y Arthur
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 510 20th St South, Faculty Office Tower 901, Birmingham, AL 35294, USA
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 510 20th St South, Faculty Office Tower 901, Birmingham, AL 35294, USA.
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Yang YC, Hsieh MH, Chien JT, Liu KC, Yang CC. Teriparatide treatment shows faster healing than sacroplasty for postmenopausal women with sacral insufficiency fracture. Osteoporos Sarcopenia 2023; 9:27-31. [PMID: 37082353 PMCID: PMC10111959 DOI: 10.1016/j.afos.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/06/2023] [Accepted: 02/03/2023] [Indexed: 04/22/2023] Open
Abstract
Objectives Sacral insufficiency fracture (SIF) is not an uncommon osteoporosis fracture among the elderly. Aside from traditional treatments, sacroplasty and teriparatide (TPTD) injection have been introduced. This report aims to compare the effects of sacroplasty and teriparatide on clinical outcomes of SIF. Methods Thirty-one elderly patients with SIF were enrolled in this retrospective observational study. Four male patients were excluded. Fourteen patients who received TPTD for 6 months were classified into the TPTD group (TT), and 13 who underwent sacroplasty were classified into the sacroplasty group (SS). All patients in both groups were instructed to take calcium and vitamin D supplements daily. Their symptoms and signs, visual analog score (VAS), Oswestry disability index (ODI), and radiographic studies were retrospectively reviewed. Results The TT group showed significantly lower VAS than SS group after 3 (P < 0.001) and 6 months of treatment (P < 0.001). The TT group also has significant lower ODI than SS group after 1 (P = 0.010), 3 (P = 0.005) and 6 months (P < 0.001) of treatment. Upon generalized estimating equations (GEE) analysis, the TT group showed significantly more reduction in both VAS and ODI compared to the SS group at 1 month (P = 0.022, P = 0.001), 3 months (P < 0.001, P < 0.001), and 6 months (P < 0.001, P < 0.001) post-treatment. Conclusions Postmenoposal woman with SIF who received TPTD healed better than those who underwent sacroplasty after 1 month treatment.
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Affiliation(s)
- Yao-Chun Yang
- National Taiwan University, School of Medicine, Taiwan
| | - Min-Hong Hsieh
- Department of Orthopedics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, 62247, Taiwan
- School of Medicine, Tzu Chi University, 97071, Taiwan
| | - Jui-Teng Chien
- Department of Orthopedics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, 62247, Taiwan
- School of Medicine, Tzu Chi University, 97071, Taiwan
| | - Keng-Chang Liu
- Department of Orthopedics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, 62247, Taiwan
| | - Chang-Chen Yang
- Department of Orthopedics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, 62247, Taiwan
- School of Medicine, Tzu Chi University, 97071, Taiwan
- Corresponding author. Department of Orthopedics, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.
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Internal fixation of radiation-induced fragility fractures of the pelvis: a case series. Arch Orthop Trauma Surg 2023; 143:865-871. [PMID: 35107637 DOI: 10.1007/s00402-022-04358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/14/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. PURPOSE The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. METHODS A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. RESULTS Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. CONCLUSION RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. LEVEL OF EVIDENCE III, retrospective study.
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Andresen JR, Radmer S, Andresen R, Prokop A, Schröder G, Nissen U, Schober HC. Comparative outcome of different treatment options for fragility fractures of the sacrum. BMC Musculoskelet Disord 2022; 23:1106. [PMID: 36536363 PMCID: PMC9762048 DOI: 10.1186/s12891-022-06039-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS. METHODS Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included. RESULTS Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases. CONCLUSIONS Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.
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Affiliation(s)
- Julian Ramin Andresen
- grid.263618.80000 0004 0367 8888Medical School, Sigmund Freud University, Vienna, Austria
| | | | - Reimer Andresen
- grid.9764.c0000 0001 2153 9986Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Axel Prokop
- grid.10392.390000 0001 2190 1447Department of Trauma Surgery, Sindelfingen, Academic Teaching Hospital of the University of Tübingen, Tübingen, Germany
| | - Guido Schröder
- Clinic of Orthopaedics and Trauma Surgery, Warnow Klinik, Bützow, Germany
| | - Urs Nissen
- grid.9764.c0000 0001 2153 9986Department of Neurosurgery and Spine Surgery, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Hans-Christof Schober
- grid.10493.3f0000000121858338Department of Internal Medicine IV, Municipal Hospital Südstadt Rostock, Academic Teaching Hospital of the University of Rostock, Rostock, Germany
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Andresen JR, Radmer S, Prokop A, Schröder G, Schober HC, Andresen R. [Sacral fragility fractures: risk factors and outcomes after cement sacroplasty]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:976-985. [PMID: 36352271 PMCID: PMC9715472 DOI: 10.1007/s00132-022-04323-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The objective of the present study on patients with fragility fractures of the sacrum (FFS) was to assess existing risk factors and clinical outcomes after cement sacroplasty (CSP). PATIENTS AND METHODS 68 patients (64 women, 4 men) with previous FFS were followed up retrospectively. CT and MRI images were used to classify fractures according to Denis et al. and Rommens and Hofmann. Bone mineral content was determined by QCT in all patients. Concomitant diseases as well as central and peripheral fractures were recorded, considering the patient's medical history and X‑ray images. Vitamin D levels were also determined. If conservative therapy was unsuccessful, CSP was performed. The results were documented on the basis of pain development, physical independence, patient satisfaction, complication rate and mortality. RESULTS The age of the women in the study was Ø 83.2 (72-99) and that of the men Ø 77.8 (76-85) years. 42.4% had a Denis type 1, 4.2% a Denis type 2, 0% a Denis type 3, 43.3% a Denis type 1-2 and 10.1% a Denis type 1-2-3 fracture zone. FFP type II a to II c fractures were found in 88.2%, FFP type III c in 7.4% and FFP type IV b in 4.4%. Bilateral FFS were found in 68.8%. The average bone mineral content (BMC) was 35.4 (2-74) mg/ml, and the average vitamin D value was 8.8 (0-28) nmol/l. Other osteoporosis-associated fractures were found in around 50% of the patients. After CSP, patients showed a rapid and significant (p < 0.001) reduction in pain and sustained clinical improvement. CONCLUSION FFS fracture risk factors were found to be female gender, advanced age, existing osteoporosis and severe vitamin‑D deficiency. Patients with non-displaced FFS who could not be mobilised due to pain experienced sustained benefit from CSP.
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Affiliation(s)
- Julian Ramin Andresen
- Medizinische Fakultät, Sigmund Freud Privatuniversität, Freudplatz 3, 1020, Wien, Österreich.
| | - Sebastian Radmer
- Zentrum für Bewegungsheilkunde, Facharztpraxis für Orthopädie, Berlin, Deutschland
| | - Axel Prokop
- Klinik für Unfallchirurgie, Sindelfingen, Klinikverbund Südwest, Akademisches Lehrkrankenhaus der Universität Tübingen, Tübingen, Deutschland
| | - Guido Schröder
- Abteilung für Orthopädie und Unfallchirurgie, Warnow Klinik Bützow, Bützow, Deutschland
| | - Hans-Christof Schober
- Klinik für Innere Medizin IV, Klinikum Südstadt Rostock, Akademisches Lehrkrankenhaus der Universität Rostock, Rostock, Deutschland
| | - Reimer Andresen
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Westküstenklinikum Heide, Akademisches Lehrkrankenhaus der Universitäten Kiel, Lübeck und Hamburg, Heide, Heide, Deutschland
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The "Eiffel Tower" technique: novel long-axis sacroplasty under electromagnetic navigation assistance; feasibility and descriptive study. Eur Radiol 2022; 32:7640-7646. [PMID: 35511259 DOI: 10.1007/s00330-022-08825-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/05/2022] [Accepted: 04/14/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To describe a novel long-axis multimodal navigation assisted technique - the so-called Eiffel Tower technique - aimed at integrating recent technological improvements for the routine treatment of sacral insufficiency fractures. MATERIALS AND METHODS The long-axis approach described in the present study aimed at consolidating the sacral bone according to biomechanical considerations. The purpose was (i) to cement vertically the sacral alae all along and within the lateral fracture lines, resembling the pillars of a tower, and (ii) to reinforce cranially with a horizontal S1 landing zone (or dense central bone) resembling the first level of the tower. An electromagnetic navigation system was used in combination with CT and fluoroscopic guidance to overtop extreme angulation challenges. All patients treated between January 2019 and October 2021 in a single tertiary center were retrospectively reviewed. RESULTS A description of the technique is provided. Twelve female patients (median age: 80 years [range: 32 to 94]) were treated for sacral insufficiency fractures with the "Eiffel Tower" technique. The median treatment delay was 8 weeks (range: 3 to 20) and the initial median pain assessed by the visual analogue scale was 7 (range: 6 to 8). Pain was successfully relieved (visual analogue score < 3) for 9 patients (75%) and persisted for 2 patients (17%). One patient was lost during the follow-up. No complication was noted. CONCLUSION The "Eiffel Tower" multimodal cementoplasty integrates recent technological developments, in particular electromagnetic navigation, with the purpose of reconstructing the biomechanical chain of the sacral bone. KEY POINTS • Sacral insufficiency fractures are common and can be efficiently treated with percutaneous sacroplasty. • The long axis sacroplasty approach can be challenging given both the shape of the sacral bone and the angulation to reach the target lesion. • The "Eiffel Tower" technique is a novel approach using electromagnetic navigation to expand the concept of the long axis route, adding a horizontal S1 landing zone.
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Vasdev R, DeWitt-Foy M, Elliott SP. Sacral Insufficiency Fractures After Total Pubectomy for Osteomyelitis: A Case Series. Urology 2022; 170:203-208. [PMID: 36115424 DOI: 10.1016/j.urology.2022.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To document the incidence, risk factors, and prevalence of sacral insufficiency fractures (SIF) among patients who have undergone total pubectomy for osteomyelitis. METHODS A retrospective chart review was performed of patients undergoing total pubectomy for osteomyelitis at a single institution from 2016 to 2021. Descriptive statistics and univariate analysis were performed using the Wilcoxon rank-sum test and Fisher exact test as appropriate. RESULTS Sixteen patients underwent total pubectomy for osteomyelitis. The median age was 68 years. 12/16 (75%) had previously received pelvic radiotherapy. The median BMI was 27.8 kg/m2. Eleven (68.75%) had postoperative pelvic imaging, of which 3 (27.3%) had a new SIF. One other patient had a SIF 3 days before pubectomy. Three SIFs were detected via MRI and one by CT scan. The median BMI of patients with SIF was significantly lower than those without SIF (22.4 v 30.5, p = 0.004). All patients with SIF presented with new pelvic or perineal pain without radiculopathy. Symptoms resolved for three patients with non-opioid analgesics, physical therapy, and/or a brief trial of opioids. CONCLUSIONS Sacral insufficiency fracture is a rare sequela of total pubectomy for osteomyelitis. Lower BMI is significantly associated with SIF perhaps due to reduced muscle mass or poor bone condition and, as a result, baseline pelvic instability. Medical management should be first-line therapy.
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Rickert MM, Windmueller RA, Ortega CA, Devarasetty VVNM, Volkmar AJ, Waddell WH, Mitchell PM. Sacral Insufficiency Fractures. JBJS Rev 2022; 10:01874474-202207000-00001. [PMID: 35849657 DOI: 10.2106/jbjs.rvw.22.00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. » The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. » Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. » Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. » The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.
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Affiliation(s)
- Mariel M Rickert
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Aranke M, McCrudy G, Rooney K, Patel K, Lee CA, Hasoon J, Kaye AD. Minimally Invasive and Conservative Interventions for the Treatment of Sacroiliac Joint Pain: A Review of Recent Literature. Orthop Rev (Pavia) 2022; 14:34098. [PMID: 35769646 PMCID: PMC9235436 DOI: 10.52965/001c.34098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/06/2021] [Indexed: 04/05/2024] Open
Abstract
Sacroiliac joint (SIJ) pain is responsible for approximately 15-25% of reported back pain. Patients with SIJ pain report some of the lowest quality of life scores of any chronic disease. Understanding of the physiology and pathology of the SI joint has changed dramatically over the years, and SI joint pain and injury can now be thought of in two broad categories: traumatic and atraumatic. Both categories of SI joint injury are thought to be caused by inflammation or injury of the joint capsule, ligaments, or subchondral bone in the SI joint. Treatment of SI joint pain usually involves a multi-pronged approach, utilizing both, multi-modal medical pain control and interventional pain/surgical techniques such as steroid injections, radiofrequency nerve ablation, and minimally invasive sacroiliac arthrodesis. Though conservative management through multi-modal pain control and physical therapy have their role as first line therapies, an increasing body of evidence supports the use of minimally invasive procedures, both as adjuvant treatments to conservative management and as second line therapies for patient's that fail first line treatment.
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Affiliation(s)
- Mayank Aranke
- Department of Anesthesiology, University of Texas Health Science Center
| | - Grace McCrudy
- LSU Health Sciences Center Shreveport School of Medicine
| | - Kelsey Rooney
- LSU Health Sciences Center Shreveport School of Medicine
| | - Kunaal Patel
- LSU Health Sciences Center Shreveport School of Medicine
| | - Christopher A Lee
- Department of Internal Medicine, Creighton University School of Medicine-Phoenix Regional Campus
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport
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14
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Heiman E, Gencarelli P, Tang A, Yingling JM, Liporace FA, Yoon RS. Fragility Fractures of the Pelvis and Sacrum: Current Trends in Literature. Hip Pelvis 2022; 34:69-78. [PMID: 35800130 PMCID: PMC9204239 DOI: 10.5371/hp.2022.34.2.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/20/2022] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Fragility fractures of the pelvis (FFP) and fragility fractures of the sacrum (FFS), which are emerging in the geriatric population, exhibit characteristics that differ from those of pelvic ring disruptions occurring in the younger population. Treatment of FFP/FFS by a multidisciplinary team can be helpful in reducing morbidity and mortality with the goal of reducing pain, regaining early mobility, and restoring independence for activities of daily living. Conservative treatment, including bed rest, pain therapy, and mobilization as tolerated, is indicated for treatment of FFP type I and type II as loss of stability is limited with these fractures. Operative treatment is indicated for FFP type II when conservative treatment has failed and for FFP type III and type IV, which are displaced fractures associated with intense pain and increased instability. Minimally invasive stabilization techniques, such as percutaneous fixation, are favored over open reduction internal fixation. There is little evidence regarding outcomes of patients with FFP/FFS and more literature is needed for determination of optimal management. The aim of this article is to provide a concise review of the current literature and a discussion of the latest recommendations for orthopedic treatment and management of FFP/FFS.
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Affiliation(s)
- Erick Heiman
- Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Pasquale Gencarelli
- Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Alex Tang
- Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - John M. Yingling
- Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Frank A. Liporace
- Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Richard S. Yoon
- Division of Orthopedic Trauma and Adult Reconstruction, Department of Orthopedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
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15
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Jäckle K, Meier MP, Seitz MT, Höller S, Spering C, Acharya MR, Lehmann W. A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries. BMC Musculoskelet Disord 2021; 22:1035. [PMID: 34903216 PMCID: PMC8670246 DOI: 10.1186/s12891-021-04925-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fragility fractures without significant trauma of the pelvic ring in older patients were often treated conservatively. An alternative treatment is surgery involving percutaneous screw fixation to stabilize the posterior pelvic ring. This surgical treatment enables patients to be mobilized quickly and complications associated with bedrest and temporary immobility are reduced. However, the functional outcome following surgery and quality of life of the patients have not yet been investigated. Here, we present a comprehensive study addressing the long-term well-being and the quality of life of patients with fragility pelvic ring fractures after surgical treatment. METHODS Between 2011-2019, 215 geriatric patients with pelvic ring fractures were surgically treated at the university hospital in Göttingen (Germany). Of these, 94 patients had fragility fractures for which complete sets of computer tomography (CT) and radiological images were available. Fractures were classified according to Tile and according to the FFP classification of Rommens and Hofmann. The functional outcome of surgical treatment was evaluated using the Majeed pelvic score and the Short Form Health Survey-36 (SF-36). RESULTS Thirty five tile type C and 48 type B classified patients were included in the study. After surgery eighty-three patients scored in average 85.92 points (± 23.39) of a maximum of 100 points using the Majeed score questionnaire and a mean of 1.60 points on the numerical rating scale ranging between 0 and 10 points where 0 points refers to "no pain" and 10 means "strongest pain". Also, the SF-36 survey shows that surgical treatment positively effects patients with respect to their general health status and by restoring vitality, reducing bodily pain and an increase of their general mental health. CONCLUSIONS Patients who received a percutaneous screw fixation of fragility fractures of the posterior pelvic ring reported an overall positive outcome concerning their long-term well-being. In particular, older patients appear to benefit from surgical treatment. TRIAL REGISTRATION Functional outcome and quality of life after surgical treatment of fragility fractures of the posterior pelvic ring, DRKS00024768. Registered 8th March 2021 - Retrospectively registered. Trial registration number DRKS00024768 .
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Affiliation(s)
- Katharina Jäckle
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany.
| | - Marc-Pascal Meier
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Mark-Tilmann Seitz
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Sebastian Höller
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Christopher Spering
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Mehool R Acharya
- Pelvic and Acetabular Reconstruction Unit, Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Bristol, BS10 5NB, UK
| | - Wolfgang Lehmann
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
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16
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Sabaliauskas V, Tiškevičius S. Diagnosing sacral insufficiency fractures after radiotherapy in women with cervical cancer: Report of three cases. Radiol Case Rep 2021; 16:2938-2944. [PMID: 34401030 PMCID: PMC8350190 DOI: 10.1016/j.radcr.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Diagnosing sacral insufficiency fractures (SIF) in oncology patients is a challenge to radiologists, and recognition of imaging features is essential in order to avoid misdiagnosis of bone metastases and prevent patients from inaccurate treatment. Clinical cases in order to better understand the essence of this pathology and to make diagnosis easier, we present three clinical cases of SIF in patients with cervical cancer. All patients received radiation therapy (external beam radiation and brachytherapy) and chemotherapy with cisplatin. Patients underwent pelvic MRI, CT, SPECT or SPECT/CT examinations. One patient underwent a FDG-PET/CT examination. Conclusions SPECT/CT should be included in the differential diagnostics when radiological features of pelvic bone pathology on CT or MRI are undetermined or SIF are suspected. SIF must always be considered in oncology patients with pelvic pain, especially in postmenopausal state and after radiation therapy. For patients with osteoporosis, bone density screening and precise review of the most common fracture sites are recommended.
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17
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Sahota O, Leighton P, Cameron M, Taylor R, Ong T, Drummond A, Hendrick P, Quraishi N, Salem K. ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation): Perceptions in the Assessment and Treatment of Pubic Rami and Sacral Fragility Fractures Amongst Healthcare Professionals in Geriatric Medicine and Surgery-A Qualitative Study. Geriatr Orthop Surg Rehabil 2021; 12:21514593211026794. [PMID: 34290898 PMCID: PMC8273401 DOI: 10.1177/21514593211026794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/27/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Pubic rami fragility fractures are common in older people and result in significant morbidity and increased mortality. Co-existing fractures of the sacrum are common, but routinely missed. The aim of the study was to explore the perceptions in the assessment and treatment of pubic rami and sacral fragility fractures amongst healthcare professionals. Methods: We interviewed 14 participants about their experience in the assessment and treatment of patients presenting with pubic rami fragility fractures. Data was analyzed using an inductive thematic approach. Results: The majority of patients presenting with a pubic rami fragility fracture were managed by geriatricians. However, many of the geriatricians were not aware that these fractures have a high association with co-existing sacral fragility fractures. Furthermore, they were not aware of the limitations of standard x-ray imaging, nor of the potential benefits of surgical intervention for sacral fragility fractures. Spinal surgeons recommended that early, more specialist imaging in patients with pubic rami fragility fractures failing to mobilize, would change clinical management, if found to have a coexisting sacral fragility fracture, amenable to surgical intervention. Conclusions: The awareness, assessment and management of sacral fragility fractures in patients presenting with pubic rami fragility fractures is poor amongst healthcare professionals in geriatric medicine. Spinal surgeons in this study advocate early further imaging and surgical intervention in patients confirmed to have a concomitant sacral fragility fracture who are failing to mobilize.
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Affiliation(s)
- Opinder Sahota
- Department of HCOP, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,University of Nottingham, Nottingham, United Kingdom.,National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham, United Kingdom
| | - Paul Leighton
- University of Nottingham, Nottingham, United Kingdom
| | - Maribel Cameron
- Department of HCOP, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Rachael Taylor
- Department of HCOP, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Terence Ong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Paul Hendrick
- University of Nottingham, Nottingham, United Kingdom
| | - Nasir Quraishi
- The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Khalid Salem
- The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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18
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Caetano AP, Mascarenhas VV, Machado PM. Axial Spondyloarthritis: Mimics and Pitfalls of Imaging Assessment. Front Med (Lausanne) 2021; 8:658538. [PMID: 33968964 PMCID: PMC8100693 DOI: 10.3389/fmed.2021.658538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/11/2021] [Indexed: 01/15/2023] Open
Abstract
Axial spondyloarthritis (axSpA) is a chronic inflammatory disorder that predominantly involves the axial skeleton. Imaging findings of axSpA can be divided into active changes, which include bone marrow edema, synovitis, enthesitis, capsulitis, and intra-articular effusion, and structural changes, which include erosions, sclerosis, bone fatty infiltration, fat deposition in an erosion cavity, and bone bridging or ankylosis. The ability to distinguish between imaging lesions suggestive of axSpA and artifacts or lesions suggestive of other disorders is critical for the accurate diagnosis of axSpA. Diagnosis may be challenging, particularly in early-stage disease and magnetic resonance imaging (MRI) plays a key role in the detection of subtle or inflammatory changes. MRI also allows the detection of structural changes in the subchondral bone marrow that are not visible on conventional radiography and is of prognostic and monitoring value. However, bone structural changes are more accurately depicted using computed tomography. Conventional radiography, on the other hand, has limitations, but it is easily accessible and may provide insight on gross changes as well as rule out other pathological features of the axial skeleton. This review outlines the imaging evaluation of axSpA with a focus on imaging mimics and potential pitfalls when assessing the axial skeleton.
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Affiliation(s)
- António Proença Caetano
- Radiology Department, Hospital de Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Vasco V Mascarenhas
- Musculoskeletal Imaging Unit, Grupo Luz Saúde, Radiology Department, Imaging Center, Hospital da Luz, Lisbon, Portugal.,EpiDoC Unit, Chronic Diseases Research Centre, NOVA Medical School, Lisbon, Portugal
| | - Pedro M Machado
- Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, United Kingdom.,National Institute for Health Research (NIHR) Biomedical Research Centre, University College London Hospitals National Health Service Foundation Trust, London, United Kingdom.,Department of Rheumatology, London North West University Healthcare National Health Service Trust, London, United Kingdom
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Urits I, Amgalan A, Israel J, Dugay C, Zhao A, Berger AA, Kassem H, Paladini A, Varrassi G, Kaye AD, Miriyala S, Viswanath O. A comprehensive review of the treatment and management of Charcot spine. Ther Adv Musculoskelet Dis 2020; 12:1759720X20979497. [PMID: 33414850 PMCID: PMC7750571 DOI: 10.1177/1759720x20979497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/16/2020] [Indexed: 12/17/2022] Open
Abstract
Charcot spine arthropathy (CSA), a result of reduced afferent innervation, is an occurrence of Charcot joint, a progressive, degenerative disorder in vertebral joints, related mostly to spinal cord injury. The repeated microtrauma is a result of a lack of muscle protection and destroys cartilage, ligaments, and disc spaces, leading to vertebrae destruction, joint instability, subluxation, and dislocation. Joint destruction compresses nerve roots, resulting in pain, paresthesia, sensory loss, dysautonomia, and spasticity. CSA presents with back pain, spinal deformity and instability, and audible spine noises during movement. Autonomic dysfunction includes bowel and bladder dysfunction. It is slowly progressive and usually diagnosed at a late stage, usually, on average, 20 years after the first initial insult. Diagnosis is rarely clinical related to the nature of nonspecific symptoms and requires imaging with computed tomography (CT) and magnetic resonance imaging (MRI). Conservative management focuses on the prevention of fractures and the progression of deformities. This includes bed rest, orthoses, and braces. These could be useful in elderly or frail patients who are not candidates for surgical treatment, or in minimally symptomatic patients, such as patients with spontaneous fusion leading to a stable spine. Symptomatic treatment is offered for autonomic dysfunction, such as anticholinergics for bladder control. Most patients require surgical treatment. Spinal fusion is achieved with open, minimally-open (MOA) or minimally-invasive (MIS) approaches. The gold standard is open circumferential fusion; data is lacking to determine the superiority of open or MIS approaches. Patients usually improve after surgery; however, the rarity of the condition makes it difficult to estimate outcomes. This is a review of the latest and seminal literature about the treatment and chronic management of Charcot spine. The review includes the background of the syndrome, clinical presentation, and diagnosis, and compares the different treatment options that are currently available.
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Affiliation(s)
- Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
| | - Ariunzaya Amgalan
- Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jacob Israel
- Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Chase Dugay
- Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, AZ, USA
| | - Alex Zhao
- Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amnon A Berger
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Hisham Kassem
- Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami, FL, USA
| | | | | | - Alan D Kaye
- Department of Anesthesiology, LSUHSC School of Medicine, Shreveport, Louisiana, USA
| | - Sumitra Miriyala
- Department of Cellular Biology and Anatomy, LSUHSC School of Medicine, Shreveport, Louisiana, USA
| | - Omar Viswanath
- Department of Anesthesiology, LSUHSC School of Medicine, Shreveport, Louisiana, USA
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20
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Effect of Complex Korean Medicine Treatment on Sacral Insufficiency Fracture: A Case Report. JOURNAL OF ACUPUNCTURE RESEARCH 2020. [DOI: 10.13045/jar.2020.00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Sacral insufficiency fractures (SIF) are a common, but often underdiagnosed source of lower back pain without apparent trauma. This report presents the clinical outcome of a 75-year-old female with SIF, and an underlying medical history of osteoporosis and rheumatoid arthritis. She was treated non-operatively, in-hospital, with Korean medicine. Patient progress was assessed using the numerical rating scale and selfreported symptoms. Post-treatment, the numerical rating scale score for pain in her hip decreased from 7 to 2. At admission, the patient was unable to sit, and could only walk 3 m with assistance. At discharge, she could sit for longer than 1 hour and walk further than 200 m unassisted. On the follow-up visit, the patient was asymptomatic, and x-ray scans showed ossification of the sacral and pubic fractures. These results suggest that, Korean medicine can effectively reduce pain and aid rehabilitation in patients with SIF, without the need for surgery.
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