Sacral stress fractures

Clinical Presentation and Outcomes of Sacral Stress Fractures in Athletes: A Case Series of 13 Patients

BACKGROUND

Sacral stress fractures are a rare cause of low back pain in athletes. Given the low incidence of these fractures, there is a scarcity of data on symptomatology, risk factors, and clinical outcomes.

HYPOTHESIS

Patients diagnosed with sacral stress fractures would be athletes presenting with low back pain.

STUDY DESIGN

Case series of 13 patients with sacral stress fractures.

LEVEL OF EVIDENCE

Level 4.

METHODS

We conducted a retrospective review of medical records to identify patients diagnosed with sacral stress fractures at a single academic institution. Fractures were diagnosed on noncontrast T2-weighted magnetic resonance imaging scans and categorized using the Bakker classification system. Subjects were administered an electronic survey that asked about (1) the onset, time course, and location of pain and other symptoms; (2) time to treatment and treatment modalities pursued; (3) sports performance and time to return to sport; and (4) risk factors for stress fractures.

RESULTS

Of 18 eligible patients, 13 (72.2%) completed the survey with mean follow-up of 49.6 months (range, 1-144 months). Mean age was 28.0 years (range, 18-52 years); 9 patients (69.2%) were female, of whom 7 (77.8%) were premenopausal. The most common fracture type was Bakker type B (8 patients; 61.5%). Most patients presented with acute lumbosacral back pain in the setting of running/jogging activities. All patients underwent nonoperative treatment for an average of 3.8 months (range, 0-8 months) and three-quarters reported pain resolution at last follow-up. Rate of return to sport was 83.3%, but most patients reported ongoing deficits in running performance.

CONCLUSION

Sacral stress fractures commonly present as acute lumbosacral back pain provoked by running sports. While the pain associated with these fractures prevents most athletes from participating in sports, nonoperative management appears to be an effective treatment modality with a high rate of return to sport.

Comparative outcome of different treatment options for fragility fractures of the sacrum

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.

[Sacral fragility fractures: risk factors and outcomes after cement sacroplasty]

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.

The "Eiffel Tower" technique: novel long-axis sacroplasty under electromagnetic navigation assistance; feasibility and descriptive study

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.

Sacral Insufficiency Fractures After Total Pubectomy for Osteomyelitis: A Case Series

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.

Sacral Insufficiency Fractures

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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.

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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.

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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.

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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.

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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.

‘XX’–Sacroplasty: A Novel Technique for Management of “H-Type” Sacral Insufficiency Fractures

Objective

Examine the feasibility, safety, and results of a novel sacral percutaneous injection technique (“XX”) addressing both the vertical and horizontal aspects of sacral insufficiency fractures (SIF).

Methods

Prospective cohort study. Eight consecutive SIF patients with immobility and pain investigated using CT and nuclear imaging confirmed “H"-type fracture. Demographics, pain level, and ambulation status were recorded. The long-term quality of life was evaluated using the ODI questionnaire and pain VAS scores. Sacroplasty procedures in prone positioning using fluoroscopy were used to insert 2 bone trochars through the S1 pedicles and 2 trochars through the sacral ale aiming toward the SIJ, thus forming 2 “X” trochar formations. Balloon kyphoplasty was done through the trocars, and PMM was injected. Postoperative ambulation and VAS were recorded.

Results

Average age was 81.5 years (±3.4 years). The time from presenting symptoms to hospital admission was 2 days to 4 months. All patients were significantly limited with ambulation. None had a neurologic compromise. Sacroplasty was performed with 2 cases that required additional lumbar kyphoplasty. The mean operative time was 54 min (±14). The average exposure was 19 mGy (±12 mGy). Two patients had cement leaks. CT and X-rays revealed good cement filling of the fractures sacral alae and body of S1. The average postoperative hospitalization was 10 days. All patients reported postoperatively pain relief immediately and were able to walk better. Follow-up time was 17 ± 12 months. Follow-up VAS was 2.7 (±2) and ODI was 57.3% (±21%).

Conclusion

“XX” technique showed good outcomes for patients with higher complexity SIF, using the same principles as for lumbar VPL/KPL, and was found to be safe and effective.

Pull-out strength evaluation of cement augmented iliac screws in osteoporotic spino-pelvic fixation

INTRODUCTION

Spino-pelvic fixation has been widely accepted for surgical treatment of sacral tumor, scoliosis surgery and pelvic fractures. Cement augmentation of screws is an option to improve implant stability in osteoporotic bone quality. Aim of the present study is to compare iliac screw fixation without cement fixation and two cement application options in a biomechanical testing.

HYPOTHESIS

Cement augmentation of iliac screws leads to superior pull-out strength.

MATERIAL AND METHODS

Thirty female and osteoporotic human iliac bones were used. Three operation treatment groups were generated: Screw fixation (cannulated screws) without cement augmentation [Operation treatment (OT) A], screw fixation with cement augmentation before screw placement (cannulated screws) (OT B) and screw fixation with perforated screws and cement augmentation after screw placement (OTC). Pull-out tests were performed with a rate of 6mm/min. A load versus displacement curve was generated. Maximum pull-out force (N) was measured in the load-displacement curve.

RESULTS

Paired group 1 (OT A vs. OT B): Screw fixation without cement augmentation: 592.6N±335.07 and screw fixation with cement augmentation before screw placement: 996N±287.43 (p=0.0042). Paired group 2 (OT A vs. OT C): screw fixation without cement augmentation: 716.2N±385.86 and fenestrated screw fixation with cement augmentation after screw placement: 1324.88N±398.76 (p=0.0489). Paired group 3 (OT B vs. OT C): Screw fixation with cement augmentation before screw placement: 1077.2±486.66 and fenestrated screw fixation with cement augmentation after screw placement: 1298.2N±726.19 (p=0.3286).

DISCUSSION

Regarding iliac screw fixation for spino-pelvic ostesynthesis in osteoporotic bone, cement augmentation is significantly superior to solid iliac screw fixation respecting pull-out-strength. Nevertheless, further biomechanical studies are needed to verify these findings.

LEVEL OF EVIDENCE

Not applicable; biomechanical cadaver study.

Significance of Lumbar MRI in Diagnosis of Sacral Insufficiency Fracture

STUDY DESIGN

Retrospective observational study.

OBJECTIVE

The aim of the present study was to evaluate the role of lumbar magnetic resonance imaging (MRI) in the diagnostic algorithm of sacral insufficiency fractures (SIF). The primary objective was to compare the sensitivity in fracture detection and correct fracture classification according to MRI and computed tomography (CT). The secondary objective was to identify differences of additional pathologies found in MRI of the lumbar spine and the pelvis and their rates.

METHODS

A total of 943 patients (from 2010 to 2017) with fracture of the pelvic ring were screened. All patients without high-energy trauma and radiologic diagnostics consisting of X-ray, CT, and MRI of the pelvis or the lumbar spine including the sacrum were included. Differences in fracture detection and description in the various radiologic procedures were evaluated. Detection rates of additional pathologies in MRI of the pelvis and lumbar spine were recorded.

RESULTS

A total of 77 subjects were included. The sensitivities for SIF were 14% in X-ray and 88% in CT, and all fractures were detected in MRI. MRI showed a more complex fracture pattern compared with CT in 65% of the cases. Additional pathologies were seen in MRI of the lumbar spine (51%) and that of the pelvis (18%).

CONCLUSIONS

We suggest performing MRI of the lumbar spine including the sacrum with coronal STIR (short tau inversion recovery) sequence for elderly patients with suddenly increasing low back pain at an early stage. This procedure might improve fracture detection, classification, and recognition of concomitant pathologies.

Postpartum bilateral sacral stress fracture without osteoporosis-a case report and literature review

PURPOSE

Sacral stress fractures are rare complications which can arise during pregnancy or in the early postpartum period. We report a case and discuss the findings of a confirmed postpartum sacral stress fracture in a 39-year-old multiparous woman and review previous case reports in the literature of sacral stress fracture related to pregnancy.

METHODS

A review of the literature was conducted to examine the main characteristics of sacral stress fractures related to pregnancy. The Ovid/Medline, Embase and Google Scholar databases were searched with the inclusion criteria: human studies, English language, intrapartum, postpartum (within 6 months of parturition), sacrum and stress fracture. Our exclusion criteria included pubic fractures, vertebral fractures and non-English articles. The search terms included "stress fracture", "postpartum", "pregnancy", "atraumatic" and the wildcard "sacr*". Thirty-four cases were found and summarised in Table 2.

RESULTS

A total of 65% of patients had onset of symptoms postpartum. Most patients did not have risk factors for sacral stress fractures including macrosomia, excessive pregnancy weight gain, heparin exposure, rapid vaginal delivery or predisposition to accelerated osteoporosis. Lumbar radiculopathy can be a feature of sacral stress fracture and it is more common (17.6%) than reported in the literature (2%). MRI is the preferred imaging modality for its safety profile in pregnancy and high sensitivity. A total of 70% reported normal bone mineral density (BMD). The mainstay treatment for sacral stress fractures includes relative bed rest, analgesia and modified weight-bearing exercises. Most patients have favourable outcome with complete symptom resolution.

CONCLUSION

Sacral stress fractures in the absence of osteoporosis are rare complications of pregnancy that can present with lumbar radiculopathy. Conservative management often produces good clinical outcomes.

Balloon-assisted sacroplasty as a successful procedure for osteoporotic sacral insufficiency fractures after failure of the conservative treatment

Osteoporotic vertebral fractures without prior adequate traumatization are frequent diagnosed in orthopedics because of the increasing life expectancy and incidence of osteoporosis. The associated high mortality is caused by reduced mobilization which leads to a higher risk of infection and a bedridden state. On the other hand the diagnosis of sacral insufficiency fractures is often prolonged because of unspecific symptoms while being associated with similar risks. This article presents an overview of the present scientific literature and a retrospective analysis of patients treated via balloon-assisted sacroplasty. In 8 years, ten patients (three men and seven women) were treated. The average age was 78.4 years and the average time until the diagnosis 4.6 weeks. In most patients a significant pain reduction after the failure of conservative treatment thanks to operative treatment as well as increased mobility was observed. Only one experienced a minor surgical complication being cement leakage with nerval impaction which did not compromise her clinical outcome or satisfaction with the procedure. Balloon-assisted sacroplasty can possibly be seen as an effective symptomatic therapy in osteoporotic insufficiency fractures.

Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management

PURPOSE OF THE REVIEW

Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management.

RECENT FINDINGS

Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.

Sacral Fractures and Sacroplasty

Sacral fractures result from high-impact trauma or in the form of insufficiency or pathologic fractures, resulting from osteoporosis, radiation therapy, or malignancy. In the emergency setting, the escalating use of computed tomography has substantially increased diagnosis of sacral fractures, which are frequently occult on radiographs. Radiologists should be familiar with and create reports using the most current fracture classification systems, because this improves communication with the treatment team and optimizes patient care. Sacroplasty is a safe, minimally invasive treatment option for many types of sacral fractures. It provides rapid and durable pain relief, with a low incidence of complications.

Comparison of sacroplasty with or without balloon assistance for the treatment of sacral insufficiency fractures

PURPOSE

Sacral insufficiency fractures (SIFs) can cause severe lower back pain and immobility, which have limited therapeutic options. No previous studies have compared clinical outcomes and radiographic findings of sacroplasty with or without balloon assistance for the treatment of SIFs.

METHODS

Forty-five patients with SIFs were divided into two groups. One group had 18 patients treated using sacroplasty with balloon assistance, and the other had 27 patients treated without balloon assistance. The operation time and cement injection volume were compared between these two groups. Clinical outcomes were evaluated using visual analog scale (VAS), Oswestry Disability Index (ODI), and Odom's criteria. Cement leakage rate was examined by postoperative radiography and computed tomography.

RESULTS

Sacroplasty with balloon assistance was associated with significantly longer operative time ( p = 0.003) and larger cement injection volume ( p = 0.038). Cement leakages were found in 4 of 18 patients (22.2%) with balloon assistance and 15 of 27 patients (55.6%) without balloon assistance, which showed significant difference ( p = 0.027). No significant differences were observed between sacroplasty with and without balloon assistance with regard to clinical outcomes including improvement in VAS, ODI, and Odom's criteria.

CONCLUSIONS

Sacroplasty with balloon assistance was shown to achieve greater cement injection with longer operation time and can decrease the risk of cement leakage. Both sacroplasty with and without balloon assistance showed good-to-excellent clinical outcomes for the treatment of SIFs.

Tarlov Cyst Causing Sacral Insufficiency Fracture

BACKGROUND AND IMPORTANCE

Tarlov cysts, also known as perineural cysts, have been described as meningeal dilations of the spinal nerve root sheath between the peri- and endoneurium at the dorsal root ganglion. Most often they are found in the sacrum involving the nerve roots. Normally asymptomatic, they have been reported to present with radiculopathy, paresthesias, and even urinary or bowel dysfunction. Sacral insufficiency has not been a well-documented presentation.

CLINICAL PRESENTATION

The patient is a 38-year-old female who started to develop left low back pain and buttock pain that rapidly progressed into severe pain with some radiation down the posterior aspect of her left leg. There was no recent history of spine or pelvic trauma. These symptoms prompted her initial emergency department evaluation, and imaging demonstrated a large Tarlov cyst with an associated sacral insufficiency fracture. She was noted to have a normal neurological examination notable only for an antalgic gait. She was taken to surgery via a posterior approach and the cyst was identified eccentric to the left. The cyst was fenestrated and the nerve roots identified. Given her large area of bone erosion and insufficiency fractures, fixation of the sacroiliac joints was deemed necessary. Fusion was extended to the L5 vertebral body to buttress the fixation. She tolerated the procedure well and was discharged from the hospital on postoperative day 3.

CONCLUSION

Tarlov cysts of the sacrum can lead to significant bone erosion and subsequent insufficiency fractures, requiring fenestration and in some cases, complex sacropelvic fixation.

An Atraumatic Sacral Fracture with Lumbosacral Radiculopathy Complicating the Early Postpartum Period: A Case Report

Patient: Female, 26

Final Diagnosis: Atraumatic fatigue sacral fracture

Symptoms: Lumbar back pain with radiculopathy

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Percutaneous Transiliac-Transsacral Screw Fixation of Sacral Fragility Fractures Improves Pain, Ambulation, and Rate of Disposition to Home

OBJECTIVE

To determine whether percutaneous transiliac-transsacral screw fixation improves pain, ambulation, length of stay, and the rate of disposition to home in patients with sacral fragility fractures.

DESIGN

Retrospective cohort study.

SETTING

Single academic Level 1 trauma center.

PATIENTS/PARTICIPANTS

Elderly patients who presented with an isolated sacral fragility fracture between August 2015 and August 2017. Of the 41 patients included in the study, 16 were treated operatively and 25 were treated nonoperatively.

INTERVENTION

Percutaneous transiliac-transsacral screw fixation.

MAIN OUTCOME MEASUREMENTS

Pain, ambulation, length of stay, complications, and disposition.

RESULTS

Patients treated operatively reported a greater improvement in pain as measured by the visual analog scale (3.9 vs. 0.6 points, P < 0.001). At the time of discharge, 100% of surgically treated patients were able to ambulate compared with 72% in the nonoperative group (P = 0.03). Average distance ambulating at the time of discharge was higher in the operative group (95 vs. 35 ft, P < 0.01). Length of stay was similar between the 2 groups (3.6 days in operative group vs. 4.2 days in nonoperative group, P = 0.5). Of the patients treated operatively, 75% were discharged to home compared with only 20% in the nonoperative group (P < 0.001). There were no complications related to surgery.

CONCLUSIONS

Percutaneous transiliac-transsacral screw fixation of sacral fragility fractures lessens pain, improves ambulation, and increases the rate of disposition to home. Further investigation is needed to determine if surgical fixation provides benefit regarding medium- and long-term outcome variables.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteoporotic sacral insufficiency fracture: An easily neglected disease in elderly patients

Sacral insufficiency fractures (SIFs) are easily neglected by clinical physicians.The incidence of SIFs remains unclear in patients with symptomatic osteoporotic compression fractures of the lumbar-sacral area.This retrospective study was conducted by reviewing the medical records and radiological reports and by reading magnetic resonance (MR) images from August 2013 to July 2016. We identified 1233 cases with symptomatic vertebral compression fractures for which surgical interventions were performed. A total of 1144 cases were eligible for this study. Neglected diagnoses by radiologists and clinical physicians were calculated, respectively.The MR imaging (MRI) findings of SIFs were divided into the body (S1, S2, S3, and S4 levels) and alar areas (unilateral, bilateral, transverse, and none).A total of 34 (3.00%) cases with SIFs were identified through MRI. A significant difference was observed between 19 (6.53%) patients aged >80 years and 15 (1.76%) aged <80 years (P < .0001). Eight (23.53%) and 26 (76.47%) cases of SIFs were neglected by radiologists and clinical physicians, respectively. The S2 and S3 levels were the predominantly involved area (23/34; 67.65%). Furthermore, the bilateral alar area was the most commonly involved (19/34; 55.88%), as observed in coronal views of MRI.While treating other levels of osteoporotic compression fractures, radiologists and clinical physicians should be aware of SIFs, particularly when the patients are aged >80 years. The coronal oblique MR images of the thoracolumbar region should be carefully read to avoid neglecting SIFs.

Mortality following benign sacral insufficiency fracture and associated risk factors

This study demonstrated increased mortality following sacral insufficiency fractures as with other major osteoporotic fractures. The 6-month mortality rate was 9.8%, the 1-year mortality rate was 17.5%, and the 3-year mortality rate was 25.5%. Sex- and age-adjusted standardized mortality ratio increased after fractures.

INTRODUCTION

There are no data about mortality after sacral insufficiency fractures. The purposes of this study were to investigate the mortality rate among sacral insufficiency fracture patients and to identify risk factors associated with mortality.

METHODS

This is a retrospective cohort study of patients diagnosed with sacral insufficiency fracture via radiological exam in a single institute from 2001 to 2014, excluding patients with pathological sacral fracture due to metastasis or primary tumor. Mortality and its predisposing factors were analyzed based on a review of electronic medical records and mortality data provided by the Korean Statistical Information Service. Kaplan-Meier survival analysis and Cox regression analysis were used for statistical analysis.

RESULTS

A total of 325 patients were included (275 women and 50 men). The mean age at the time of diagnosis was 69.4 years. One hundred and forty patients (43.1%) had a history of malignancy, and 71 patients (21.8%) had undergone pelvic radiation therapy before fracture diagnosis. Twenty-one patients (6.5%) underwent sacroplasty, and the others underwent conservative management after fracture diagnosis. The mean follow-up was 51.5 months, and a total of 101 patients died at the final follow-up. The 6-month mortality rate was 9.8%, the 1-year mortality rate was 17.5%, and the 3-year mortality rate was 25.5%. Sex- and age-adjusted standardized mortality ratio (SMR) increased after fractures. The overall SMR is 8.9 at 3 months decreasing to 4.5 at 2 years. Multivariable Cox regression analysis showed that significant factors associated with increased mortality were male gender, malignancy history, lumbosacral fusion with distal fusion level S1, stroke history, low total femur bone mineral density score, and low body mass index.

CONCLUSIONS

Like other types of osteoporotic fractures, sacral insufficiency fractures are associated with increased mortality.

Enhanced bone healing and decreased pain in sacral insufficiency fractures after teriparatide treatment: retrospective clinical-based observational study

The purpose of this retrospective clinical-based observational study was to evaluate the effects of teriparatide (TPTD) on clinical outcomes and radiologic findings of sacral insufficiency fractures (SIFs). Seven elderly women with SIFs received TPTD for at least 6 months. We evaluated the symptoms, pain, and radiological findings. At their initial clinic visit, 86% patients could not walk or sit. Computed tomography (CT) images revealed sacral wing fracture in 6 patients, and bone scintigram showed H-shaped uptake over the bilateral sacral wings in 1 patient. After the treatment, 5 patients could walk. Mean visual analog scale score was significantly lower after (12.9 mm) than before (87.4 mm) TPTD treatment (p < 0.0001). CT images revealed bone union (four patients) and sclerotic changes (three patients) at the fracture sites. Seven elderly women with SIFs had significant improvement in pain and demonstrated bone union or sclerotic changes at fracture sites by TPTD.

CT-guided cement sacroplasty (CSP) as pain therapy in non-dislocated insufficiency fractures

Introduction

In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically associated with severe disabling pain. The objective of the present study was to examine the feasibility of cement augmentation by CSP, to determine post-interventional leakages and other complications, and to present the outcome of pain over the course of 18 months.

Materials and methods

In 23 patients (20 women and 3 men) with an average age of 81.3 (71–92) years, a total of 41 sacral fractures were detected by MRI, 5 of them unilateral and 18 bilateral. Conservative treatment initially performed over a period of 3 weeks did not bring any satisfactory reduction in the severe disabling pain. The indication for intervention was established after an interdisciplinary case conference. The intervention was performed under intubation anaesthesia. Single-shot antibiotic prophylaxis was given routinely immediately prior to the intervention. Under sterile conditions, a Jamshidi needle was then advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. High-viscosity PMMA cement was then inserted discontinuously with the aid of a pressure gauge under low-dose CT control. Cement leakages were determined in the CT image on the day after the intervention, all cement outside of the cortical boundary being rated as a leakage. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and 6, 12, and 18 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to rate their satisfaction after 6 and 18 months.

Results

CSP was technically feasible in all patients. In the control CT scan, sufficient cement distribution and interlocking with vital bone were found along the course of the fracture in the sacrum. An average of 6.0 ± 0.83 ml of cement was inserted per fracture. Leakage was found in 5 of 41 (12.2%) of the fractures treated, although none were symptomatic. The mean pain score on the VAS was 8.8 ± 0.59 before the intervention, a significant pain reduction (p < 0.0005) was seen on the second post-operative day, with an average value of 2.1 ± 0.36, and this was stable at 2.2 ± 0.28 after 6, 2.3 ± 0.31 after 12, and 2.2 ± 0.41 after 18 months. Now that they no longer experienced disabling pain, all of the patients were fully remobilised and discharged back home. A high level of patient satisfaction was found after 6 and 18 months.

Conclusion

As a minimally invasive procedure, CSP is an effective treatment method for rapid, significant, and sustained pain reduction.

Pelvic Insufficiency Fracture in Severe Osteoporosis Patient

Purpose

To evaluate clinical features and the effect of parathyroid hormone (PTH) on treatment outcomes of patients with pelvic insufficiency fractures.

Materials and Methods

Fifteen patients diagnosed with pelvic insufficiency fractures were evaluated retrospectively. All patients had osteoporosis with mean lumbar T score of −3.9 (range, −3.1 to −6.4) and the mean age was 76.5 years. In all cases, simple radiography and computed tomography was used for final diagnosis; additional magnetic resonance imaging and technetium bone scans were used to confirm the diagnosis in 2 and 6 patients, respectively. Initial conservative treatment was used in all cases; treatment with PTH was applied in 5 cases. Radiological follow-up was done every 4 weeks up to 6 months and every 3 months thereafter. Symptom improvement was measured using visual analogue scale (VAS) score.

Results

Fractures were located: i) sacrum and pubis (9 cases), ii) isolated sacrum (4 cases) and iii) isolated pubis (2 cases). One case showed fracture displacement and pain aggravation at 4 week follow-up which was treated with percutaneous sacro-iliac fixation using cannulated screws. Duration of bone union was significantly shorter in the patients who used PTH (P<0.05). VAS scores were also lower in the group treated with PTH; however, statistical significance was not reached.

Conclusion

In patients with osteoporosis, a pelvic insufficiency fracture should be considered if pain is experienced in the pelvic area in the absence of major trauma. While nonoperatic has been shown to be sufficient for treatment, our study shows that PTH therapy shortens treatment period and could be a favorable treatment option.

Effects of Percutaneous Sacroplasty on Pain and Mobility in Sacral Insufficiency Fracture

Objective

Sacral insufficiency fracture (SIF) contributes to severe low back pain. Prolonged immobilization resulting from SIF can cause significant complications in the elderly. Sacroplasty, a treatment similar to vertebroplasty, has recently been introduced for providing pain relief in SIF. The purpose of this study is to investigate the clinical short-term effects of percutaneous sacroplasty on pain and mobility in SIF.

Methods

This study is conducted prospectively with data collection. Sixteen patients (3 men and 13 women) with a mean age of 77.5 years (58 to 91) underwent sacroplasty. Patients reported visual analogue scale (VAS; 0–10) and Oswestry disability index (ODI; 0–100%) scores. VAS and ODI scores were collected preoperatively and again at one day, one month, and three months postoperatively. Questionnaires measuring six activities of daily living (ADLs) including ambulating, performing housework, dressing, bathing, transferring from chair, and transferring from bed were collected. Ability to perform ADLs were reported preoperatively and again at three months postoperatively.

Results

The mean preoperative VAS score (mean±SD) of 7.5±0.8 was significantly reduced to 4.1±1.6, 3.3±1.0, and 3.2±1.2 postoperatively at one day, one month, and three months, respectively (p<0.01). The mean ODI score (%) also significantly improved from 59±14 preoperatively to 15.5±8.2 postoperatively at one month and 14.8±8.8 at three months (p<0.01). All ADL scores significantly improved at three months postoperatively (p<0.01).

Conclusion

Percutaneous sacroplasty alleviates pain quickly and improves mobility and quality of life in patients treated for SIF.

Transsacral-Transiliac Screw Stabilization: Effective for Recalcitrant Pain Due to Sacral Insufficiency Fracture

OBJECTIVES

To evaluate the effectiveness of transsacral-transiliac screw fixation for the treatment of sacral insufficiency fractures that fail nonoperative treatment.

DESIGN

A pilot study series of consecutive patients identified over 5 years were treated and followed prospectively.

SETTING

Academic-affiliated, tertiary referral, level 1 trauma center in Dallas, TX.

PATIENTS/PARTICIPANTS

Patients were selected on the basis of presenting diagnosis, and failure of nonoperative treatment of their sacral insufficiency fracture. Eleven patients entered to the study, and 10 completed follow-up.

INTERVENTION

Placement of transsacral-transiliac screws for sacral insufficiency fracture.

MAIN OUTCOME MEASUREMENTS

Comparison of preoperative and postoperative Visual Analog Scale scores and Oswestry Low Back Disability Index scores.

RESULTS

Patients experienced statistically significant improvement in both outcome measures after intervention. No complications encountered.

CONCLUSIONS

Transsacral-transiliac screw fixation seems to be a safe and effective treatment for sacral insufficiency fractures recalcitrant to nonoperative management.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Postpartum sacral stress fracture: a case report

BACKGROUND

Stress fractures are classified as insufficiency and fatigue fractures. Insufficiency fractures occur when normal stresses are placed on bone with decreased mineralization and elastic resistance; whereas fatigue fractures occur when abnormal forces are applied to normal bone.

CASE PRESENTATION

We report a case of postpartum bilateral sacral fracture in the absence of documented osteoporosis in a 30 year old Lebanese female, thus satisfying the classification of fatigue fractures. Clinical presentation was mainly low back pain, pelvic pain, and abnormal gait.

CONCLUSIONS

This case stresses the importance of including sacral fractures in the differential diagnosis of patients presenting with similar symptoms during pregnancy or the postpartum period.

Primary stability of three different iliosacral screw fixation techniques in osteoporotic cadaver specimens-a biomechanical investigation

BACKGROUND

The incidence of osteoporotic and insufficiency fractures of the pelvic ring is increasing. Closed reduction and percutaneous fixation with cannulated sacroiliac screws is well-established in the operative treatment of osteoporotic posterior pelvic ring fractures. However, osteoporotic bone quality might lead to the risk of screw loosening. For this reason, cement augmentation of the iliosacral screws is more frequently performed and recommended.

PURPOSE

The aim of the present biomechanical study was to evaluate the primary stability of three methods of iliosacral screw fixation in human osteoporotic sacrum specimens.

STUDY DESIGN/SETTING

This study used methodical cadaver study.

METHODS

A total of 15 fresh frozen human cadaveric specimens with osteoporosis were used (os sacrum). After matched pair randomization regarding bone quality (T-score), three operation technique groups were generated: screw fixation (cannulated screws) without cement augmentation (Group A); screw fixation with cement augmentation before screw placement (cannulated screws) (Group B); and screw fixation with perforated screws and cement augmentation after screw placement (Group C). In all specimens both sides of the os sacrum were used for operative treatment, resulting in a group size of 10 specimens per group. One operation technique was used on each side of the sacral bone to compare biomechanical properties in the same bone quality. Pull-out tests were performed with a rate of 6 mm/min. A load versus displacement curve was generated.

RESULTS

Subgroup 1 (Group A vs. Group B): Screw fixation without cement augmentation: 594.4 N±463.7 and screw fixation with cement augmentation before screw placement: 1,020.8 N±333.3; values were significantly different (p=.025). Subgroup 2 (Group A vs. Group C): Screw fixation without cement augmentation: 641.8 N±242.0 and perforated screw fixation with cement augmentation after screw placement: 1,029.6 N±326.5; values were significantly different (p=.048). Subgroup 3 (Group B vs. Group C): Screw fixation with cement augmentation before screw placement: 804.0 N±515.3 and perforated screw fixation with cement augmentation after screw placement: 889.8 N±503.3; values were not significantly different (p=.472).

CONCLUSIONS

Regarding iliosacral screw fixation in osteoporotic bone, the primary stability of techniques involving cement augmentation is significantly higher compared with screw fixation without cement augmentation. Perforated screws with the same primary stability as that of conventional screw fixation in combination with cement augmentation might be a promising alternative in reducing complications of cement leakage. These biomechanical results have to be transferred into clinical practice and prove their clinical value.

[Implant augmentation in pelvic surgery. Options and technique]

BACKGROUND

Osteoporotic fractures of the pelvis are an increasing problem in trauma surgery. Sufficient implant anchorage is reduced due to the poor bone stock; however, early mobilization is especially necessary for geriatric patients in order to prevent additional complications.

MATERIAL AND METHODS

Implant augmentation may be one technique to increase implant anchorage and stability in osteoporotic bone. This procedure is currently used in the treatment of osteoporotic fractures of the dorsal pelvic ring. Beside the augmentation of iliosacral screws in the treatment of sacral insufficiency fractures, cement augmentation with lumbar or sacral pedicle screws is used for increased stability.

INDICATIONS AND RISKS

Implant augmentation in pelvic surgery should be indicated crucially due to the specific risks of the procedure. Cement leakage and heat generation during cement curing (when PMMA--polymethylmetacrylate--cement is used) can compromise neurovascular structures. Potential complications like cement embolism are possible.

CONCLUSION

The use of special implants (cannulated and perforated screws) as well as intraoperative navigation and 3D imaging increase patient safety and help to make implant augmentation a low risk procedure.

Risk factors associated with sacral stress fractures: a systematic review

OBJECTIVES

The objective of this study was to examine and identify risk factors associated with the development of sacral stress fractures in order to improve diagnosis in clinical practice.

METHODS

Electronic search strategies in PubMed, CINAHL, Scopus, and SPORTDiscus were combined with a hand search to identify articles for inclusion. Studies were considered if they described patient cases in which imaging confirmed diagnosis of a sacral stress fracture, and the diagnosis included whether the fracture was a sacral insufficiency or sacral fatigue stress fracture.

RESULTS

In those that developed sacral insufficiency fractures, the risk factors that were most prevalent included osteoporosis, pelvic radiation therapy, rheumatoid arthritis, long-term corticosteroid therapy, and postmenopausal, each with a prevalence of 100%. Risk factors with 100% prevalence in those diagnosed with sacral fatigue fractures included recent increase in training intensity and deficient diet.

DISCUSSION

A pattern of signs and symptoms are consistent among subjects with sacral stress fractures. Patients being unsuccessfully treated for low-back and buttock pain who fit the risk factor profiles for sacral stress fractures should be referred to a physician for further diagnostic workup.

Radiofrequency sacroplasty (RFS) for the treatment of osteoporotic insufficiency fractures

INTRODUCTION AND OBJECTIVE

In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically accompanied by severe, disabling pain. The objective of this study was to evaluate the feasibility of cement augmentation by RFS, as well as to determine postinterventional leakages and present the patients' outcomes.

MATERIAL AND METHOD

In 20 patients (18 women, 2 men) with an average age of 80.4 (65-92) years, a fracture of the sacrum was detected by CT and MRI. Clinically manifest osteoporosis with QCT values of below 50 mg/ml was found in all patients. An initially performed conservative treatment over a period of 3 weeks did not achieve a satisfactory reduction in the severe, disabling pain. The cement augmentation was performed under CT guidance by means of RFS under intubation anaesthesia. A Jamshidi needle was advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. The highly viscous polymethyl methacrylate (PMMA) cement, activated by radiofrequency, was then inserted into the prepared fracture zone through a substituted screw cannula. Cement filling was performed discontinuously under instrumental guidance at 1.3 ml/min under CT guidance. Cement leakages were determined in CT images and conventional X-rays on the day after the intervention. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and after 6 and 12 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to state how satisfied they were after 12 months.

RESULTS

RFS was technically feasible in all patients. In the control CT scans and X-rays, sufficient cement distribution and interlocking with vital bone was found along the course of the fracture in the sacrum. 7.2 (4-9) ml of cement were inserted per fracture. Leakage could be ruled out. The mean pain score on the VAS was 8.8 ± 1.2 before the intervention, and a significant reduction in pain (p < 0.001) was seen on the second postoperative day, with an average value of 2.3 ± 0.7, which was stable at 2.2 ± 1.3 after 6 months and 2.1 ± 1.1 after 12 months. All of the patients could be fully re-mobilised and discharged back home. A high level of patient satisfaction was found after 12 months, with 18 of the 20 patients stating that they would undergo the intervention again. One patient died of a stroke, another of cancer over the course.

CONCLUSION

As a minimally invasive procedure, RFS is an effective and safe method of treatment for rapid, significant and sustained pain reduction.

Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment

Paralleling the growing popularity of organized sports among pediatric athletes, the stress and intensity of training regimens has escalated the frequency and severity of pediatric overuse injuries. It is essential that radiologists have a thorough knowledge of the pathogenesis of these injuries and of their characteristic patterns with different imaging techniques in order to appropriately diagnose overuse injuries in the pediatric skeleton. Knowledge of the classification, mechanism, clinical and imaging manifestations of acute and chronic overuse injuries of the lower extremities common among pediatric athletes can assist in imaging-based diagnosis and characterization of injury.

Surgical management of osteoporotic pelvic fractures: a new challenge

The number and variety of osteoporotic fractures of the pelvis are rapidly growing around the world. Such fractures are the result of low-impact trauma. The patients have no signs of hemodynamic instability and do not require urgent stabilization. The clinical picture is dominated by immobilizing pain in the pelvic region. Fractures may be located in both the ventral and the dorsal pelvic ring. The current well-established classification of pelvic ring lesions in younger adults does not fully reflect the criteria for osteoporotic and insufficiency fractures of the pelvic ring. Most osteoporotic fractures are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to complex displacement and instability. Therefore, vertical sacral ala fractures, fracture dislocations of the sacroiliac joint, and spinopelvic dissociations are best treated with operative stabilization. Angular stable bridge plating, the insertion of a transsacral positioning bar, and iliolumbar fixation are operative techniques that have been adapted to the low bone mineral density of the pelvic ring and the high forces acting on it.

Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome

INTRODUCTION

Due to ageing of our population the number of fatigue fractures of the pelvic ring is steadily growing. These fractures are often treated with bed rest but may result in a disabling immobility with severe pain. An operative treatment is an option in these cases. The aim of operative treatment is bony healing obtained by stable fixation giving back to the patient's previous mobility. Optimal surgical treatment is currently under debate. Sacroiliac screw fixation and sacroplasty are used for stabilization of the dorsal pelvis. Due to the technique and the low density of spongious sacral bone, no or only low compression in the fracture site is obtained, which may inhibit bony healing. The trans-sacral bar compression osteosynthesis is presented as an alternative procedure. We present the outcome of 11 patients, who were treated with this method.

METHODS

The patient is placed in prone position on the operation table. Under image intensifier control, a 5mm threaded sacral bar is inserted through the body of S1 from the left to the right dorsal ilium. Nuts are placed over the bar achieving fracture compression. When anterior pelvic instability is present, an anterior osteosynthesis is also performed. Clinical and radiological outcome were evaluated one year after index surgery with different scoring systems.

RESULTS

Eleven patients (9 F and 2 M) were treated between 2005 and 2010. The mean age of the patients was 73 years at time of operation. There were no mechanical complications. Postoperatively there was a temporary nerve palsy of L5 in one case. The mean follow-up was 14 months. In all patients, a bony healing of the dorsal pelvic ring was achieved. Seven patients showed a major clinical improvement, in four patients a moderate.

CONCLUSIONS

Trans-sacral bar osteosynthesis is a promising method for stabilization of fatigue fractures of the pelvic ring. Only with this method, a high interfragmentary compression is achieved, independent of the quality of the spongious bone of the sacral body.

Low back pain post partum - a case report

Sacral stress fracture is an unusual source of low back pain and can be easily confused with a number of other clinical conditions seen in physiotherapy clinics. The purpose of this case report is to describe the case of a patient presenting with low back pain post partum illustrating pertinent aspects of differential diagnosis and issues of management. A 31 year old female presented complaining of low back pain since the birth of her second child 11 months earlier. Subjective and objective examination led the Therapist to consider a diagnosis of sacral stress fracture. This diagnosis was confirmed by MRI. Three months after presenting to physiotherapy the patient was pain free and had returned to all aspects of her daily life without any difficulties. Clinicians must be aware of the less common pathologies in any hypotheses development. A careful history and physical examination and broad hypotheses generation will ensure that patients are accurately diagnosed and receive appropriate and effective treatments.

Sacral kyphoplasty for the treatment of painful sacral insufficiency fractures and metastases

BACKGROUND CONTEXT

Sacral insufficiency fractures and metastases are a source of severe intractable pain, with limited therapeutic options. Sacroplasty has demonstrable efficacy and safety; sacral kyphoplasty, however, is rarely reported.

PURPOSE

To evaluate the safety and efficacy of sacral kyphoplasty for sacral insufficiency fractures and metastases.

STUDY DESIGN

Retrospective, with long-term follow-up; rural community-based practice.

PATIENT SAMPLE

Patients with sacral insufficiency fractures and metastases.

OUTCOME MEASURES

Numerical pain rating scale, opioid equivalent usage. SELF-REPORT MEASURE: Numerical pain rating scale. FUNCTIONAL MEASURE: Opioid equivalent consumption.

METHODS

Retrospective analysis.

RESULTS

Statistically significant improvement in pain; overall, an improvement in opioid consumption.

CONCLUSIONS

Sacral kyphoplasty appears to be a safe and efficacious procedure, comparable to sacroplasty, in the treatment of SIFs and sacral metastases.

Effects of bone density alterations on strain patterns in the pelvis: Application of a finite element model

Insufficiency fractures occur when physiological loads are applied to bone deficient in mechanical resistance. A better understanding of pelvic mechanics and the effect of bone density alterations could lead to improved diagnosis and treatment of insufficiency fractures. This study aimed to develop and validate a subject-specific three-dimensional (3D) finite element (FE) model of a pelvis, to analyse pelvic strains as a function of interior and cortical surface bone density, and to compare high strain regions with common insufficiency fracture sites. The FE model yielded strong agreement between experimental and model strains. By means of the response surface method, changes to cortical surface bone density using the FE model were found to have a 60 per cent greater influence compared with changes in interior bone density. A small interaction was also found to exist between surface and interior bone densities (< 3 per cent), and a non-linear effect of surface bone density on strain was observed. Areas with greater increases in average principal strains with reductions in density in the FE model corresponded to areas prone to insufficiency fracture. Owing to the influence of cortical surface bone density on strain, it may be considered a strong global (non-linear) indicator for insufficiency fracture risk.

Survey of spine surgeons on attitudes regarding osteoporosis and osteomalacia screening and treatment for fractures, fusion surgery, and pseudoarthrosis

BACKGROUND CONTEXT

Osteoporosis and osteomalacia are significant risk factors for fracture and spine instrumentation failure. Low-energy fractures are becoming increasingly more common because of an increase in life expectancy and age of the population. Decreased bone density is an independent risk factor for instrumentation failure in spinal fusion operations.

PURPOSE

To assess the awareness and practice patterns of spine surgeons regarding metabolic bone disorders and osteoporosis with emphasis on fracture care and arthrodesis.

STUDY DESIGN/SETTING

Questionnaire study.

PATIENT SAMPLE

Spine surgeons attending the "Disorders of the Spine" conference (January 2007, Whistler, British Columbia, Canada).

OUTCOME MEASURES

Respondent reported frequencies of diagnostics, screening, and treatment methods for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis.

METHODS

A ten-question survey was administered to orthopedic surgeons and neurosurgeons who treated spine fractures and degenerative spine conditions in their practice. The survey was given to those who were attending a continuing medical education spinal disorders conference. The survey asked about treatment patterns with respect to osteoporosis and osteomalacia workup and treatment for patients with low-energy spine fractures, pseudoarthrosis, and those undergoing spinal arthrodesis.

RESULTS

Of the 133 surgeons to whom the questionnaire was distributed at this meeting, 114 questionnaires were returned that corresponds to a response rate of 86%. Twenty-one surveys were excluded because of incomplete biographical information, resulting in a total of 93 completed questionnaires that were available for analysis. When treating patients with low-energy spine fractures, 60% checked dual-energy X-ray absorptiometry (DEXA) and 39% checked metabolic laboratories (of those who did not order laboratories and DEXA about 63% refer for treatment). Before instrumented fusion, 44% of those queried checked DEXA and 12% checked metabolic laboratories (vitamin D, parathyroid hormone [PTH], and calcium [Ca]). Before noninstrumented fusion, 22% checked DEXA and 11% checked metabolic laboratories. Before addressing pseudoarthrosis, 19% checked DEXA and 20% checked metabolic laboratories.

CONCLUSIONS

Despite of the large number of elderly patients undergoing spine care and the high incidence of osteoporosis and/or osteomalacia in this population, a large portion of the spine surgeons who responded to the survey reported that they do not perform routine osteoporosis/osteomalacia workups. Of those who do perform workups, some commented that it will change their surgical plan or preoperative treatment. It appears that there is a need for increased awareness among spine specialists regarding osteoporosis screening and treatment. Osteoporosis practice patterns may also be affected with newly evolving government quality reporting regulations.

Sacroplasty in a cadaveric trial: comparison of CT and fluoroscopic guidance with and without balloon assistance

Sacral insufficiency fractures can cause severe, debilitating pain to patients concerned. The incidence of this fracture type correlates with the appearance of osteoporosis in the elderly population. A polymethylmethacrylate (PMMA) cement injection procedure called sacroplasty has been recently described as an optional method for the treatment of this fracture type. However, the correct cement placement in the complex anatomical structure of the sacrum is a surgical challenge. The aim of the study is to compare the precision, safety, and radiation exposure of standard multiplanar fluoroscopy and computed tomography (CT) guidance for PMMA application to the sacrum using both balloon-assisted sacroplasty and conventional sacroplasty. A controlled experimental investigation in a human cadaver trial has been performed. Two imaging and two application modalities to monitor percutaneous PMMA injection to the sacrum were examined. The application forms were randomized from side to side of the pelvis. We found less cement extravasation in the CT-guided groups, but also a significant higher radiation exposure (P < 0.05) by using CT guidance. The conventional fluoroscopy-guided sacroplasty revealed the shortest procedure time (incision to closure time) of all treatment groups (P < 0.01). These findings show no difference regarding cement extravasation between ballon-assisted and conventional sacroplasty. Further, in comparison to fluoroscopy-assisted technique, the CT-guided cement injection seems to decrease the risk of cement extravasation, irrespective of the use of an additional balloon assistance. However, we have to consider a greater radiation exposure using CT guidance. Further investigations will proof the suitability in the normal course of clinical life.

Three-dimensional C-arm computed tomography-guided sacroplasty for the treatment of sacral body fracture

STUDY DESIGN

Case report.

OBJECTIVE

To report our results of a sacroplasty technique, using 3-dimensional C-arm CT for the treatment of sacral body fracture.

SUMMARY OF BACKGROUND DATA

Sacroplasty may provide symptomatic relief and hasten recovery in the treatment of sacral insufficiency fractures. To our knowledge, there is no case report in the literature describing the application of sacroplasty for the treatment of sacral body fracture. We present a case of patient who had percutaneous sacroplasty for sacral body fracture and sacral alar fracture under 3-dimensional C-arm CT guidance and discuss the clinical results and technical considerations.

METHODS

The procedure included a standard prone positioning of the patient and the area to be treated was prepared in a strictly sterile manner, and a local anesthesia was used. After a small skin incision, an 11-gauge vertebroplasty needle was positioned at the entry point in the sacrum. Then, the needle was inclined, directed, and advanced from the posterior aspect to the anterior aspect of the sacral vertebral body. PMMA cement was incrementally introduced in 0.5 mL aliquots and the volume of PMMA cement injected was total 4 mL. Precise needle placement and PMMA cement injection was performed under the 3-dimensional C-arm CT system and the right sacral alar region was performed in a similar manner.

RESULTS

There were no peri-procedural complications occurred and the patient experienced an immediate and substantial pain relief that was persistent during a 12-month follow-up.

CONCLUSIONS

3-dimensional C-arm CT-guided sacroplasty is a safe, practical, and effective solution to treatment of sacral body fracture.

Trans-iliac-sacral-iliac-bar procedure to treat insufficiency fractures of the sacrum

BACKGROUND

Osteoporosis is an increasing problem attributed to the greater longevity of the population and the incidence of fractures related to osteoporosis. The presence of osteoporotic bone, comorbidities, and functional status of the patient require adequate solutions to improve the clinical outcome of sacral insufficiency fractures. Conservative treatment by means of prolonged bed rest and analgesics are associated with increased risks and complications. A sacroplasty significantly improves the functional outcome. We describe the trans-iliac-sacral-iliac-bar (TISIB) procedure and our clinical experience to treat insufficiency fractures of the sacrum.

MATERIALS AND METHODS

The records of 19 consecutive patients with a mean age of 71.7 years (range: 57-82 years) who had been managed with a TISIB procedure from 2005 till 2007 were reviewed retrospectively. There were 15 females and 4 males. Predisposing factors for sacral insufficiency fractures were osteoporosis (n = 12, 63%), radiotherapy (n = 6, 32%), and rheumatoid arthritis (n =1). Diagnosis with a mean delay of 3.7 months was mainly made by CT. All patients were preoperatively and at follow-up assessed by means of the visual analogue score (VAS), analgesic consumption, and the ability to perform activities of daily living (ADLs) using a 5-point pain scale: 1, without pain; 2, mild pain; 3, moderate pain; 4, severe pain and, 5 unable to perform ADLs because of pain.

RESULTS

The average duration of postoperative follow-up was 9 months (range: 3-24.5 months). No neurological complications occurred during the surgery. A postoperative radiographic study showed a well-positioned bar in every case. The mean VAS improved 44.7 mm (preoperative: 67.8; at follow-up: 23.2). Fifteen patients (79%) consumed narcotic analgesics before surgery, and only one (5%) at follow-up; two patients (10%) consumed NSAIDS before surgery and three (15%) after. Two patients (10%) consumed minor analgesics before, and 11 (58%) after the procedure. Finally, four patients (21%) were not taking any analgesics at follow-up. Before surgery, 9 patients (47%) were able to perform ADLs with a pain score of 4; 6 (32%) with a score of 3, and 4 (21%) a score of 2. At follow-up 1 (5%) did have a score of 4; 1 (5%) a score of 3, 8 (42%) a score of 2 and 9 (47%) a pain score of 1.

CONCLUSION

A TISIB PROCEDURE RELIES ON THE PRINCIPLES OF FRACTURE TREATMENT: fracture stabilisation and compression. The incapacitating problem of an insufficiency fracture of the sacrum can be elegantly solved by means of this minimally invasive procedure. A near-immediate improvement is noticed when looking at the VAS score, analgesics consumption, and the ability to perform ADLs.

Examination and treatment of pediatric injuries of the hip and pelvis

Injuries to the hip and pelvis are the least common of lower extremity injuries in youth sports, but include many of the more serious conditions. This article describes the bone and soft-tissue conditions of the hip and pelvis that may present to health care providers caring for the pediatric and adolescent sporting population. The article discusses epidemiology, mechanisms, clinical presentation, evaluation, and treatment options.