Sacral insufficiency fracture, usually overlooked cause of lumbosacral pain

‘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.

Diagnosing sacral insufficiency fractures after radiotherapy in women with cervical cancer: Report of three cases

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.

Effect of Complex Korean Medicine Treatment on Sacral Insufficiency Fracture: A Case Report

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.

Is a Fracture of the Transverse Process of L5 an Indicator of the Presence and/or Severity of a Pelvic Fracture?

Introduction

A transverse process of L5 (L5TP) fracture may be associated with the presence and/or severity of a pelvic fracture. However, there is little evidence to support this view. The purpose of this study was to investigate the relationship between L5 TP fracture and the presence and/or severity of a pelvic fracture on radiograph and CT.

Methods

A total of 146 patients (82 women and 64 men; age range, 5-97 years) who were treated for pelvic fractures were evaluated. The site of pelvic fractures, presence of an L5 TP fracture with radiograph and CT, associated injuries and the need for blood transfusion, surgical intervention, and mortality were investigated retrospectively. According to the Burgess and Young classification, there were 42 unstable fractures. For each parameter, correlations between the parameters were evaluated using a chi-squared test and a logistic regression analysis. A p-value <0.05 was considered to be statistically significant.

Results

The sensitivity of L5 TP fractures on radiograph and CT were 51% and 95%, respectively (p < 0.0001). Multiple logistic regression analysis revealed that, of the L5 TP fractures patients on radiograph, the odds ratios for sacral fractures were 4.5 (95% confident interval [CI], 1.1-17.9); based on CT, the odds ratios for sacral fractures and the need for blood transfusion were 18.2 (95%CI, 5.1-64.9) and 3.2 (95%CI, 1.1-9.1), respectively.

Conclusions

This study demonstrated that L5 TP fractures on radiograph and/or CT could indicate a high risk of sacral fracture and need for blood transfusion. When an L5TP fracture is diagnosed on initial radiograph or CT in the emergency setting, it is necessary to conduct further investigations for pelvic ring fractures and to alert the attending staff to the high-risk fracture.

PELVIC INSUFFICIENCY: UNDERDIAGNOSED CONDITION, THERAPEUTIC DIAGNOSTIC REVIEW

ABSTRACT Objective: The importance of sacral fractures has recently been recognized. However, its diagnosis is difficult, both clinically and through image, but there are more options for comprehensive diagnosis. Methods: We conducted a literature review about its diagnosis and the treatments currently offered, and also to check which treatments had the best results. Results: Patients with pelvic insufficiency have limited mobility due to lumbar or pelvic pain. As radiculopathy is a neurologically stable condition, it has a reported incidence of only 5% and sphincter disorders. The pain improves when lying down and increases with load. The treatments vary from conservative to surgical. Discussion: The different treatments were compared, and the one that has more morbidity is the conservative, because it predisposes us to complications (pneumonia, pulmonary embolism, deep vein thrombosis, heart failure, decubitus ulcers); in the interventionists we observe a faster improvement to normal activity of these patients, the complications are minor and the pain improvement is noticeable and much faster. Conclusion: Fractures due to pelvic insufficiency are underdiagnosed. However, there are already better imaging techniques and combined with good exploration and clinical history we can suspect this condition and offer the best possible treatment, these being the invasive ones that have had better results with lower morbidity and recovery of activity much more quickly. Level of Evidence III; Review of therapeutic studies - Investigation of treatment results.

Combined Sacroplasty and Iliosacral Fixation Using Triangular Titanium Implants for the Treatment of Sacral Insufficiency Fractures with Concomitant Sacral Instability

Sacral insufficiency fractures (SIFs) are a common, under-recognized cause of debilitating low back pain, particularly in elderly patients with osteoporotic bone disease or risk factors for bone demineralization. Conservative therapy has been the mainstay of treatment for these types of fractures. This places patients at increased risk for the development of secondary illnesses associated with prolonged immobility, which might prevent a full return to the preinjury level of function. Surgical intervention for SIFs has increased over the past two decades in an attempt to overcome these complications and improve patient functionality. Sacroplasty and iliosacral screw stabilization are two specific procedures performed to treat SIFs. The purpose of this case report is to further document the existence of this condition, as well as to detail a novel approach for surgically treating this condition with a combination of the above procedures.

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.

Combined Percutaneous Iliosacral Screw Fixation With Sacroplasty Using Resorbable Calcium Phosphate Cement for Osteoporotic Pelvic Fractures Requiring Surgery

Osteoporotic sacral fractures, including acute and chronic insufficiency fractures, are increasing in frequency and present a number of management problem. Many of these patients are treated nonoperatively with relative immobility (eg, bedrest, wheelchair, or weight-bearing restrictions) and analgesics, which likely make the osteoporotic component worse. Surgery in this patient population may be desirable in some cases with the goals of improving mobility, relieving pain, and healing in an aligned position while minimizing deformity progression. However, internal fixation of the osteoporotic pelvis can be difficult. Large unicortical lag screws are the workhorse of posterior pelvic fixation, and yet fixation in cancellous bone corridors of an osteoporotic sacrum seems unlikely to achieve optimal fixation. As a result, the operative management and clinical results of these difficult injuries may not be uniformly successful. The authors present a technique for treating osteoporotic patients with a sacral fracture when operative treatment is indicated using percutaneous screw fixation combined with screw augmentation using a resorbable calcium phosphate bone substitute or "cement." The guide wire for a 7.3-mm or other large cannulated lag screw is fully inserted along the desired bony sacral corridor as is standard. The lag screw is then inserted over the wire to the depth where cement is desired. The guide wire is removed, and the aqueous calcium phosphate is injected through the screw's cannulation. For acute fractures, cement was applied to the areas distant to the fracture; whereas in insufficiency fractures, the cement was inserted along most of the screw path. The guide wire then can be reinserted and the lag screw fully inserted. The rationale for using these 2 modalities is their synergistic effect: the cannulated screw provides typical screw fixation and also a conduit for cement application. The cement augments the lag screw's purchase in osteoporotic bone, enhancing fixation strength. The authors propose that combining percutaneous screw fixation with calcium phosphate augmentation may provide an improved biomechanical environment for healing of these difficult fractures that might translate into earlier mobility, better pain control, and improved outcomes.

Fragility fractures of the sacrum: how to identify and when to treat surgically?

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.

Therapeutic considerations of percutaneous sacroplasty for the sacral insufficiency fracture

Sacral insufficiency fracture is a debilitating injury not easily found in general radiologic examinations and is rarely diagnosed, since its symptoms are obscure. It is known to frequently occur in patients with osteoporosis, but the treatment has not yet been established and various kinds of treatment methods are being attempted. Sacroplasty is sometimes performed by applying percutaneous vertebroplasty which is known to be a less invasive treatment. Since the course of diagnosis of sacral insufficiency fracture is difficult and clear guidelines for treatments have not yet been established, many spine surgeons fail to diagnose patients or speculate on treatment methods. We report our experience in diagnosing a sacral insufficiency fracture in a 54-year-old healthy female patient using MRI and treating her with sacroplasty. From a therapeutic point of view, we then cover the usefulness, effects and characteristics relating to the complications of sacroplasty, along with literature review.