Therapeutic considerations of percutaneous sacroplasty for the sacral insufficiency fracture

Sacral Insufficiency Fracture Following Short-Segment Lumbosacral Fusion: Case Series and Review of the Literature

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Sacral insufficiency fracture is a rare and serious complication following lumbar spine instrumented fusion. The purpose of this study was to describe the patient characteristics, presentation, evaluation, treatment options, and outcomes for patients with sacral insufficiency fracture after short-segment lumbosacral fusion.

METHODS

Six patients from our institutional database and 16 patients from literature review were identified with a sacral insufficiency fracture after short-segment (L4-S1 or L5-S1) lumbar fusion within 1 year of surgery.

RESULTS

Patients were 55% female with a mean age of 58 years and body mass index of 30 kg/m². Osteoporosis or osteopenia was the most common comorbidity (85%). Half of patients sustained a sacral fracture after surgery from a posterior approach, while the others had anterior or anterior-posterior surgery. Mean time to fracture was 42 days with patients clinically presenting with new sacral pain (86%), radiculopathy (60%), or neurologic deficit (5%). Ultimately, 73% of patients underwent operative fixation often involving extension of the construct (75%) and fusion to the pelvis (69%). Men (P = .02) and patients with new radicular pain or neurologic deficit (P = .01) were more likely to undergo revision surgical treatment while women over 50 years of age were more likely to be treated conservatively (P = .003).

CONCLUSIONS

Spine surgeons should monitor for sacral insufficiency fracture as a source of new-onset pain in the postoperative period in patients with a short segment fusion to the sacrum. The recognition of this complication should prompt an assessment of bone health and management of underlying bone fragility.

Combination of long- and short-axis alar sacroplasty techniques under fluoroscopic guidance for osteoporotic sacral insufficiency fracture

BACKGROUND

Sacral insufficiency fracture (SIF) is rarer than osteoporotic vertebral compression fracture that occurs at other levels of the thoracolumbar spine. Percutaneous sacroplasty can effectively relieve pain and improve mobility. Several sacroplasty-based techniques have been reported to date. Sacroplasty is often performed with computed tomography-guided cannula placement, which is time intensive and results in greater radiation exposure than that resulting from fluoroscopy. Herein, we report our preliminary experience with a combination of long- and short-axis alar sacroplasty techniques under fluoroscopic guidance for osteoporotic SIFs.

METHODS

We retrospectively reviewed 44 consecutive patients with symptomatic osteoporotic SIFs who underwent alar sacroplasty between January 2013 and February 2020. The study group comprised 19 patients who underwent a combination of long- and short-axis alar sacroplasty techniques under fluoroscopic guidance. The control group comprised the remaining 25 patients who underwent short-axis alar sacroplasty under fluoroscopic guidance. Visual analog scale (VAS) scores, operation times, injected cement volumes, and postoperative complications were recorded.

RESULTS

The VAS score for pain decreased in both groups; however, no significant difference was noted between the study and control groups in injected cement volume (3.55 ± 0.96 vs 2.94 ± 0.89 mL). The operation time was longer in the study group than in the control group (32 ± 7.1 vs 28.04 ± 4.99 min; P = 0.046). No major complications were noted.

CONCLUSION

A combination of long- and short-axis alar sacroplasty techniques can be effectively performed under fluoroscopic guidance for osteoporotic SIFs.

Successful Repeat Sacroplasty in a Patient With a Recurrent Sacral Insufficiency Fracture: A Case Presentation

The standard of care for treatment of sacral insufficiency fracture (SIF) remains conservative management with limited weight-bearing and analgesics, as most fractures heal within 12 weeks. For those who fail to respond to conservative therapy, are immobile, or cannot tolerate the pain despite analgesic therapy, as well as those who do not improve with time, rest, or activity modification, minimally invasive surgery with percutaneous transverse screw fixation across the fracture is effective. However, a less invasive procedure, percutaneous sacroplasty, may be an option for potential rapid pain reduction. This is a novel report of repeat sacroplasty in a patient with a recurrent SIF to the same anatomical area as a previously treated SIF. To our knowledge, this is the first report of such an occurrence.

LEVEL OF EVIDENCE

Not applicable.

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.

Clinical impact of sacroplasty on patient mobility

PURPOSE

To evaluate the effect of sacroplasty on patient mobility and pain when performed as a treatment for sacral insufficiency fractures.

MATERIALS AND METHODS

Imaging with computed tomography (CT), magnetic resonance imaging, or bone scan confirmed the diagnosis of sacral insufficiency fractures. Baseline clinical mobility scale (CMS) score and visual analog scale (VAS) pain score were recorded. Sacroplasty was performed under CT guidance. Follow-up CMS and VAS scores were assessed at 4, 24, and 48 weeks.

RESULTS

Eighteen elderly patients (age 80 y ± 8.5; 17 women) were treated. Repeated-measures analysis of variance was conducted to assess changes in CMS and VAS scores over time. Pairwise comparisons revealed a significant increase in average CMS score between baseline and all three follow-up points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in mobility over time. Pairwise comparisons revealed significant differences in mean VAS scores between baseline and all three follow-up time points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in overall pain level over time.

CONCLUSIONS

Treatment with CT-guided sacroplasty for sacral insufficiency fractures in this elderly population resulted in significant improvement in patient mobility.

Outcome of long-axis percutaneous sacroplasty for the treatment of sacral insufficiency fractures with a radiofrequency-induced, high-viscosity bone cement

Our goal was to assess the technical results in patients who underwent long-axis sacroplasty for the treatment of sacral insufficiency fractures (SIF) by radiofrequency-induced high-viscosity bone cement augmentation. Twelve patients with bilateral sacral fractures were treated by augmentation with radiofrequency-activated, high-viscosity polymethylmethacrylate (PMMA) bone cement under local anesthesia. CT-guided sacroplasty was performed by using a long-axis approach through a single entry point. Thirty-six vertebrae were treated in 12 sessions under a combination of CT and fluoroscopic guidance using a bilateral access and a cavity-creating osteotome prior to remote-controlled, hydraulically driven cement injection. The visual analogue scale (VAS) score before sacroplasty and at 1 and 3 months after the treatment was obtained. PMMA leaks were evaluated retrospectively using the post-interventional CT. The mean amount of high-viscosity PMMA injected per patient was 7.8 ml. No major adverse events were observed. In the first 4 days after the procedure, the mean VAS score decreased from 8.1 ± 1.9 to mean 3.1 ± 1.2 and was followed by a gradual but continuous decrease throughout the rest of the follow-up period at 24 weeks (mean 2.2 ± 1.1) and 48 weeks (mean 2.1 ± 1.4). CT fluoroscopy-guided sacral augmentation was safe and effective in all 12 patients with osteoporotic SIF.

Analgesic effect of sacroplasty in osteoporotic sacral fractures: a study of six cases

OBJECTIVES

To evaluate the short-term analgesic effect of sacroplasty in patients with osteoporotic sacral fractures.

METHODS

Single-center retrospective observational study of all patients managed with sacroplasty for osteoporotic sacral fractures between October 2008 and November 2009. For each patient, symptom duration, pain intensity, and analgesic consumption were recorded. Sacroplasty was performed under local analgesia, in the prone position, with computed tomography guidance. The long-axis approach was sued to introduce the needles and polymethylmethacrylate cement along the fracture line(s). Pain was evaluated on a 10-point visual analog scale (VAS) 24 hours before sacroplasty then at the time of weight-bearing resumption 24 hours after the procedure. Hospital stay length before and after the procedures were recorded.

RESULTS

We identified six patients (five women and one man) with a mean age of 83.2 years. All six patients presented with low back pain and four also had buttock pain. The interval from pain onset to diagnosis ranged from 1 month to 1 year. All patients reported that pain onset followed a fall. The mean VAS pain score was 8.2 before sacroplasty and decreased by 7.6 points 24 hours after the procedure (with four patients having a score of 0). Mean hospital stay length were 12 days before and 4 days after sacroplasty. All patients required opioid analgesics before sacroplasty. At discharge, analgesic requirements were a step II analgesic in one patient, acetaminophen in one patient, and no analgesics in four patients. No adverse events were recorded.

DISCUSSION

The findings from our small population are consistent with a recent literature review of 15 case-series studies showing a significant analgesic effect of sacroplasty. The rapid effect of sacroplasty allows prompt ambulation, thus avoiding complications related to immobility.

CONCLUSION

Sacroplasty is effective in relieving pain due to sacral insufficiency fractures.

Spinous process fractures in osteoporotic thoracolumbar vertebral fractures

OBJECTIVES

To evaluate the incidence and pattern of spinous process fractures (SPFs) in patients with osteoporotic compression fractures (OCFs) of the thoracolumbar spine.

METHODS

Spinal MRI or CT of 398 female patients (age range 50-89 years, mean age 70 years) who had OCFs in the thoracolumbar spine were retrospectively reviewed. The incidence, location and imaging results for the SPFs were evaluated.

RESULTS

Of the 398 patients who had thoracolumbar OCFs, 14 (3.5%) had SPF. In six patients with single compression fractures, the SPF occurred at the level just above the vertebral compression fracture. In six out of seven patients with multiple continuous compression fractures, the SPF occurred just one level above the uppermost level of the compression fracture. The remaining one patient who had thoracolumbar spinal fixation at T12-L2 with continuous compression fractures in T12-L5 had a SPF in L2. In one patient who had multiple compression fractures in discontinuous levels (fractures at T10 and L1, respectively), the SPF occurred at T12. The directions of the fractures were vertical or oblique vertical (perpendicular to the long axis of the spinous process) in all cases.

CONCLUSION

In the presence of an OCF in the thoracolumbar spine, a SPF was found in 3.5% of cases, and most of the fractures were located just one level above the compression fracture. Therefore, in patients who have OCF, the possibility of a SPF in the level just above the compression fracture should be considered.