A novel technique to repair a transverse sacral fracture in a previously fused lumbosacral spondylolisthesis

Treatment for sacral insufficiency fractures: A systematic review

Intro

Sacral insufficiency fractures after lumbosacral fusion continue to establish themselves as a rare complication after surgery. The diagnosis can often be missed due to inconclusive imaging and non-specific symptoms. In the literature, the treatment of sacral insufficiency fractures varies from non-operative and conservative management to surgical intervention with lumbopelvic fixation.

Methods

We performed a systematic review searching the PubMed database using sacral insufficiency fracture treatment after lumbosacral fusion and sacral insufficiency fracture after posterior spinal instrumentation as keywords.

Results

This search strategy identified 32 publications from the PubMed database for literature review. After evaluating the inclusion and exclusion criteria, a total of 17 articles were included in the review. 65% of sacral insufficiency fractures were managed surgically with 35% of patients proceeding with non-operative, conservative management only. Revision surgery always involved sacropelvic fixation which typically led to immediate resolution or reduction of symptoms, with the exception of 2 cases that did not receive adequate reduction of symptoms. Five cases reported failed non-operative management that subsequently responded to revision surgery.

Conclusion

Outcomes after non-operative management usually leads to symptom resolution; however has a slower symptom relief time as well as a higher chance of failed treatment. Operative outcomes, generally with a variation of sacropelvic fixation lead to immediate symptom resolution and very rarely failed treatment. Clinicians must always maintain a high index of suspicion of new onset lower back or sacral pain after lumbosacral surgery and order a CT scan to rule out a potential insufficiency fracture.

Objectives

The objective of this study was to review the literature to examine treatment options for sacral insufficiency fractures after lumbosacral fusion in order to improve clinical practice and management. This systematic review of the literature regarding treatment of sacral insufficiency fractures will assist clinicians in making the accurate diagnosis and devise a strategic treatment plan for patients with sacral insufficiency fractures after spinal instrumentation.

Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm

OBJECTIVE

Sacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors' operative experience managing this complication, review pertinent literature, and propose a treatment algorithm.

METHODS

The authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication.

RESULTS

Nine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8-96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score -1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8-90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to-lumbar lordosis (LL) mismatch.

CONCLUSIONS

A high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5-S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.

Diagnosis, Risk Factors, and Management of Sacral and Pelvic Fractures After Instrumented Lumbar Fusions: A Systematic Review

STUDY DESIGN

Systematic literature review.

OBJECTIVES

To evaluate risk factors, diagnosis, and management of sacral and pelvic fractures (SPFs) after instrumented fusions.

METHODS

A systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed using the PubMed database. Articles with patients with an SPF after a lumbar instrumented fusion were included. The articles addressing specifically proximal junctional kyphosis were excluded. Eleven small cases series (level of evidence IV) were reviewed.

RESULTS

The incidence of SPF was 1.86% in one study. The risk factors reported were elderly patients, multilevel surgery, long fusions stopping at L5 or S1 instead of the ilium, osteoporosis, obesity, and sagittal imbalance. Computed tomography scan was the preferential image modality for diagnosing. Nonsurgical treatment may be used in patients with tolerable pain and nondisplaced fracture. Persistent pain was an indication for surgery, as well as fracture displacement. The most common surgical treatment reported was an extension of the fusion to the iliac using iliac screws.

CONCLUSION

SPFs after lumbar instrumented fusion are rare but clinically meaningful complications. The risk factors, diagnosis, and management of SPFs are described in our review.