Elsevier

Clinical Radiology

Volume 62, Issue 11, November 2007, Pages 1094-1100
Clinical Radiology

CT-guided sacroplasty for the treatment of sacral insufficiency fractures

https://doi.org/10.1016/j.crad.2007.04.017Get rights and content

Aim

To describe the clinical presentation, procedure and outcome in patients treated with computed tomography (CT)-guided sacroplasty as a treatment for sacral insufficiency fractures.

Materials and Methods

Three patients (mean age 80 years, range 75–87 years) were treated with CT-guided sacroplasty. The mean pre-procedure visual analogue score (VAS) for pain was 8 (range 7–9) with a mean symptom duration of 8 months (range 2.5–18). The procedure was performed under CT guidance with needles being placed along the fracture lines from a posterior approach. Polymethylmethacrylate (PMMA) cement was introduced in 0.2 ml aliquots after cement temperature reduction. Cement injection was monitored by four-secton block axial acquisition to assess potential cement migration.

Results

All three procedures were performed without significant complication. One patient developed a tiny asymptomatic cement leak into the S1 foramen. The mean volume of cement injected into a unilateral sacral fracture was 4 ml. All patients tolerated the procedure well under intravenous sedation. The mean VAS score post-procedure was 2. Continued symptomatic relief was seen at 6 weeks and 3 months.

Conclusion

CT-guided sacroplasty represents an alternative treatment for sacral insufficiency fractures that are resistant to conservative treatment. The symptomatic relief the procedure produces seems to be excellent both in this small series and in described cases in the literature.

Introduction

Sacral insufficiency fractures are an often under-diagnosed condition in the elderly population.1 They typically present with severe low back pain and resultant secondary immobility. The diagnosis is often overlooked as radiographic assessment of the sacrum is difficult, and frequently, imaging is not specifically targeted at the sacrum. Isotope bone scintigraphy may identify increased uptake in the sacrum and the typical “Honda sign” has been described.2 Cross-sectional imaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) can demonstrate the fracture line traversing through the sacral ala.3 Current treatment regimes consist of medical therapy, predominantly in the form of analgesia and bed-rest.

Percutaneous sacroplasty has been described and involves the injection of bone cement (polymethylmethacrylate; PMMA) into the sacrum.4 The aims are to alleviate pain and facilitate more rapid mobilization than conservative therapy alone allows. Therefore, this can reduce analgesic requirement and the length of any inpatient hospitalization. In the elderly population, prolonged immobility may be a cause of significant morbidity and early mobilization can reduce this problem. The procedure is predominantly performed for sacral insufficiency fractures; however, its use has also been reported in the treatment of symptomatic metastatic lesions of the sacral ala.5, 6

We describe three patients treated with CT-guided sacroplasty at a single institution for sacral insufficiency fractures. The initial presentation, procedure, and clinical outcome are presented along with a review of the literature. All three cases had associated fractures of the pubic rami, which have been reported to occur in up to a third of cases of sacral insufficiency fractures.7 We are not aware of previous reports describing this procedure in patients with concomitant, symptomatic pubic rami fractures. Institutional approval was obtained prior to the first procedure being performed, and all cases were discussed both pre- and postoperatively at our spinal multidisciplinary meeting.

Section snippets

Study population and imaging findings

Three patients were referred to a single institution over a 1-year period for sacroplasty. The mean age was 80 years (range 75–87 years). The mean duration of symptoms was 8 months (range 2.5–18 months). Table 1 lists the clinical presentation and symptom complex of the patients included in the study.

The first patient was a 75-year-old woman who was referred with an initial suspicion of metastatic disease, prompting referral to the Orthopaedic Oncology Service. Radiographs demonstrated a

Results

Table 2 lists the approach, number of needles required for access, volume of cement injected, and outcome in each of the cases. Cement was demonstrated filling the fracture line in all cases. In the final case, a small cement leak occurred into the right S1 foramen; however, this was recognized intra-operatively and injection was terminated. The patient was completely asymptomatic from this after the procedure. All patients were screened for osteoporosis, with two requiring ongoing medical

Discussion

Lourie first described osteoporotic fractures of the sacrum in 1982, and it has been estimated that more than 1% of over 55-year-old women may be affected.8 Patients usually have underlying osteoporosis and a history of either minimal or no trauma. Subsequently, additional risk factors have been reported, including rheumatoid arthritis, steroid therapy, hip replacement, and pelvic radiotherapy.7 When recognized, standard medical therapy consists of bed rest and analgesia, however, this leads to

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