CT-guided sacroplasty for the treatment of sacral insufficiency fractures
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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Sacral Fractures and Sacroplasty
2019, Neuroimaging Clinics of North AmericaCitation Excerpt :Proponents of the long axis approach cite better filling of the entire longitudinal fracture line with cement, and less potential for breaching the sacral anterior cortex as benefits of this needle trajectory. Studies of both techniques have shown similar effectiveness in treating pain and safety in terms of cement extravasation.17,20,26–29 The transiliac approach, in which the needle enters the iliac bone and traverse the sacroiliac joint, has been found useful to reach sacral body lesions (Fig. 12).
Cement-augmented sacroiliac screw fixation with cannulated versus perforated screws – A biomechanical study in an osteoporotic hemipelvis model
2018, InjuryCitation Excerpt :So far, no published data exists on cement displacement after cement augmented sacroiliac screw fixation. However, several studies reporting cement leakage after sacroplasty can be found, with cement displacement in up to 33% of patients [15–21]. In two of these studies, symptomatic cement dislocations appeared [15,17].
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2010, International Journal of Radiation Oncology Biology PhysicsBalloon, Radiofrequency, Vertebro and Cement Sacroplasty for the Treatment of Non-Displaced Insufficiency Fractures
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