Technical reportCT-guided sacroplasty in advanced sacral destruction secondary to tumour infiltration
Introduction
Percutaneous sacroplasty is an image-guided technique that involves the injection of bone cement into the sacrum with the aim of alleviating pain and facilitating mobilization. The techniques, outcomes, and complications have been variously reported,1, 2, 3 and sacroplasty is increasingly being performed as a treatment for disabling low back pain associated with insufficiency fractures of the sacrum. There are multiple reports describing this technique to be both safe and effective in providing substantial pain relief and improved quality of life.4, 5, 6, 7, 8, 9
Percutaneous vertebroplasty has been widely studied in the treatment of osteoporotic compression fractures and spinal metastatic disease. The pain relief rates reported for malignant vertebral infiltration have been shown to be significant and range from 86–92%.10, 11 As the vertebral column is a frequent site for skeletal metastases and pain control is important when maintaining the patient quality of life, the natural extension of sacroplasty from the treatment of sacral insufficiency fractures is in the treatment of painful sacral tumour infiltration.
Although vertebroplasty for metastatic lesions is well described, experience in treating patients with painful sacral metastases is limited in the published literature. Furthermore, as reported case numbers are so small, there is no consensus on the indications or degree of sacral destruction in which this technique can be utilized. We present two cases where there was very extensive sacral destruction and no viable surgical alternative. We describe the technique used and the outcome in these patients with a review of the relevant literature.
Section snippets
Patients
Two patients were referred to our tertiary referral centre for spinal oncology for consideration of sacroplasty for disabling painful sacral destruction. Hospital approval had been granted for the utilization of cement augmentation in the sacrum and both patients were discussed by a multidisciplinary team prior to intervention.
Results
In the first case, 6 ml PMMA was injected into the right sacral ala (Fig. 6) and a total of 8 ml on the left (upper needle 6 ml, lower needle 2 ml). A small amount of cement extended to breach the anterior cortex necessitating termination of injection. This was distant from the anatomical course of the lumbar plexus and was of no clinical significance. In the second case, 6 ml PMMA was used on the left and 5 ml on the right. There was satisfactory fill with no significant cement leak or extension of
Discussion
There are limited reports in the published literature on the effectiveness of sacroplasty in providing pain relief for sacral tumour infiltration (Table 1). The technical challenges of the procedure are twofold. First, safe and accurate placement of the needle is required, and second, cement injection needs to be carefully monitored. This is to prevent intra-operative cement leakage either into the sacral exit foramina or around the lumbar plexus. Needle placement and cement injection can be
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Cited by (17)
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).
Reliability and effectiveness of percutaneous sacroplasty in sacral insufficiency fractures
2015, Journal of Clinical NeuroscienceCitation Excerpt :This approach is also superior to CT scan navigation because it allows for real time imaging during the injection of the cement and, thus, reduces the risk of leakage. There are only a limited number of studies on sacroplasty to date (Table 4) [1,3,7,15,16,18–32]. A large proportion of the reported patients (n = 222) had osteoporotic SIF.
Sacral fractures and sacroplasty
2010, Neuroimaging Clinics of North AmericaCitation Excerpt :The inherent difficulty in fluoroscopic visualization of important sacral landmarks, including the spinal canal and neural foramina, makes the detection of cement leaks into these spaces difficult. The authors recommend specific training and the use of CT guidance for sacroplasty.22–24 In a prospective, multicenter, observational study of 52 patients treated with sacroplasty, there was a statistically significant immediate improvement with dramatic decrease in pain after the procedure.25
Lymphoma and myeloma of the sacrum
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