Osteoporotic sacral insufficiency fracture

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Abstract

Sacral insufficiency fractures (SIFs) are easily neglected by clinical physicians.

The incidence of SIFs remains unclear in patients with symptomatic osteoporotic compression fractures of the lumbar-sacral area.

This retrospective study was conducted by reviewing the medical records and radiological reports and by reading magnetic resonance (MR) images from August 2013 to July 2016. We identified 1233 cases with symptomatic vertebral compression fractures for which surgical interventions were performed. A total of 1144 cases were eligible for this study. Neglected diagnoses by radiologists and clinical physicians were calculated, respectively.

The MR imaging (MRI) findings of SIFs were divided into the body (S1, S2, S3, and S4 levels) and alar areas (unilateral, bilateral, transverse, and none).

A total of 34 (3.00%) cases with SIFs were identified through MRI. A significant difference was observed between 19 (6.53%) patients aged >80 years and 15 (1.76%) aged <80 years ( P < .0001). Eight (23.53%) and 26 (76.47%) cases of SIFs were neglected by radiologists and clinical physicians, respectively. The S2 and S3 levels were the predominantly involved area (23/34; 67.65%). Furthermore, the bilateral alar area was the most commonly involved (19/34; 55.88%), as observed in coronal views of MRI.

While treating other levels of osteoporotic compression fractures, radiologists and clinical physicians should be aware of SIFs, particularly when the patients are aged >80 years. The coronal oblique MR images of the thoracolumbar region should be carefully read to avoid neglecting SIFs.

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Most cited references 32

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Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly.

C Lourie (1982)

Three elderly patients with incapacitating back and leg pain were found to have spontaneous osteoporotic fractures of the sacrum. The clinical picture in these three patients suggests a distinct clinical entity of spontaneous osteoporotic fracture of the sacrum (SOFS). This is characterized by severe low back, hip, and leg pain that suggests initially lumbosacral radicular compression, either from disk disease, spinal stenosis, tumor. However, objective mechanical signs more typical of those entities may be absent or minimal in SOFS. Symptoms suggestive of a cauda equina syndrome may be present, but there is minimal or no neurological deficit on examination. Marked sacral tenderness is a hallmark of SOFS.

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Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study.

Michael Frey, Michael J DePalma, David Cifu … (2008)

Sacral insufficiency fractures (SIFs) can cause low back pain in osteoporotic patients. Symptomatic improvement may require up to 12 months. Treatment includes limited weightbearing and bed rest, oral analgesics, and sacral corsets. Significant mortality and morbidity are associated with pelvic insufficiency fractures. Percutaneous injection of polymethylmethacrylate (PMMA) into the fractured ala, sacroplasty, is an alternative treatment for SIF patients. Under fluoroscopic control, 13-G bone trochars are inserted into the fractured ala while the patient is maintained under conscious sedation. Initial reports have documented safe and effective performance of sacroplasty. Yet, these uncontrolled findings do not allow any precision in estimating complication rates or expected outcome. Assess rates of complications and observe outcomes after sacroplasty in a medium-sized uncontrolled cohort of SIF patients. A prospective observational cohort study of consecutive osteoporotic SIF patients. Consecutive, osteoporotic patients with symptomatic SIFs electing to enter the study. Visual Analogue Scale (VAS) score, analgesic utilization, and patient satisfaction. Baseline VAS rating, analgesic usage, and duration of symptoms were recorded. Subsequent VAS ratings were assessed within 30 minutes after the procedure, at 2-, 4-, 12-, 24-, and 52-week postprocedure. Analgesic usage and patient satisfaction were assessed at final follow-up. Each procedure was performed under light intravenous conscious sedation using fluoroscopy. Two bone trochars were inserted between the sacral foramen and sacroiliac joint through which 2 to 3 cc of PMMA were injected. Fifty-two patients, 40 females, were treated. The mean age was 75.9 years with a mean symptom duration of 34.5 days. All patients were available at each follow-up interval except one patient who died because of unrelated pulmonary disease before the 4-week follow-up. The mean VAS score at baseline was 8.1 and 3.4 within 30 minutes after the procedure, 2.5 at 2, 2.1 at 4, 1.7 at 12, 1.4 at 24, and 0.8 at 52 weeks. Improvement was statistically significant using a repeated measures single-factor analysis of variance. One case of transient S1 radiculitis occurred but resolved completely with one transforaminal epidural steroid injection. Sacroplasty for SIF appears to be associated with rapid and sustained pain relief in most patients with few complications. More rigorous trials are warranted to provide definitive evidence of the safety and efficacy of sacroplasty for SIFs.

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Complications related to cement leakage in sacroplasty.

Ulrich Seidel, P Heini, Lorin M Benneker … (2012)

Data concerning the safety of sacroplasty in terms of cement leakage is scarce. Frequency, distribution patterns and clinical consequences of cement leakage were assessed in 33 patients (28 female, mean age: 74 +/- 10 yrs; bilateral SIF: n = 30, 63 sacroplasties) treated with sacroplasty between 06/2003 and 11/2010 in a retrospective study using patients' records, operative notes and postoperative radiographs. Cement leakage was noted within the fracture gap (27%), into veins (6%), neuroforamina (3%) or in the intervertebral disc space L5/S1 (2%). In one patient, cement leakage into the fracture gap led to unilateral radiculopathy of the 5th lumbar nerve root. Leakage into the fracture gap is at high risk of affecting the 5th lumbar nerve root due to the special course of its ventral branch over the sacral promontory. The risks of cement leakage with neurological impairment should be explained to patients.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: December 2017

Publication date (Electronic): 22 December 2017

Volume: 96

Issue: 51

Electronic Location Identifier: e9100

Affiliations

[a ]Department of Orthopaedics, E-Da Hospital

[b ]School of Medicine for International Students, I-Shou University, Kaohsiung

[c ]School of Medicine, Big Data Research Center, Fu-Jen Catholic University

[d ]Division of Gastroenterology, Fu-Jen Catholic University Hospital, New Taipei

[e ]Graduate Institute of Clinical Medicine, China Medical University, Taichung

[f ]Division of Gastroenterology and Hepatology, E-Da Hospital

[g ]Department of Biomedical Engineering, I-Shou University

[h ]Department of Radiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.

Author notes

[∗ ]Correspondence: Yuan-Kun Tu, Department of Orthopedics, E-Da Hospital/I-Shou University, No. 1, E-Da Road, Yan-Chao District, Kaohsiung 824, Taiwan (e-mail: ed100130@ 123456edah.org.tw ); Feng-Chen Kao, Department of Orthopedics, E-Da Hospital/I-Shou University, No. 1, E-Da Road, Yan-Chao District, Kaohsiung 824, Taiwan (e-mail: ed100735@ 123456edah.org.tw ).

Article

Publisher ID: MD-D-17-03900 Accession ID: 09100

DOI: 10.1097/MD.0000000000009100

PMC ID: 5758140

PubMed ID: 29390438

SO-VID: 8ae919ef-84e9-4ffc-aaf4-7b0154f1fe15

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This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

History

Date received : 23 June 2017

Date revision received : 13 November 2017

Date accepted : 14 November 2017

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Keywords: osteoporotic compression fracture,sacral insufficiency fracture,sacroplasty

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Keywords: osteoporotic compression fracture, sacral insufficiency fracture, sacroplasty

Osteoporotic sacral insufficiency fracture : An easily neglected disease in elderly patients

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Fracture and Structural Integrity

Most cited references 32

Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly.

Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study.

Complications related to cement leakage in sacroplasty.

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