Diagnosis Of Sacral Insufficiency Fractures Research Articles

Sacral insufficiency fracture: a single-center experience of 185 patients with a minimum 5-year follow-up.

Sacral insufficiency fracture (SIF) is a commonly underdiagnosed etiology of back pain, especially in the geriatric and osteoporotic population. In this clinical study, we present our experience of 185 patients who were diagnosed with SIF and managed either with conservative or surgical treatment with a minimum 5-year follow-up. Patients who were diagnosed with SIF, managed either conservatively or surgically, and had a minimum 5-year follow-up medical record were included in this study. CT scans and MR imaging including coronal STIR sequence were obtained from all. Bone densitometry (DEXA) was performed to detect accompanying osteopenia or osteoporosis. Patients were treated either conservatively or surgically. VAS and ODI scores were evaluated prior to the treatment and 1st day, 10th day, 3rd month, and 1st year postoperatively. The mean age of 185 patients was 69.2 and the mean follow-up period was 7.23years (range: 5-11years). 46 (24.9%) patients had a previous spinal or spinopelvic surgery and spinal instrumentation was implemented in 22(11.89%) of them. The time interval between the fusion surgery and the diagnosis of SIF was approximately 9.48weeks. The fracture line could be detected with the MRI in 164 patients and with the CT in 177 patients. The fracture was bilateral in 120 (64.8%) patients. 102 patients were treated conservatively, and 83 received sacroplasty. VAS and ODI scores showed better improvement in pain and functionality in the surgical management group than in the conservative management group. SIF should be considered in the differential diagnosis of back and pelvic pain, especially in elderly and osteoporotic patients. MRI with coronal STIR imaging should be a standard protocol for patients with a risk of SIF. Our results show that sacroplasty provides better and faster pain relief and recovery than conservative management.

Sacral insufficiency fracture after lumbosacral decompression and fusion

Sacral insufficiency fracture is becoming increasingly recognized as a complication of lumbosacral fusion, due to alteration of spinal biomechanics. Recognition of patient presentation is important because plain films may initially be negative with this complication. This case series of seven sacral insufficiency fractures following lumbosacral fusion characterizes key characteristics of presentation and management for sacral insufficiency fracture following lumbosacral fusion, which does not have a clearly defined algorithm for treatment. These seven fractures presented with initial complaints of back pain, lower extremity radicular symptoms, or a combination of the two. All identified fractures in this series were located below the inferior-most level of the fusion construct. Cross-sectional imaging such as computed tomography or magnetic resonance imaging was utilized in each case to make the diagnosis of sacral insufficiency fracture. Management depends on the patient’s presentation, symptoms, and fracture pattern, but treatment options include operative revision surgery and nonoperative modalities such as a standard rehabilitation protocol, lumbar bracing, and bone stimulators with close follow-up.

Balloon-assisted sacroplasty as a successful procedure for osteoporotic sacral insufficiency fractures after failure of the conservative treatment

Osteoporotic vertebral fractures without prior adequate traumatization are frequent diagnosed in orthopedics because of the increasing life expectancy and incidence of osteoporosis. The associated high mortality is caused by reduced mobilization which leads to a higher risk of infection and a bedridden state. On the other hand the diagnosis of sacral insufficiency fractures is often prolonged because of unspecific symptoms while being associated with similar risks. This article presents an overview of the present scientific literature and a retrospective analysis of patients treated via balloon-assisted sacroplasty. In 8 years, ten patients (three men and seven women) were treated. The average age was 78.4 years and the average time until the diagnosis 4.6 weeks. In most patients a significant pain reduction after the failure of conservative treatment thanks to operative treatment as well as increased mobility was observed. Only one experienced a minor surgical complication being cement leakage with nerval impaction which did not compromise her clinical outcome or satisfaction with the procedure. Balloon-assisted sacroplasty can possibly be seen as an effective symptomatic therapy in osteoporotic insufficiency fractures.

Significance of Lumbar MRI in Diagnosis of Sacral Insufficiency Fracture.

Study Design:Retrospective observational study.Objective:The aim of the present study was to evaluate the role of lumbar magnetic resonance imaging (MRI) in the diagnostic algorithm of sacral insufficiency fractures (SIF). The primary objective was to compare the sensitivity in fracture detection and correct fracture classification according to MRI and computed tomography (CT). The secondary objective was to identify differences of additional pathologies found in MRI of the lumbar spine and the pelvis and their rates.Methods:A total of 943 patients (from 2010 to 2017) with fracture of the pelvic ring were screened. All patients without high-energy trauma and radiologic diagnostics consisting of X-ray, CT, and MRI of the pelvis or the lumbar spine including the sacrum were included. Differences in fracture detection and description in the various radiologic procedures were evaluated. Detection rates of additional pathologies in MRI of the pelvis and lumbar spine were recorded.Results:A total of 77 subjects were included. The sensitivities for SIF were 14% in X-ray and 88% in CT, and all fractures were detected in MRI. MRI showed a more complex fracture pattern compared with CT in 65% of the cases. Additional pathologies were seen in MRI of the lumbar spine (51%) and that of the pelvis (18%).Conclusions:We suggest performing MRI of the lumbar spine including the sacrum with coronal STIR (short tau inversion recovery) sequence for elderly patients with suddenly increasing low back pain at an early stage. This procedure might improve fracture detection, classification, and recognition of concomitant pathologies.

Etiology of Lumbosacral Radiculoplexopathy: Sacral Insufficiency Fracture on Magnetic Resonance Imaging.

Sacral insufficiency fracture (SIF) can cause lumbosacral radiculoplexopathy (LSRP) and is probably under-recognized. Symptoms may include nonspecific lumbar spine or buttock pain that is exacerbated by physical activity and alleviated with rest. The frequency of LSRP secondary to SIF has not been reported. We aimed to determine the frequency of LSRP associated with SIF using magnetic resonance imaging (MRI) of the lumbar spine. We searched a radiology database at our institution using the keywords "sacral insufficiency fracture" and "lumbar spine MRI" for patient records from January 2014 through December 2017. We assessed for the presence of LSRP, reflected by elevated T2-weighted or short tau inversion recovery (STIR) signal intensity and enlargement of the nerve on noncontrast lumbar spine MRI. An incompletely healed vertically oriented SIF was confirmed if there was a persistent bone marrow edema pattern adjacent to the fracture site; we did not include purely transverse SIFs. The final cohort comprised 57 patients (48 female; age range, 14 to 89years). Abnormalities of the extraforaminal L5 nerve root or the combined L4 and L5 nerve roots (the lumbosacral trunk) were identified in 19 (33%) of 57 patients, with a total of 23 sites (bilateral involvement in four cases). Of the 23 abnormal nerves, 19 (82.6%) had corresponding, clinically documented radicular symptoms and 16 (69.6%) had no other explanation on MRI for their radicular symptoms other than SIF. LSRP caused by SIF is an entity all radiologists should be cognizant of, especially in cases of otherwise unexplained radicular symptoms. The diagnosis of SIF can be helpful in cases involving concomitant multilevel lumbar spondylosis and neural foraminal stenosis.

Percutaneous Sacroplasty for Sacral Insufficiency Fractures: Case Series and Review of Presentation, Diagnosis, and Treatment

Sacral insufficiency fractures (SIFs) are a cause of debilitating low back pain that is often difficult to diagnosis and manage. The diagnosis of SIF is often delayed due to inaccurately attributing symptoms to spondylosis, which is a commonly present in the elderly population where SIFs are most prevalent. Historically, treatment consisted of medical management and open reduction internal fixation reserved for severe cases. However, percutaneous sacroplasty has emerged as a minimally invasive treatment option which provides early pain relief without significant complications. The objective of this article is to raise awareness of SIFs and percutaneous sacroplasty as an effective and safe treatment method.

Comparison of patients with diagnosed and suspected sacral insufficiency fractures

BackgroundPatients with sacral insufficiency fractures can have a range of symptoms, and because these fractures are difficult to detect using plain radiographs, it can be tough to make a definitive diagnosis of fracture early after injury. The aim of this study was to compare the diagnosis and treatment of patients with known sacral insufficiency fractures to those with suspected insufficiency fractures to clarify the features of sacral insufficiency fractures. MethodsWe compared patients with sacral insufficiency fractures (S group) to those with suspected insufficiency fractures (N group) using demographic data, symptoms, time to definitive diagnosis, radiological methods, and treatments. ResultsPatients in the S group were older than those in the N group (p = 0.0042) and showed less localized sacral pain (p = 0.0042). Almost all of the patients in the S group (74%) required magnetic resonance imaging for definitive diagnosis. ConclusionsSacral insufficiency fractures should not be diagnosed based on the site of pain or using plain radiographs. Patient age and magnetic resonance imaging are more informative to obtain a definitive diagnosis of sacral insufficiency fractures.

Lumbar spine MRI versus non-lumbar imaging modalities in the diagnosis of sacral insufficiency fracture: a retrospective observational study

BackgroundSacral insufficiency fractures (SIFs) are a common cause of lower back pain in the elderly. However, because clinical symptoms are frequently vague and nonspecific and can mimic lumbar spine pathologies, initial imaging in SIF patients is frequently targeted at the lumbar spine rather than the sacrum, resulting in delayed diagnosis. The purpose of this study is to show the proportions of modalities used in diagnosing SIF in practice and to compare the clinical and imaging features of SIF diagnosed by lumbar spine MRI (L-spine MRI) with those diagnosed by non-lumbar imaging modalities (bone scan, pelvic bone CT, pelvis MRI).MethodsForty-two patients with SIF were enrolled in this study. SIFs diagnosed by L-spine were assigned to group 1 and SIFs diagnosed by non-lumbar imaging modalities (bone scan, pelvic bone CT, pelvis MRI) were assigned to group 2. The clinical and imaging features of SIFs were assessed and compared between two groups.ResultsSIF were more commonly diagnosed by L-spine MRI (group 1: n = 27, 64.3%) than non-lumbar imaging modalities (group 2: n = 15, 35.7%), which was comprised of pelvic bone CT (n = 6, 14.3%), bone scan (n = 5, 11.9%), and pelvis MRI (n = 4, 9.5%). Lower back pain, radiating pain and comorbid other causes of pain were more frequently identified in group 1. Fracture involving bilateral sacral ala with horizontal component was the most common shape and S2 being the most commonly involved horizontal component, without significant difference between two groups.ConclusionSIFs are more commonly diagnosed by L-spine MRI than non-lumbar imaging modalities, because of symptoms that mimic lumbar spine pathology and variable comorbid causes of pain. To know that L-spine MRI commonly reveal SIF and to be familiar with SIF features on L-spine MRI would help increase sensitivity in detecting this commonly underrecognized entity and achieve earlier and more appropriate management.

Reliability and effectiveness of percutaneous sacroplasty in sacral insufficiency fractures

We evaluated the clinical results of sacroplasty for sacral insufficiency fracture (SIF). SIF are rare fractures that present as low back and groin pain. The diagnosis of SIF is difficult and sacroplasty is the last line of treatment. We reviewed the clinical and radiological data of 15 patients who underwent sacroplasty. Fifteen patients were selected, 12 women and three men, all of whom had failed to respond to medical therapy and bed rest, and were aged 39–76years (mean 65.7). A retrospective electronic medical record review and face-to-face or phone interview was conducted. The patients’ pain was assessed using the visual analogue scale (VAS) and functional status was assessed using the Oswestry disability index (ODI). Radiological diagnoses and investigations were performed using sacral CT scans and MRI. The sacroplasty procedures were performed using the short axis technique. The preoperative VAS scores (mean±standard deviation) were reduced from 7.6±0.7 to 1.7±0.7 postoperatively (p<0.05). The preoperative ODI was also reduced from an mean of 44 (range: 38–46) to 14 (11–22) postoperatively (p<0.05). Sacroplasty is an effective and safe procedure to relieve pain due to SIF.

Clinical Impact of Sacroplasty on Patient Mobility

PurposeTo evaluate the effect of sacroplasty on patient mobility and pain when performed as a treatment for sacral insufficiency fractures. Materials and MethodsImaging with computed tomography (CT), magnetic resonance imaging, or bone scan confirmed the diagnosis of sacral insufficiency fractures. Baseline clinical mobility scale (CMS) score and visual analog scale (VAS) pain score were recorded. Sacroplasty was performed under CT guidance. Follow-up CMS and VAS scores were assessed at 4, 24, and 48 weeks. ResultsEighteen elderly patients (age 80 y ± 8.5; 17 women) were treated. Repeated-measures analysis of variance was conducted to assess changes in CMS and VAS scores over time. Pairwise comparisons revealed a significant increase in average CMS score between baseline and all three follow-up points—4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)—indicating improvement in mobility over time. Pairwise comparisons revealed significant differences in mean VAS scores between baseline and all three follow-up time points—4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)—indicating improvement in overall pain level over time. ConclusionsTreatment with CT-guided sacroplasty for sacral insufficiency fractures in this elderly population resulted in significant improvement in patient mobility.

Therapeutic Considerations of Percutaneous Sacroplasty for the Sacral Insufficiency Fracture

Sacral insufficiency fracture is a debilitating injury not easily found in general radiologic examinations and is rarely diagnosed, since its symptoms are obscure. It is known to frequently occur in patients with osteoporosis, but the treatment has not yet been established and various kinds of treatment methods are being attempted. Sacroplasty is sometimes performed by applying percutaneous vertebroplasty which is known to be a less invasive treatment. Since the course of diagnosis of sacral insufficiency fracture is difficult and clear guidelines for treatments have not yet been established, many spine surgeons fail to diagnose patients or speculate on treatment methods. We report our experience in diagnosing a sacral insufficiency fracture in a 54-year-old healthy female patient using MRI and treating her with sacroplasty. From a therapeutic point of view, we then cover the usefulness, effects and characteristics relating to the complications of sacroplasty, along with literature review.

Case report: Sacral insufficiency fractures masking malignancy

The H-shaped sacral pattern on bone scintigraphy, considered characteristic for the diagnosis of sacral insufficiency fractures, was demonstrated in a 77-year-old woman with recurrent metastatic carcinoma of the breast. In addition to confirming the presence of sacral and pubic insufficiency fractures, computed tomography showed a malignant lesion in the right sacral ala. We suggest that the scintigraphic 'H' or 'butterfly' sign is not pathognomonic for sacral insufficiency fractures as it may mask coexisting malignancy.

Magnetic resonance appearance of sacral insufficiency fractures

Insufficiency fractures of the sacrum are a commonly recognized form of stress fracture typically occurring in elderly patients. As such patients usually present with low back pain, MR imaging is often performed initially as a means of evaluation. We present 5 patients with sacral insufficiency fractures imaged with MR. Metastatic disease was a leading clinical suspicion as all patients were elderly and three had known primary neoplasms. T1-weighted sequences demonstrated bands of decreased signal intensity, usually paralleling the sacral aspect of the sacroiliac joints and occasionally occurring as a horizontal band across the sacral body. Four of five patients underwent further evaluation with computed tomography (CT) or nuclear bone scanning, which confirmed the diagnosis of sacral insufficiency fracture. We conclude that MRI is sensitive but not specific in detecting sacral insufficiency fractures. As MR imaging is rapidly becoming the method of choice for evaluating back pain, it is important to consider this diagnosis in elderly persons.