Sacral Insufficiency Fractures Research Articles

Acetabular and sacral insufficiency fractures in a patient with a long-term history of Alendronate consumption; a case report

BackgroundLong-term Bisphosphonate consumption has been reported to be associated with the incidence of atypical or insufficiency fracture, particularly in the proximal femur. We observed a case of acetabular and sacral insufficiency fractures in a patient with a long-term history of Alendronate consumption.Case presentationA 62-year-old woman was admitted with a complaint of pain in right lower limb following low-energy trauma. The patient had a history of Alendronate consumption for more than 10 years. The bone scan revealed increased radiotracer uptake in the right side of the pelvic, proximal right femur, and sacroiliac joint. The radiographs showed type 1 sacrum fracture, acetabulum fracture with femur head protrusion into the pelvis, quadrilateral surface fracture, fracture of the right anterior column, and right superior and inferior pubic fracture. The patient was treated with total hip arthroplasty.ConclusionThis case highlights the concerns regarding long-term bisphosphonate therapy and its potential complications.

Teriparatide treatment shows faster healing than sacroplasty for postmenopausal women with sacral insufficiency fracture

ObjectivesSacral insufficiency fracture (SIF) is not an uncommon osteoporosis fracture among the elderly. Aside from traditional treatments, sacroplasty and teriparatide (TPTD) injection have been introduced. This report aims to compare the effects of sacroplasty and teriparatide on clinical outcomes of SIF. MethodsThirty-one elderly patients with SIF were enrolled in this retrospective observational study. Four male patients were excluded. Fourteen patients who received TPTD for 6 months were classified into the TPTD group (TT), and 13 who underwent sacroplasty were classified into the sacroplasty group (SS). All patients in both groups were instructed to take calcium and vitamin D supplements daily. Their symptoms and signs, visual analog score (VAS), Oswestry disability index (ODI), and radiographic studies were retrospectively reviewed. ResultsThe TT group showed significantly lower VAS than SS group after 3 (P < 0.001) and 6 months of treatment (P < 0.001). The TT group also has significant lower ODI than SS group after 1 (P = 0.010), 3 (P = 0.005) and 6 months (P < 0.001) of treatment. Upon generalized estimating equations (GEE) analysis, the TT group showed significantly more reduction in both VAS and ODI compared to the SS group at 1 month (P = 0.022, P = 0.001), 3 months (P < 0.001, P < 0.001), and 6 months (P < 0.001, P < 0.001) post-treatment. ConclusionsPostmenoposal woman with SIF who received TPTD healed better than those who underwent sacroplasty after 1 month treatment.

Le traitement conservateur des fractures du sacrum par insuffisance osseuse est-il toujours d’actualité ? Étude clinique observationnelle à propos de 46 patients

BackgroundAccording to current forecasts, our society will grow older and older, so that the proportion of 6 % of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures. HypothesisThe aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance. Patients and methodsA cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded. ResultsForty-six patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0 %) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8 %). ConclusionIn geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests – consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test – are well suited for further reproducible, objective studies with a larger patient collective. Level of evidenceIV.

A rare case of hairy cell leukaemia presenting as an isolated pathological neck of femur fracture

Hairy cell leukaemia (HCL) is a rare B non-Hodgkin lymphoma that commonly presents with cytopenias, splenomegaly and infection. We report a 58-year-old man who presented acutely with left hip pain. MRI scan identified a pathological neck of femur fracture, along with a subacute sacral fracture. A left total hip replacement was performed and sent for histology which showed infiltration of the bone and surrounding tissue by monotonous small lymphocytes. Immunohistochemistry was positive for CD20, CD25 and BRAF (VE1) and negative for CD5, CD10, cyclin D1 and S100, consistent with HCL. BRAF V600E mutation was also identified using real-time PCR, supporting the diagnosis. Full blood examination and film was normal at presentation. Bone marrow aspirate was normal, with no clonal B cells on flow cytometry and normal cytogenetics. FDG-PET scan did not show splenomegaly or lymphadenopathy, but the sacral insufficiency fracture was PET-avid, possibly representing a second distinct site of bone involvement. Due to ongoing pain the patient was treated with radiation to the hip and sacrum and remains well with follow-up. In summary we present a rare case of HCL presenting as multiple localised skeletal lesions without any detectable marrow or organ involvement, highlighting a unique presentation of this condition.

An Undiagnosed Sacral Insufficiency Fracture in an Osteoporotic Elderly Woman

An Undiagnosed Sacral Insufficiency Fracture in an Osteoporotic Elderly Woman

Is the conservative treatment of sacral insufficiency fractures still up to date? Retrospective clinical observational study in 46 patients

BackgroundAccording to current forecasts, our society will grow older and older, so that the proportion of 6% of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures. HypothesisThe aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance. Patients and MethodsA cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded. Results46 patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0%) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8%). ConclusionIn geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests–consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test–are well suited for further reproducible, objective studies with a larger patient collective. Level of evidenceIV.

PO30 Presentation Time: 10:30 AM: Intracavitary Brachytherapy Using a Shielded Cylinder, Clinical Use and Patient Toxicity

<h3>Purpose</h3> The utility of shielded cylinder intracavitary brachytherapy applicators in clinical practice has not been reported. We evaluated patients treated using this applicator to report its use in clinical practice and toxicity following treatment. <h3>Materials and Methods</h3> This single institution retrospective study included all patients who received high-dose rate (HDR) intracavitary brachytherapy using a shielded cylinder applicator (#GM11003380, Varian Systems, Palo Alto, CA) as a component of treatment between July 2013-November 2021. Treatment parameters, dosimetry; tumor and treatment characteristics were abstracted from the medical record. Patient toxicities were collected prospectively through an institutional radiation toxicity database. <h3>Results</h3> A total of 48 patients received 188 HDR intracavitary brachytherapy treatments, with 157 using a shielded cylinder. The majority (90%) also received external beam radiation (EBRT) to a median dose of 4500cGy in 25 fractions (interquartile range, IQR, 4500-5625cGy). Common fractionations (fx) for brachytherapy included 2000cGy/4fx with EBRT for patients with recurrent uterine cancer, 2000-2800cGy/4fx with EBRT or 3000cGy/5fx without EBRT for patients with primary vaginal or vulvar cancer, and 500cGy/1fx with EBRT for rectal cancer patients. The median total EBRT + brachytherapy EQD2 was 6930cGy (IQR 6930-7900cGy). In the treatments delivered with a shielded cylinder, shielding was used to reduce dose to rectum (51%), uninvolved vagina (34%), and bladder/urethra (8%). The most common shielding pattern was 180° (78%) and 90° (20%), with a minority of treatments using 270° shielding (2%). In cases where shielding was used to reduce rectal dose, the D2cc[Gy] rectal dose in delivered plans was 1.18Gy (range 0.53 - 3.92Gy). In patients who had both unshielded and shielded treatment plans, the D2cc[Gy] rectal dose was reduced from 4.07Gy to 1.69Gy, respectively. The median total EQD2 rectal dose in patients who received EBRT in 25 fractions in addition to brachytherapy was 38.9Gy (range 14.8 - 47.8Gy). Acute grade 2-3 toxicities included dermatitis (9), cystitis (4), proctitis (3), fatigue (2), nausea (2), pain (2), and anemia (1). In patients who received brachytherapy alone there were no grade 2+ toxicities reported. Late grade 2-3 toxicities reported 6+ months after radiation therapy included vaginal stricture (4), vaginal dryness (1), fatigue (1), lower GI hemorrhage (1), lymphedema (1), urinary frequency (1), and urinary incontinence (1). One patient had a grade 3 vaginal fistula noted at 6-months. There was one grade 2 sacral insufficiency fracture noted at 4-months. There were no acute or late grade 4-5 toxicities. Median follow-up was 35 months (IQR 11-55 months). Fifteen patients died, 6 from cancer progression and 9 from non-cancer causes. Fifteen patients had cancer progression at a median of 28 months from completion of brachytherapy. Five patients had local-only failures, 9 patients had distant-only failures, and 1 patient had pelvic nodal failure. There was no difference in total EQD2 delivered to tumor between those patients who had local failure versus local control, with a median EQD2 of 69.3Gy and 69.5Gy, respectively. The location of local failure was in the unshielded area in three patients and involved the shielded area in two patients. <h3>Conclusions</h3> Shielded cylinder applicators can be utilized successfully in the treatment of well selected patients with primary and recurrent gynecologic cancers and rectal cancers, enabling dose reduction to non-target structures with low treatment-related toxicity.

Anterior Transpsoas Approach for Removal of Cement Leakage after Sacroplasty.

Sacroplasty is a minimally invasive treatment option for severe pain due to sacral insufficiency fracture. Cement leakage is a known risk of sacroplasty. Despite the elevated risk to the L5 nerve root and lumbosacral trunk from cement leakage anterior to the sacral ala, there are no reports regarding surgical management of this complication. We describe an anterior retroperitoneal transpsoas approach to the sacral ala to remove cement leakage causing acute L5 radiculopathy in a 57-year-old gentleman who had undergone sacroplasty for sacral insufficiency fracture (Denis zone 1). The approach provides rapid and excellent visualization of the sacral ala without manipulation of the iliac vessels. We recommend that surgery be considered in a timely fashion, to utilize neuromonitoring, and that surgeons be aware of the considerable variability of the neurologic structures that will be encountered, which is described in this technical note.

Sacral Insufficiency Fractures After Total Pubectomy for Osteomyelitis: A Case Series

ObjectiveTo document the incidence, risk factors, and prevalence of sacral insufficiency fractures (SIF) among patients who have undergone total pubectomy for osteomyelitis. MethodsA retrospective chart review was performed of patients undergoing total pubectomy for osteomyelitis at a single institution from 2016 to 2021. Descriptive statistics and univariate analysis were performed using the Wilcoxon rank-sum test and Fisher exact test as appropriate. ResultsSixteen patients underwent total pubectomy for osteomyelitis. The median age was 68 years. 12 of 16 (75%) had previously received pelvic radiotherapy. The median BMI was 27.8 kg/m2. Eleven (68.75%) had postoperative pelvic imaging, of which 3 (27.3%) had a new SIF. One other patient had a SIF 3 days before pubectomy. Three SIFs were detected via MRI and 1 by CT scan. The median BMI of patients with SIF was significantly lower than those without SIF (22.4 vs 30.5, P = .004). All patients with SIF presented with new pelvic or perineal pain without radiculopathy. Symptoms resolved for three patients with non-opioid analgesics, physical therapy, and/or a brief trial of opioids. ConclusionSacral insufficiency fracture is a rare sequela of total pubectomy for osteomyelitis. Lower BMI is significantly associated with SIF perhaps due to reduced muscle mass or poor bone condition and, as a result, baseline pelvic instability. Medical management should be first-line therapy.

Superiority of MRI for Evaluation of Sacral Insufficiency Fracture.

Study Design: Retrospective observational study. Background: Sacral insufficiency fractures (SIF) are relatively rare fractures and difficult to diagnose on plain radiographs. The primary objective of the present study was to evaluate the role of lumbar magnetic resonance imaging (MRI) for the diagnosis of SIF. The secondary objective was to identify the classification of SIF by computed tomography (CT). Methods: A total of 77 (Male 11, female 66, mean 80.3 years) people were included in this study. Inclusion criteria for this study were: age ≥ 60 years and no history of high energy trauma. Exclusion criteria were high energy trauma and a current history of malignancy. Differences in the fracture detection and description in the various radiologic procedures were evaluated. Fracture patterns were evaluated with CT. The detection rates of additional pathologies in the MRI of the pelvis and lumbar spine were also recorded. Results: The sensitivities for SIF were 28.5% in radiographs and 94.2% in CT, and all fractures were detected in MRI. MRI showed a more complex fracture pattern compared with CT in 65% of the cases. We observed 71.4% of single SIFs, 9.1% with other spinal fractures, 13.0% with other pelvic fractures, and 7.8% with other fractures. According to the SIF fracture pattern, the H/U type was 40.2%, transverse type was 33.7%, λ/T type was 24.7%, unilateral vertical type was 1.3%, and bilateral vertical type was 0%. Conclusions: an MRI of the lumbar spine including the sacrum with a coronal fat-suppressed T2-weighted image is useful for elderly patients with suddenly increasing low back pain at an early stage. This procedure improves an early SIF detection, recognition of concomitant pathologies, and adequate treatment for the patients.

Percutaneous Sacroplasty with or without Radiofrequency Ablation for Treatment of Painful Sacral Metastases.

Percutaneous sacroplasty is a variation of percutaneous vertebroplasty that has gained attention as a therapeutic option for patients with painful sacral insufficiency fractures due to osteoporosis or metastases. Additionally, percutaneous sacroplasty can also be used to treat painful sacral metastases without a pathologic fracture. The purpose of this retrospective study was to compare the efficacy and safety of fluoroscopy-guided percutaneous sacroplasty alone versus percutaneous sacroplasty plus radiofrequency ablation for the treatment of painful sacral metastases. For this retrospective study, 126 patients (with a total of 162 painful sacral metastases) were enrolled from October 2012 to February 2021 and assigned to receive either percutaneous sacroplasty plus radiofrequency ablation (n = 51, group A) or percutaneous sacroplasty alone (n = 75, group B). Four different approaches were used for percutaneous sacroplasty: transiliac, interpedicular, anterior-oblique, and posterior. The Visual Analog Scale, Oswestry Disability Index, and Karnofsky Performance Scale were used to evaluate outcomes. The Visual Analog Scale, Oswestry Disability Index, and Karnofsky Performance Scale scores showed significant improvement in both groups after treatment (P < .05). The overall pain relief rate was significantly better in group A than in group B (90% versus 76%, P = .032). There were no significant differences in the incidence of polymethylmethacrylate leakage between the 2 groups or among the 4 different approaches (P > .05). Both percutaneous sacroplasty alone and the combination of percutaneous sacroplasty and radiofrequency ablation are safe and effective for treatment of painful sacral metastases. The combination of percutaneous sacroplasty and radiofrequency ablation appears to be more effective than percutaneous sacroplasty alone.

Sacral Insufficiency Fractures.

Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.

Sacral insufficiency fracture after treatment for cervical cancer

A 61-year-old female patient was referred to the gynaecologic oncology clinic of the Regional Cancer Centre, Thiruvananthapuram, Kerala, India, in December, 2019, with complaints of postmenopausal bleeding and vaginal discharge with a cervical mass. She was diagnosed to have squamous cell carcinoma of the uterine cervix (stage IIIC1). She received radical radiotherapy using a four-field 2D conventional technique with concurrent weekly intravenous cisplatin 40 mg/m2 followed by high-dose-rate intracavitary brachytherapy, which was completed in January, 2020. She had a complete response to treatment and was on regular follow-up.

Clinical and MRI features of sacral insufficiency fractures after radiotherapy in patients with cervical cancer

BackgroundTo determine the incidence, clinical and MRI features of sacral insufficiency fracture (SIF) after radiotherapy (RT) in patients with cervical cancer.MethodsOur study included 167 patients with cervical cancer after radiotherapy that underwent pelvic MRI for follow-up. MRIs included pre-enhanced T1-weighted, coronal fat-Suppressed T2-weighted (FS-T2W) and enhanced T1-weighted imaging. The clinical and MRI dates were reviewed. The gold standard of SIF was based on radiologic findings, clinical data and follow-up at least 12 months.Results28 patients (10.8%) with 47 sites were diagnosed with SIFs, including 9 patients with unilateral SIF and 19 patients with bilateral SIFs. The median age was 60 years (range 41–72 years), and 89.3% (25/28) of patients were postmenopausal. 64.3% (18/28) of patients were symptomatic, and 53.6% of patients (15/28) had concomitant pelvic fractures. The median interval time from RT to SIFs was 10 months (range 3–34 months). For the lesion-wise analysis based on all MR images, all lesions were detected by visualizing bone marrow edema patterns, and fracture lines were detected in 64.6% (31/47) of SIFs. No soft-tissue tumors were founded. For each MRI sequence analysis, coronal FS-T2WI detected the most bone marrow edema pattern and fracture line than T1WI or enhanced T1WI.ConclusionSIF is a common complication in cervical cancer after radiotherapy, which has some certain clinical and MRI features. Coronal FS-T2WI may be more useful to detect and characterize these fractures than other imaging sequences.

The "Eiffel Tower" technique: novel long-axis sacroplasty under electromagnetic navigation assistance; feasibility and descriptive study.

To describe a novel long-axis multimodal navigation assisted technique - the so-called Eiffel Tower technique - aimed at integrating recent technological improvements for the routine treatment of sacral insufficiency fractures. The long-axis approach described in the present study aimed at consolidating the sacral bone according to biomechanical considerations. The purpose was (i) to cement vertically the sacral alae all along and within the lateral fracture lines, resembling the pillars of a tower, and (ii) to reinforce cranially with a horizontal S1 landing zone (or dense central bone) resembling the first level of the tower. An electromagnetic navigation system was used in combination with CT and fluoroscopic guidance to overtop extreme angulation challenges. All patients treated between January 2019 and October 2021 in a single tertiary center were retrospectively reviewed. A description of the technique is provided. Twelve female patients (median age: 80 years [range: 32 to 94]) were treated for sacral insufficiency fractures with the "Eiffel Tower" technique. The median treatment delay was 8 weeks (range: 3 to 20) and the initial median pain assessed by the visual analogue scale was 7 (range: 6 to 8). Pain was successfully relieved (visual analogue score < 3) for 9 patients (75%) and persisted for 2 patients (17%). One patient was lost during the follow-up. No complication was noted. The "Eiffel Tower" multimodal cementoplasty integrates recent technological developments, in particular electromagnetic navigation, with the purpose of reconstructing the biomechanical chain of the sacral bone. • Sacral insufficiency fractures are common and can be efficiently treated with percutaneous sacroplasty. • The long axis sacroplasty approach can be challenging given both the shape of the sacral bone and the angulation to reach the target lesion. • The "Eiffel Tower" technique is a novel approach using electromagnetic navigation to expand the concept of the long axis route, adding a horizontal S1 landing zone.

MP25-17 PELVIC INSUFFICIENCY FRACTURE—AN UNDERRECOGNIZED CAUSE OF PAIN AFTER PUBECTOMY

You have accessJournal of UrologyCME1 May 2022MP25-17 PELVIC INSUFFICIENCY FRACTURE—AN UNDERRECOGNIZED CAUSE OF PAIN AFTER PUBECTOMY Molly DeWitt-Foy, Ranveer Vasdev, and Sean Elliott Molly DeWitt-FoyMolly DeWitt-Foy More articles by this author , Ranveer VasdevRanveer Vasdev More articles by this author , and Sean ElliottSean Elliott More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002568.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pubectomy is traditionally used in repair of complex pelvic fracture urethral injuries (PFUI) but is now increasingly used in the management of pubic osteomyelitis that results from prostate cancer treatment. Classically, pubectomy after PFUI is thought to not disrupt the stability of the pelvic ring. However, this has not been studied in detail in patients with osteomyelitis, who often have comorbid conditions that may alter said stability and increase risk of fracture.). Our aim is to document the incidence, presentation and risk factors of sacral insufficiency fracture (SIF) in patients who have undergone pubectomy for osteomyelitis. METHODS: Retrospective chart review was performed of patients undergoing pubectomy for osteomyelitis at a single institution from 2016-2021. Descriptive statistics and univariate analysis were performed using R. Wilcoxon rank-sum test and Fisher exact test were used as appropriate. RESULTS: Sixteen patients underwent pubectomy for osteomyelitis, all after prostate radiotherapy. Mean age was 68 years and mean BMI 28.5. Six (37.5%) underwent cystectomy with urinary diversion at the time of pubectomy, 4 (23.5%) had cystectomy prior to pubectomy. Eleven (68.7%) had postoperative cross-sectional pelvic imaging, of which 3 (25%) were found to have a new SIF; one additional patient had SIF prior to pubectomy. Three SIFs were detected on MRI and one on CT scan. All patients were symptomatic of SIF, most commonly with new pelvic or perineal pain. The median BMI of patients with SIF was significantly lower than those without SIF (22.4 v 30.5, p value=0.004). Age, chronic kidney disease, bone metastasis, hyperbaric oxygen, diabetes, and androgen deprivation therapy were not significantly associated with risk of SIF. CONCLUSIONS: Sacral insufficiency fracture is a rarely described sequela of pubectomy for osteomyelitis. Lower BMI is significantly associated with SIF, perhaps indicative of overall frailty. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e435 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Molly DeWitt-Foy More articles by this author Ranveer Vasdev More articles by this author Sean Elliott More articles by this author Expand All Advertisement PDF DownloadLoading ...

ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation): randomised controlled, feasibility trial in older people

ObjectiveTo determine the feasibility of designing and conducting a definitive trial to evaluate the effectiveness of sacral fracture fixation compared with non-surgical management among older people admitted with a lateral...

Risk factors for developing sacral insufficiency fractures

Risk factors for developing sacral insufficiency fractures

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.

Minimally Invasive Iliac Screw Insertion: Clinical Case Series and Technical Note

Objective: Iliac screw fixation has numerous indication and techniques. To describe the technique of minimally invasive screw insertion of the iliac screw by freehand and navigated iliac screw placement using intraoperative image guidance.Methods: Bilateral iliac screws were inserted in a total of seven patients. Five patients underwent navigation guided iliac screw placement and the freehand technique was used in 2 patients. Results: A total of 7 patients underwent minimally invasive iliac screw fixation in our series. The pathology in 4 of the cases was spondylodiscitis, among them 2 cases each at L5-S1 and L4-L5, one with the destruction of L5 vertebral body and the other with the destruction of both L4 and L5 vertebral bodies. Of the remaining cases, two cases had sacral insufficiency fracture and the last case was implant failure after L2-L5 oblique lumbar fusion. None of the cases required conversion to open procedure and none had wound or hardware related complications till the last follow-up. All patients had an uneventful post-operative period with improvement in pain scores and were mobilized on the 1st postoperative day. One 50-year-old female patient suffering from L5-S1 tubercular spondylodiscitis died due to underlying chronic kidney disease three months post-surgery. Conclusion: Minimal invasive iliac screw placement with or without navigation offers the same biomechanical stability as the open approach but without the need for extensive soft tissue exposure needed for a conventional/open procedure; thereby reducing exposure-related complications and enhancing post-operative recovery and early mobilization. Incorporating intra-operative 3D navigation provides real-time multi-planar images which help in easy planning and safe screw placement whilst reducing radiation exposure.