Sacral Insufficiency Fractures Research Articles

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.

Sacroiliitis and sacral insufficiency fracture: A rare coexistence

Sacral insufficiency fracture (SIF) is an uncommon cause of hip and back pain. Sacroiliitis, often a feature of inflammatory conditions of spinal column, is inflammation of sacroiliac joints. Herein, we report a 41-year-old woman presenting with a SIF and sacroiliitis as a part of non-radiographic axial spondyloarthritis.

Risk Factors for Sacral Insufficiency Fractures in Cervical Cancer After Whole Pelvic Radiation Therapy

To evaluate the incidence and risk factors of sacral insufficiency fractures (SIFs), particularly dose-volume histogram (DVH) parameters, in patients with cervical cancer after whole pelvic radiation therapy (WPRT). The medical records of 61 patients with cervical cancer who underwent WPRT were retrospectively reviewed. The cumulative incidence of SIF, as well as the risk factors that could affect its incidence were assessed. Of the 61 patients, 11 (18%) were diagnosed with SIF, as revealed by computed tomography. Multivariate analysis revealed that abnormal body mass index (BMI) (more than 25 kg/m2 or below 18 kg/m2) and administration of five or more chemotherapy cycles were independently associated with SIF. A slight difference was observed in the D50% (the administered dose covering half of the sacrum) between patients with and those without SIF (p=0.052). Thus, the D50% of the sacrum should be particularly considered in patients with abnormal BMI and five or more cycles of chemotherapy.

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.

Sacral insufficiency fracture after stereotactic body radiation therapy for sacral metastasis.

Key Clinical MessageStereotactic body radiation therapy (SBRT) allows the targeting of high doses of radiation with steep dose gradients. Vertebral fracture is increasingly recognized as an adverse event after SBRT; however, no sacral fractures have been observed after SBRT. We report an extremely rare case of sacral insufficiency fracture after SBRT.

Poster 312: Bilateral Sacral Insufficiency Fractures in a Patient with Low Back Pain: A Case Report

Poster 312: Bilateral Sacral Insufficiency Fractures in a Patient with Low Back Pain: A Case Report

Sacral insufficiency fractures after high-dose carbon-ion based radiotherapy of sacral chordomas

BackgroundThis study aimed to analyse the frequency and clinical relevance of sacral insufficiency fractures (SIFs) after high-dose carbon-ion based irradiation of sacral chordomas.MethodsA total of 56 patients were included in this retrospective study. Twenty one patients (37%) were treated with definitive radiotherapy (RT), and 35 patients (63%) received postoperative RT using carbon ions, either in combination with photons or as single-modality treatment (median radiation dose 66 Gy RBE, range 60–74 Gy). Follow-up examinations including MRI of the pelvis were performed at 3-monthly intervals in the first year and consecutively at 6-monthly intervals. Median follow-up was 35.5 months (range 2–83).ResultsSIFs were diagnosed in 29 patients (52%) after a median follow-up of 11 months (range 1–62 months). Most sacral fractures (79%) occurred within 2 years after RT. For the overall study population, the fracture-free survival probability amounted to values of 0.68 (95% CI, 0.53–0.79) after 1 year, 0.46 (95% CI, 0.31–0.60) after 2 years, and 0.31 (95% CI, 0.16–0.47) after 5 years. Statistical analysis showed no significant difference regarding the fracture rates between patients who received an operation and postoperative RT and patients treated with definitive RT. About one third of the patients with SIFs (34%; 10 of 29 patients) had associated clinical symptoms, most notably pain. All patients with symptomatic fractures required strong analgesics and often intensive pain management.ConclusionsSacral fractures after high-dose carbon ion-based RT of sacral chordomas were shown to be a considerable radiogenic late effect, affecting about half of the treated patients. However, only one third of these fractures were clinically symptomatic requiring regular medical care and pain therapy.Further hazard factor analysis in the future with larger patient numbers will possibly enable the identification of high-risk patients for developing SIFs with the ultimate goal to prevent symptomatic fractures.

Clinical applications of a computed tomography color "marrow mapping" algorithm to increase conspicuity of nondisplaced trabecular fractures.

To explore clinical applications of a novel conventional computed tomography (CT) color post-processing algorithm to increase conspicuity of nondisplaced trabecular fractures. The algorithm was created in Adobe Photoshop and Adobe Extendscript, utilizing DICOM images from conventional CT as source images. A total of six representative cases were selected and processed. No statistical analyses were performed. A total of six cases are demonstrated, five with MRI correlation demonstrating corresponding fractures and bone marrow edema, including a case of sacral insufficiency fracture, two cases of vertebral body fracture, two cases of nondisplaced hip fracture, and a knee bone marrow edema lesion (without MRI correlate). All cases were processed successfully without error. A conventional CT color post-processing algorithm may be clinically useful in increasing conspicuity of nondisplaced fractures and bone marrow edema. A potential pitfall is the presence of subchondral or marrow sclerosis, which may mimic edema. Future prospective studies will be necessary to evaluate diagnostic performance.

Imaging of Sacral Stress and Insufficiency Fractures.

Fractures of the os sacrum without relevant trauma history are defined as stress or insufficiency fractures and often affect the anterior pelvis. Sacral insufficiency fractures are associated with osteoporosis and occur under physiological load. In contrast, sacral stress fractures are caused by mechanical overloading. Diagnostic confirmation is delayed in many of these patients. Thus, MRI and/or CT should be performed early. Fracture stability should be evaluated by CT. MRI is the better approach to rule out fractures and is highly sensitive. Itis indicated in young patients and in patients with non-specific lumbosacral pain. Nuclear imaging techniques are viable alternatives in patients with a contraindication for MRI.

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.

Treatment of primary rectal adenocarcinoma after prior pelvic radiation: The role of hyperfractionated accelerated reirradiation

PurposePrevious studies have reported that hyperfractionated accelerated reirradiation can be used as part of multimodality treatment of locally recurrent rectal cancer with acceptable toxicity and promising outcomes. The purpose of this study was to evaluate the outcomes and toxicity of hyperfractionated accelerated reirradiation for patients with primary rectal adenocarcinoma and a history of prior pelvic radiation for other primary malignancies. Methods and materialsWe identified 10 patients with a prior history of pelvic radiation for other primary malignancies who were treated with hyperfractionated accelerated reirradiation for primary rectal adenocarcinoma. Radiation therapy was administered with 1.5 Gy twice daily fractions to a total dose of 39 Gy to 45Gy. ResultsThe median follow-up time was 3.2 years (range, 0.6-9.0 years). Seven of 10 patients received surgery after reirradiation. The 3-year freedom-from-local-progression rate was 62% for all patients and 80% for patients who underwent surgery. The 3-year overall survival rate was 100%, with 3 deaths occurring at 4.7, 6.5, and 9.0 years after reirradiation. One patient had an acute Grade 3 toxicity of diarrhea, and 1 patient experienced a late Grade 3 toxicity of sacral insufficiency fracture. ConclusionsHyperfractionated accelerated reirradiation was well tolerated with promising rates of freedom from local progression and overall survival in patients with primary rectal cancer with a history of prior pelvic radiation therapy. This approach, along with concurrent chemotherapy and surgery, appears to be a viable treatment strategy for this patient population.

Comparison of sacroplasty with or without balloon assistance for the treatment of sacral insufficiency fractures.

Sacral insufficiency fractures (SIFs) can cause severe lower back pain and immobility, which have limited therapeutic options. No previous studies have compared clinical outcomes and radiographic findings of sacroplasty with or without balloon assistance for the treatment of SIFs. Forty-five patients with SIFs were divided into two groups. One group had 18 patients treated using sacroplasty with balloon assistance, and the other had 27 patients treated without balloon assistance. The operation time and cement injection volume were compared between these two groups. Clinical outcomes were evaluated using visual analog scale (VAS), Oswestry Disability Index (ODI), and Odom's criteria. Cement leakage rate was examined by postoperative radiography and computed tomography. Sacroplasty with balloon assistance was associated with significantly longer operative time ( p = 0.003) and larger cement injection volume ( p = 0.038). Cement leakages were found in 4 of 18 patients (22.2%) with balloon assistance and 15 of 27 patients (55.6%) without balloon assistance, which showed significant difference ( p = 0.027). No significant differences were observed between sacroplasty with and without balloon assistance with regard to clinical outcomes including improvement in VAS, ODI, and Odom's criteria. Sacroplasty with balloon assistance was shown to achieve greater cement injection with longer operation time and can decrease the risk of cement leakage. Both sacroplasty with and without balloon assistance showed good-to-excellent clinical outcomes for the treatment of SIFs.

Fragility fractures of the sacrum occur in elderly patients with severe loss of sacral bone mass.

Patients suffering from osteoporosis-associated fragility fractures of the sacrum (FFS; also termed sacral insufficiency fractures) are increasingly observed. They have typical fracture patterns with fracture lines located in the sacral ala. When treating these patients operatively, iliosacral screw loosening is not uncommon. We aimed to study the sacral bone mass in patients presenting with a FFS using 3D statistical models. 3D models of averaged Hounsfield units (HU) were generated based on CT scans from 13 patients with a unilateral FFS (mean age 79.6 years; 11 females, 2 males). The control group without fractures consisted of 28 males and 32 females (mean age of 68.3years). A virtual bone probe along the trans-sacral corridors S1 and S2 was taken. The bone mass distribution in the fractured sacra was similar to the control group, however, with overall lower HU. Large zones of negative HU were located in the sacral ala. In the fractured sacra, the HU in the sacral ala was significantly lower on the non-injured side when comparing to the fractured side (p < 0.001) as well as compared to the non-fractured group (p < 0.001). Low bone mass was observed in sacral body S1 (40 HU) and S2 (20 HU). The extensive area of negative HU may explain the fracture location in the sacral ala. The low HU in the sacral bodies advocates the use of trans-sacral implants or augmented iliosacral screws to enhance the strength of fracture fixation. The increased HU in the fractured ala could be explained by fracture-asssociated hemorrhage and can be used as a diagnostic tool.

Initial Experience with Intraoperative Phosphorous-32 Brachytherapy During Resection of Malignant Spinal Tumors

Brachytherapy is a major adjuvant modality for neoplasms, but few have trialed its use for spinal tumors. This study examines perioperative and oncologic outcomes of patients with malignant spinal tumors who underwent resection with intraoperative phosphorous-32 (P32) brachytherapy. Consecutive adult patients who underwent P32 brachytherapy during malignant spinal tumor resection were retrospectively identified from 2014 to 2015. Complications, tumor recurrence, and survival were reviewed. A comprehensive review of the literature was performed. A total of 8 patients were included. Average age was 54.3 years, and 25.0% were males. Tumor types included metastatic leiomyosarcoma, chordoma, multifocal recurrent ependymomas, breast metastasis, malignant meningioma, and myxofibrosarcoma. One-half of patients underwent en bloc tumor resection. P32 plaques were applied to 2 sites per patient for mean 13.1 minutes per site with a goal penetration of 10 Gy to 1-mm depth. Perioperative complications occurred in 3 patients (37.5%), including a persistent cerebral spinal fluid leak, deep infection requiring reoperation, and sacral insufficiency fracture. At a mean 25.6 months follow-up, local recurrence rate was 25.0%, and overall survival was 75.0%. Mean time to recurrence was 14.4 months. Survival at 6, 12, 18, and 24 months was 100.0%, 100.0%, 85.7%, and 71.4%, respectively. The use of P32 is safe and feasible. P32 intraoperative brachytherapy does not seem to increase the rate of complications. The sample size of this series is small with heterogeneity in tumor type, but recurrence and survival outcomes seem promising compared with previous reports. Further clinical trials are needed.

Sacral Insufficiency Fractures : How to Classify?

ObjectiveThe diagnosis of insufficiency fractures of the sacrum in an elder population increases annually. Fractures show very different morphology. We aimed to classify sacral insufficiency fractures according to the position of cortical break and possible need for intervention.MethodsBetween January 1, 2008 and December 31, 2014, all patients with a proven fracture of the sacrum following a low-energy or an even unnoticed trauma were prospectively registered : 117 females and 13 males. All patients had a computer tomography of the pelvic ring, two patients had a magnetic resonance imaging additionally : localization and involvement of the fracture lines into the sacroiliac joint, neural foramina or the spinal canal were identified.ResultsPatients were aged between 46 and 98 years (mean, 79.8 years). Seventy-seven patients had an unilateral fracture of the sacral ala, 41 bilateral ala fractures and 12 patients showed a fracture of the sacral corpus : a total of 171 fractures were analyzed. The first group A included fractures of the sacral ala which were assessed to have no or less mechanical importance (n=53) : fractures with no cortical disruption (“bone bruise”) (A1; n=2), cortical deformation of the anterior cortical bone (A2; n=4), and fracture of the anterolateral rim of ala (A3; n=47). Complete fractures of the sacral ala (B; n=106) : parallel to the sacroiliac joint (B1; n=63), into the sacroiliac joint (B2; n=19), and involvement of the sacral foramina respectively the spinal canal (B3; n=24). Central fractures involving the sacral corpus (C; n=12) : fracture limited to the corpus or finishing into one ala (C1; n=3), unidirectional including the neural foramina or the spinal canal or both (C2; n=2), and horizontal fractures of the corpus with bilateral sagittal completion (C3; n=8). Sixty-eight fractures proceeded into the sacroiliac joint, 34 fractures showed an injury of foramina or canal.ConclusionThe new classification allowes the differentiation of fractures of less mechanical importance and a risk assessment for possible polymethyl methacrylate leaks during sacroplasty in the direction of the neurological structures. In addition, identification of instable fractures in need for laminectomy and surgical stabilization is possible.

From radiation osteitis to osteoradionecrosis: incidence and MR morphology of radiation-induced sacral pathologies following pelvic radiotherapy.

To investigate the incidence rate, time-to-onset and recovery, MRI morphology and occurrence of insufficiency fractures in radiation-induced changes in the sacrum following pelvic radiotherapy. 410 patients with pelvic malignancies treated with radiotherapy were reviewed. Follow-up was 1-124 months (mean 22 months). Serial MRI (average four studies/patient) were analysed using a new semi-quantitative score (Radiation-Induced Sacral Changes=RISC). A size category (I/II/III), a type category for MR signal morphologies (a/b/c) and sacral insufficiency fractures (+/-) were applied. Seventy-two patients (17.6 %) were found to have new pathological signal changes. Radiation osteitis was documented in 83.3 % (60/72, RISC stage a + b), and definite osteonecrosis (stage c) in 12 patients (16.7 %, 12/72). Thirty-one patients (43.1 %) had sacral insufficiency fractures. Initial bone marrow signal changes were found 1-35 months (median 4 months) after radiotherapy. The maximum manifestation of radiation-induced signal changes occurred after 1-35 months (mean 11 months). Fifty-six cases (77.8 %) showed a significant signal recovery within 16.5 months. Radiation-induced bone marrow changes appear with a high incidence at the sacrum with an early onset and frequent recovery. The majority presented a pattern of radiation osteitis, whereas osteoradionecrosis was proportionately rare. • Radiation-induced sacral bone marrow changes appear frequently (17.6 %) following pelvic radiotherapy. • Insufficiency fractures are common late effects (43 %). • Radiation osteitis develops early (4 mo), withrecovery between 16.5 and 39.5 months. • Definite radiological osteoradionecrosis is proportionately rare (3 %). • A 3-stage classification system simplifies and standardizes the morphological disease staging.

Unilateral S2 alar-iliac screws for spinopelvic fixation.

Background:This study compared the clinical complications, radiographic measurements of deformity, and quality of life outcomes for patients with de novo scoliosis undergoing thoracolumbar fusions for spinopelvic fixation (SPF) utilizing unilateral S2 alar-iliac (S2AI) screw or unilateral iliac bolt fixation.Methods:This retrospective review was performed in 29 patients who underwent SPF at one institution; 10 patients received unilateral S2AI screws, and 19 patients received unilateral iliac bolts. The following variables were studied: reoperation rates, pseudarthrosis, sacral insufficiency fracture, hardware prominence, infection, proximal junctional kyphosis (PJK), deformity correction (radiographs), windshield wipering, hardware fracture, and hardware removal. Outcomes were analyzed utilizing both the visual analog scale (VAS) and Oswestry Disability Index (ODI). The mean follow-up period was 27 months.Results:The reoperation rate for unilateral S2AI screws was 30% vs. 53% for unilateral iliac bolts (P = 0.43); reoperations were performed with a 1:5 ratio for infection, a 1:4 ratio for pseudarthrosis, and 1:1 a ratio for PJK comparing S2AI screws to iliac bolts, respectively.Conclusion:There were no significant differences in postoperative complications and reoperation rates between unilateral S2AI screws and unilateral iliac bolts utilized for SPF. For the S2AI screw group, there were no instances of hardware prominence or need for removal. The use of unilateral S2AI screws resulted in adequate fixation and comparably low complication rates.

A case report of emergency removal surgical decompression to sacral insufficiency fracture which caused urinary retention

A case report of emergency removal surgical decompression to sacral insufficiency fracture which caused urinary retention

Outcomes of Patients With Primary Sacral Chordoma Treated With Definitive Proton Beam Therapy

To evaluate the efficacy and safety of definitive proton beam therapy (PBT) for primary sacral chordoma. We conducted a retrospective analysis of the clinical outcomes of eligible patients with primary sacral chordoma who had undergone definitive PBT with 70.4Gy (relative biological effectiveness) in 32 fractions at our institution from September 2009 to October 2015. Local progression-free survival, distant metastasis-free survival, disease-free survival, cause-specific survival, and overall survival were evaluated. To explore the factors that influenced local progression, the following parameters were analyzed: sex, the presence of a spacer (Gore-Tex sheets), gross tumor volume, and extent of cranial tumor extension. Adverse events were evaluated using the Common Terminology Criteria for Adverse Events, version 4.0. To assess the impact of PBT on pain relief, the change in pain grades was investigated between the initiation of PBT and the last follow-up visit. Thirty-three eligible patients were analyzed. The median follow-up period was 37months. The 3-year estimated local progression-free survival, distant metastasis-free survival, disease-free survival, cause-specific survival, and overall survival rates were 89.6%, 88.2%, 81.9%, 95.7%, and 92.7%, respectively. No significant association was between the patients' clinicopathologic characteristics and local progression-free survival. Four patients developed grade 3 adverse events, including acute dermatitis (n = 1), ileus (n = 1), and pain due to sacral insufficiency fractures (n = 2). The pain grades had improved, were unchanged, or had deteriorated in 15, 7, and 11 patients, respectively. Definitive PBT with 70.4Gy (relative biological effectiveness) in 32 fractions is an effective treatment with acceptable toxicity for primary sacral chordoma and has the potential to reduce pain.

Multilevel Contiguous Osteoporotic Lumbar Compression Fractures: The Relationship of Scoliosis to the Development of Cascading Fractures.

Osteoporotic patients can present with either single or multiple fractures secondary to repeated falls and progressive osteoporosis. Multiple fractures often lead to additional spinal deformity and are a sign of more severe osteoporosis. In the thoracic spine, multiple fractures are associated with the development of gradual thoracic kyphosis but neurologic deficits are uncommon. In the lumbar spine, patients with multiple lumbar fractures have more constant lumbar pain, may have symptoms related to concurrent lumbar stenosis or degenerative scoliosis, and may present with radiculopathy, especially with fractures at L4 and L5. In a review of a series of patients with recurrent multiple lumbar fractures or 'cascading' fractures, it was found that all the patients were female, had severe osteoporosis, often untreated, had a previous history of multiple previous thoracic and lumbar fractures, and all had associated scoliotic spinal deformities ranging from 6o to 50o. It was found that if the curve progressed and the greater the degree of curvature, the more frequently subsequent multiple fractures developed, leading to recurrent acute episodes of pain. Forty percent also had additional sacral insufficiency fractures, an unusually high percentage. Biomechanically, the lumbar spine is both more mobile and supports a larger portion of the spinal load compared to the thoracic spine. The existence or worsening of a lumbar spinal deformity from degenerative lumbar scoliosis shifts the mechanical forces more to one side on already weakened osteoporotic lumbar vertebrae and sacrum, leading to an increased incidence of these fractures. Because of the chronic and uneven lower lumbar spinal load with severe vertebral osteoporosis in certain patients with repeat lumbar fractures and worsening degenerative lumbar scoliosis, there may be a rationale to add preventive vertebroplasty at adjacent vertebral endplates when treating acute recurrent lumbar fractures to decrease the incidence of recurrence in other vertebrae.