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

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Abstract

Purpose

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.

Materials and method

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.

Results

The mean age of 185 patients was 69.2 and the mean follow-up period was 7.23 years (range: 5–11 years). 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 9.48 weeks. 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.

Conclusion

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.

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References

  1. Lourie H (1982) Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA 248(6):715–717

    Article  CAS  PubMed  Google Scholar 

  2. Urits I, Orhurhu V, Callan J, Maganty NV, Pousti S, Simopoulos T, Yazdi C, Kaye RJ, Eng LK, Kaye AD, Manchikanti L, Viswanath O (2020) Sacral insufficiency fractures: a review of risk factors, clinical presentation, and management. Curr Pain Headache Rep 24(3):10. https://doi.org/10.1007/s11916-020-0848-z

    Article  PubMed  Google Scholar 

  3. Schindler OS, Watura R, Cobby M (2007) Sacral insufficiency fractures. J Orthop Surg 15(3):339–346. https://doi.org/10.1177/230949900701500320

    Article  CAS  Google Scholar 

  4. Yoo JI, Ha YC, Ryu HJ, Chang GW, Lee YK, Yoo MJ, Koo KH (2017) Teriparatide treatment in elderly patients with sacral insufficiency fracture. J Clin Endocrinol Metab 102(2):560–565. https://doi.org/10.1210/jc.2016-3582

    Article  PubMed  Google Scholar 

  5. Sakaguchi M, Maebayashi T, Aizawa T, Ishibashi N (2019) Risk factors for sacral insufficiency fractures in cervical cancer after whole pelvic radiation therapy. Anticancer Res 39(1):361–367. https://doi.org/10.21873/anticanres.13120

    Article  CAS  PubMed  Google Scholar 

  6. Speziali A, Tei MM, Placella G, Chillemi M, Cerulli G (2015) Postpartum sacral stress fracture: an atypical case report. Case Rep Orthop 2015:704393. https://doi.org/10.1155/2015/704393

    Article  PubMed  PubMed Central  Google Scholar 

  7. Hmida B, Boudokhane S, Migaou H, Kalai A, Jellad A, Salah ZB (2018) Postpartum sacral stress fracture associated with mechanical sacroiliac joint disease: a case report. Medicine 97(32):e11735. https://doi.org/10.1097/MD.0000000000011735

    Article  PubMed  PubMed Central  Google Scholar 

  8. Rawlings CE 3rd, Wilkins RH, Martinez S, Wilkinson RH Jr (1988) Osteoporotic sacral fractures: a clinical study. Neurosurgery 22(1 Pt 1):72–76. https://doi.org/10.1227/00006123-198801010-00011

    Article  PubMed  Google Scholar 

  9. Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH (2012) The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat 221(6):537–567. https://doi.org/10.1111/j.1469-7580.2012.01564.x

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Kinoshita H, Miyakoshi N, Kobayashi T, Abe T, Kikuchi K, Shimada Y (2019) Comparison of patients with diagnosed and suspected sacral insufficiency fractures. J Orthop Sci Off J Jpn Orthop Assoc 24(4):702–707. https://doi.org/10.1016/j.jos.2018.12.004

    Article  Google Scholar 

  11. Su B, O’Connor JP (2013) NSAID therapy effects on healing of bone, tendon, and the enthesis. J Appl Physiol 115(6):892–899. https://doi.org/10.1152/japplphysiol.00053.2013

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Lyders EM, Whitlow CT, Baker MD, Morris PP (2010) Imaging and treatment of sacral insufficiency fractures. AJNR Am J Neuroradiol 31(2):201–210. https://doi.org/10.3174/ajnr.A1666

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Frey ME, Warner C, Thomas SM, Johar K, Singh H, Mohammad MS, Beall DP (2017) Sacroplasty: a ten-year analysis of prospective patients treated with percutaneous sacroplasty: literature review and technical considerations. Pain Physician 20(7):E1063–E1072

    PubMed  Google Scholar 

  14. Blake SP, Connors AM (2004) Sacral insufficiency fracture. Br J Radiol 77(922):891–896. https://doi.org/10.1259/bjr/81974373

    Article  CAS  PubMed  Google Scholar 

  15. Bostel T, Nicolay NH, Welzel T, Bruckner T, Mattke M, Akbaba S, Sprave T, Debus J, Uhl M (2018) Sacral insufficiency fractures after high-dose carbon-ion based radiotherapy of sacral chordomas. Radiat Oncol 13(1):154. https://doi.org/10.1186/s13014-018-1095-x

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Kawamoto T, Ito K, Furuya T, Sasai K, Karasawa K (2018) Sacral insufficiency fracture after stereotactic body radiation therapy for sacral metastasis. Clin Case Rep 6(11):2293–2294. https://doi.org/10.1002/ccr3.1850

    Article  PubMed  PubMed Central  Google Scholar 

  17. Holderread BM, Shin CP, Syed IY, Avramis I, Rizkalla JM (2022) Sacral insufficiency fracture after lumbosacral decompression and fusion. In Bayl Univ Med Cent Proc 35(4):451–454. https://doi.org/10.1080/08998280.2022.2058832

    Article  Google Scholar 

  18. Meredith DS, Taher F, Cammisa FP Jr, Girardi FP (2013) Incidence, diagnosis, and management of sacral fractures following multilevel spinal arthrodesis. Spine J Off J North Am Spine Soc 13(11):1464–1469. https://doi.org/10.1016/j.spinee.2013.03.025

    Article  Google Scholar 

  19. Odate S, Shikata J, Kimura H, Soeda T (2013) Sacral fracture after instrumented lumbosacral fusion: analysis of risk factors from spinopelvic parameters. Spine 38(4):E223–E229. https://doi.org/10.1097/BRS.0b013e31827dc000

    Article  PubMed  Google Scholar 

  20. Wilde GE, Miller TT, Schneider R, Girardi FP (2011) Sacral fractures after lumbosacral fusion: a characteristic fracture pattern. AJR Am J Roentgenol 197(1):184–188. https://doi.org/10.2214/AJR.10.5902

    Article  PubMed  Google Scholar 

  21. Buell TJ, Yener U, Wang TR, Buchholz AL, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS (2020) Sacral insufficiency fractures after lumbosacral arthrodesis salvage lumbopelvic fixation and a proposed management algorithm. J Neurosurg Spine. https://doi.org/10.3171/2019.12.SPINE191148

    Article  PubMed  Google Scholar 

  22. Gotis-Graham I, McGuigan L, Diamond T, Portek I, Quinn R, Sturgess A, Tulloch R (1994) Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br Vol 76(6):882–886

    Article  CAS  Google Scholar 

  23. Cabarrus MC, Ambekar A, Lu Y, Link TM (2008) MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol 191(4):995–1001. https://doi.org/10.2214/AJR.07.3714

    Article  PubMed  Google Scholar 

  24. Smith DK, Dix JE (2006) Percutaneous sacroplasty: long-axis injection technique. AJR Am J Roentgenol 186(5):1252–1255. https://doi.org/10.2214/AJR.05.0823

    Article  PubMed  Google Scholar 

  25. Grangier C, Garcia J, Howarth NR, May M, Rossier P (1997) Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skelet Radiol 26(9):517–524. https://doi.org/10.1007/s002560050278

    Article  CAS  Google Scholar 

  26. Finiels H, Finiels PJ, Jacquot JM, Strubel D (1997) Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases. Presse Med 26(33):1568–1573

    CAS  PubMed  Google Scholar 

  27. Fujii M, Abe K, Hayashi K, Kosuda S, Yano F, Watanabe S, Katagiri S, Ka WJ, Tominaga S (2005) Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 30(3):165–169. https://doi.org/10.1097/00003072-200503000-00004

    Article  PubMed  Google Scholar 

  28. Lundin B, Björkholm E, Lundell M, Jacobsson H (1990) Insufficiency fractures of the sacrum after radiotherapy for gynaecological malignancy. Acta Oncol 29(2):211–215. https://doi.org/10.3109/02841869009126547

    Article  CAS  PubMed  Google Scholar 

  29. Babayev M, Lachmann E, Nagler W (2000) The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate? Am J Phys Med Rehabil 79(4):404–409. https://doi.org/10.1097/00002060-200007000-00014

    Article  CAS  PubMed  Google Scholar 

  30. Mahmood B, Pasternack J, Razi A, Saleh A (2019) Safety and efficacy of percutaneous sacroplasty for treatment of sacral insufficiency fractures: a systematic review. J Spine Surg 5(3):365–371

    Article  PubMed  PubMed Central  Google Scholar 

  31. Frey ME, Depalma MJ, Cifu DX, Bhagia SM, Carne W, Daitch JS (2008) Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine J Off J North Am Spine Soc 8(2):367–373. https://doi.org/10.1016/j.spinee.2007.05.011

    Article  Google Scholar 

  32. Pommersheim W, Huang-Hellinger F, Baker M, Morris P (2003) Sacroplasty: a treatment for sacral insufficiency fractures. AJNR Am J Neuroradiol 24(5):1003–1007

    PubMed  PubMed Central  Google Scholar 

  33. Frey ME, DePalma MJ, Cifu DX, Bhagia SM, Daitch JS (2007) Efficacy and safety of percutaneous sacroplasty for painful osteoporotic sacral insufficiency fractures: a prospective, multicenter trial. Spine 32(15):1635–1640. https://doi.org/10.1097/BRS.0b013e318074d4e1

    Article  PubMed  Google Scholar 

  34. Gupta AC, Chandra RV, Yoo AJ, Leslie-Mazwi TM, Bell DL, Mehta BP, Vanderboom TL, Rabinov JD, Larvie M, Hirsch JA (2014) Safety and effectiveness of sacroplasty: a large single-center experience. AJNR Am J Neuroradiol 35(11):2202–2206. https://doi.org/10.3174/ajnr.A4027

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Park JW, Park SM, Lee HJ, Lee CK, Chang BS, Kim H (2017) Mortality following benign sacral insufficiency fracture and associated risk factors. Arch Osteoporos 12(1):100. https://doi.org/10.1007/s11657-017-0395-3

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurosurgery, Medicana International Atasehir Hospital, Istanbul, Turkey

    Buse Sarigul, Ahmet Ogrenci & Sedat Dalbayrak

  2. Department of Neurosurgery, Neurospinal Academy, Istanbul, Turkey

    Mesut Yilmaz

  3. Department of Neurosurgery, Lokman Hekim Hospital, Istanbul, Turkey

    Orkun Koban & Mazhar Mammadov

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  1. Buse Sarigul
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Correspondence to Buse Sarigul.

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Sarigul, B., Ogrenci, A., Yilmaz, M. et al. Sacral insufficiency fracture: a single-center experience of 185 patients with a minimum 5-year follow-up. Eur Spine J 33, 1511–1517 (2024). https://doi.org/10.1007/s00586-023-08027-2

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