Imaging and Treatment of Sacral Insufficiency Fractures

Abstract

SUMMARY: SIFs are a common, though often unsuspected, cause of low back pain in the elderly. Although numerous radiographic modalities can be used to diagnose SIFs, bone scintigraphy and MR imaging are the most sensitive. Conservative management involves various combinations of bed rest, rehabilitation, and analgesics. More recently, sacroplasty has emerged as an alternative therapy for the treatment of SIFs, with prospective studies and case reports suggesting that it is a safe and effective therapy. This article reviews the imaging appearance of SIFs and discusses treatment options with a focus on sacroplasty.ABBREVIATIONS: FEA ϭ finite-element analysis; MDP ϭ methylene diphosphonate; PMMA ϭ polymethylmethacrylate; SIF ϭ sacral insufficiency fracture; VAS ϭ visual analog pain scale.

Radiofrequency sacroplasty (RFS) for the treatment of osteoporotic insufficiency fractures

“…Cement augmentation analogous to vertebroplasty [8][9][10] or balloon kyphoplasty [4,9,11,13,14] come into question here. Greater clinical experience has been gained in cement insertion via a placed hollow needle in accordance with vertebroplasty, although higher rates of cement leakage are experienced here, as in the treatment of vertebral body fractures [9,10]. A central cavity for insertion of the cement can be created using a balloon catheter, whereby a compaction of the surrounding fracture zone seals possible fracture fissures and thus minimises cement leakage [4,[12][13][14].…”

“…Since a rapid analgesic effect with a positive effect on mobility and the activities of daily living has been repeatedly shown after sacroplasty [4,8,9,11,13,14], this therapeutic option should be taken after an unsuccessful attempt at conservative treatment with persistent disabling pain. Cement augmentation analogous to vertebroplasty [8][9][10] or balloon kyphoplasty [4,9,11,13,14] come into question here. Greater clinical experience has been gained in cement insertion via a placed hollow needle in accordance with vertebroplasty, although higher rates of cement leakage are experienced here, as in the treatment of vertebral body fractures [9,10].…”

“…As an alternative minimally invasive form of treatment, cement can be inserted via hollow needles, analogously to vertebroplasty [8]. Rapid and virtually complete pain reduction has been demonstrated with this new method, although leakages may occur as a complication and are not always free of symptoms [9,10]. Sacroplasty with balloon dilatation, analogous to kyphoplasty, was first performed by Deen and Nottmeier [11] on three patients.…”

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

“…Insufficiency fractures are more common and are most often seen in older women with osteoporosis. 39,40 Fatigue-type sacral stress fractures are prevalent in athletic populations, and as such, the clinical history should rule out recent changes in training volume and repetitive movements. 41 Although more common in females, athletes with relative energy deficiency in sports may be more prone to insufficiency type stress fractures occurring in the pelvis.…”

“…However, radiography may demonstrate a horizontal or vertical sclerotic line indicative of fracture. 39 Magnetic resonance imaging and skeletal scintigraphy (SS) both demonstrate high sensitivity for stress fracture detection, although MRI has the additional value of evaluating the surrounding soft tissue structures that may be contributing to the patient's complaint. On MRI, high-signal reactive edema surrounding a low-signal fracture line will be seen on fluid sensitive T2-weighted or inversion recovery-weighted sequences.…”