Sacral insufficiency fracture, an unsuspected cause of low-back pain in elderly women

Abstract

Sacral insufficiency fractures (SIF) usually occur in elderly women and are secondary to various conditions, mainly postmenopausal or steroid-induced osteoporosis and radiation therapy. They are often overlooked or confused clinically and radiographically with metastatic disease. We report a case of a 72-year-old woman who presented to our department with severe low-back pain. She was thoroughly investigated for the cause of her back pain. Plain X-rays did not reveal any abnormality, but magnetic resonance (MR) scan revealed marked oedema within both sides of the sacrum, suggesting a neoplastic lesion. Bone scintigraphy did show a hyperfixation pattern forming an 'H' in the sacrum which is a characteristic sign of SIF. Computed tomography (CT) confirmed sclerotic changes interpreted as insufficiency fractures through both sacral alae. Increased awareness of these fractures may help to avoid unnecessary investigations and treatment. Bed rest and analgesia followed by rehabilitation provide good relief of symptoms.

Characteristics of fracture and related factors in patients with rheumatoid arthritis

“…The second point was that insufficiency fractures, which are caused by normal physiological stress, are the most common type of fracture (69.7%) in patients with RA. It has been reported that RA is one of the most common underlying diseases in patients with insufficiency fracture [11][12][13][14][15], and there have been many case reports of insufficiency fractures in RA patients [21][22][23], but the frequency of these fractures has been unclear. In our study, misdiagnosis and the overlooking of insufficiency fractures or juxta-articular fractures were presumably minimized.…”

Sacroplasty versus Vertebroplasty: Comparable Clinical Outcomes for the Treatment of Fracture-Related Pain

“…34 The current standard of care for treatment of sacral insufficiency fractures involves pharmacotherapy for pain, and often prolonged bed rest. 35 In particular, bed rest is known to be associated with such risks as progressive loss of bone mineralization and muscle mass, as well as the development of pneumonia and pulmonary embolism, which may outweigh the benefits of bed rest for some patients. [36][37][38][39][40] Sacroplasty is a relatively new minimally invasive percutaneous intervention that provides a treatment alternative to current therapeutic options.…”

Imaging and Treatment of Sacral Insufficiency Fractures

“…SIFs commonly affect elderly women with osteoporosis, 9,10 though other reported risk factors include pelvic radiation, steroid-induced osteopenia, rheumatoid arthritis, multiple myeloma, Paget disease, renal osteodystrophy, and hyperparathyroidism. 2,9,11 Of these, osteoporosis is the most prevalent, and almost all patients with SIFs will demonstrate severe osteopenia on dual x-ray absorptiometry, even if other risk factors are present.…”

“…21 SIFs can occasionally be confused with metastatic disease, both clinically and on imaging studies, 22 resulting in unnecessary work-up and biopsy. [9][10] This is frequently a confounding factor in elderly patient populations, many of whom have a known primary malignancy or are being evaluated for an occult tumor. 16,22,23 In fact, approximately 45% of patients with SIFs have a history of malignancy.…”