Sacral insufficiency fractures in the elderly

Abstract

Sacral insufficiency fractures are not uncommon in elderly patients. We have diagnosed 20 cases in a fiveyear period, and have reviewed the clinical records, radiographs, CT and bone scans. We also assessed the degree of osteoporosis by measuring bone density using dual-energy X-ray absorptiometry and bone histomorphometry, and monitored the patients' functional outcome. Bone scans were positive in all 20 patients, CT showed a fracture or sclerosis in 7 of 12 patients and was useful in excluding malignancy. Plain radiographs were the least helpful, showing sclerosis in only 4 of the 20 patients. Involutional osteoporosis with a reduced bone formation rate was the most common underlying cause. Seventeen patients had complete resolution of pain within nine months, and no patient lost independence in daily activities. Increased awareness of these fractures may help to avoid unnecessary investigation and treatment. Bedrest and analgesia followed by rehabilitation provide good relief of symptoms.

Imaging and Treatment of Sacral Insufficiency Fractures

“…The standard of care for the treatment of SIFs has been conservative management, with variable courses of bed rest, rehabilitation, and analgesics prescribed. [2][3][4] More recently, sacroplasty, a minimally invasive procedure akin to vertebroplasty in the thoracolumbar spine, has been advocated as an alternative to conservative therapy. Retrospective case series and prospective studies suggest that sacroplasty is a safe and effective procedure, providing early symptomatic relief in patients with SIFs.…”

“…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. 2 Prior pelvic radiation is another wellestablished risk factor for the development of SIFs, with a reported prevalence of 21%-34%. 12,13 The incidence may even be as high as 89%, as suggested by a prospective study of patients undergoing pelvic radiation for cervical cancer.…”

“…15 Neurologic symptoms related to SIFs are unusual, though may be seen in 5%-6% of patients, most commonly manifesting as a sacral radiculopathy. 2 However, a case of cauda equina syndrome related to SIFs has been reported. 21 SIFs can occasionally be confused with metastatic disease, both clinically and on imaging studies, 22 resulting in unnecessary work-up and biopsy.…”

Sequential Sacral Insufficiency Fracture After Unilateral Pubic Fractures - A Case Report -

“…1 SIFs are often bilateral and commonly associated with other fractures, most frequently a pubic ramus fracture. [2][3][4] However, it remains unclear which fracture (sacral or pubic rami) occurs first, and in cases of bilateral SIFs, whether fractures occur simultaneously or sequentially. Only one English report has described this sequence, and in this report it was suggested initial disruption is likely to occur in the sacrum, and that the subsequent instability creates mechanical failure of the pubic rami.…”

Sacroplasty in a cadaveric trial: comparison of CT and fluoroscopic guidance with and without balloon assistance

“…Treatments for this fracture type are commonly conservative including bed rest, moderate weight-bearing exercise, analgesia, osteoporosis medication, which often lead to complete healing within 9 months [23,29]. However, physicians have to be aware of complications from immobility including DVT, pulmonary embolism, pneumonia, progressive osteopenia, lingering illness, and death [2,9,18].…”