Sacral Insufficiency Fractures Mimicking Lumbar Spine Pathology

Abstract

Sacral insufficiency fractures (SIFs) are a common cause of back pain in the elderly. SIFs mimic the symptoms of lumbar spine pathology and so are commonly missed or underdiagnosed. Here we present four cases of missed SIFs that were subsequently identified and treated. One patient was treated as mechanical lower back ache, another patient underwent root block and two patients underwent surgery for lumbar canal stenosis. None experienced relief of their symptoms after these procedures. Retrospective analysis of X-ray and magnetic resonance imaging data revealed SIFs that were confirmed by computed tomography scans. All four patients were treated for underlying osteoporosis. Two patients who underwent surgery were treated conservatively and other two were treated by sacroplasty involving injection of cement into the fracture. Sacroplasty produced immediate pain relief and early mobilization compared to the conservative group. SIFs should always be considered in the differential diagnosis of an elderly patient presenting with low back symptoms. Sacroplasty can be considered for immediate pain relief and rapid mobilization.

Balloon-assisted sacroplasty as a successful procedure for osteoporotic sacral insufficiency fractures after failure of the conservative treatment

“…Besides, sacral insufficency fractures are concomitant pathologies in osteoporotic lumbar spine body fractures and therefore overseen when finding the latter 1 . Clinical symptoms are unspecific being caudal lumbar or gluteal pain, rarely sciatica or a neurological deficit 2 , 3 .…”

“…Typically, a second look on imiginary findings in patients with persistent pain are the key to finding the right diagnosis 2 . The average time span between onset of symptoms to diagnosis is several weeks to months 1 .…”

“…The incidence of sacral insufficency fractures varies between different authors in current scientific papers being 1–5% in risk patients or 37/100.000 in total 10 , 11 . Osteoporosis is the main risk factor because the sacrum consists mainly of cancellous bone which is reduced and altered in patients with reduced bone quality 2 . Therefore, patients are typically 60–70 years old and of the female gender 5 , 12 .…”

Osteoporotic sacral insufficiency fracture

“…Studies have reported a delay of approximately 40 to 55 days from symptom onset to sacrum imaging. [ 30 ] Only some cases have reported about neglected or delayed diagnosis of SIFs after treating other levels of osteoporotic compression fractures [ 14 , 21 – 23 ] In our study, 23.53% and 76.47% cases of SIFs were neglected by radiologists and clinical physicians, respectively. Unclear conditions under which SIFs were not identified, some procedures, such as sacroiliac joint injection, hip replacement, or spinal fusion, were performed and might have been ineffective.…”

“…[ 3 , 19 , 20 ] Only some studies have reported on neglected or delayed diagnosis of SIFs after treating other levels of osteoporotic compression fractures. [ 21 – 23 ] Therefore, we conducted a retrospective study to assess the rate of SIFs in patients with symptomatic osteoporotic compression fractures of the lumbar–sacral region. We calculated the rate of neglected diagnosis by radiologists and clinical physicians.…”