Analysis of Fracture Patterns and Characteristics in Sacral Insufficiency Fracture: Do Sacral Fractures Occur in Patients Who Had Previous Lumbosacral Fusion Insufficiency Fractures or Stress Fractures?

Sacral insufficiency fracture is a painful injury, for which no effective treatment currently exists. The objective of this study was to report on the clinical outcomes and technical aspects of balloon kyphoplasty, which was used in three patients with this injury. Three elderly women with intractable pain from sacral insufficiency fractures were treated with polymethyl methacrylate (PMMA) injections into the sacrum by using a modified balloon kyphoplasty procedure. The visual analog scale pain score improved by four points in each case. Functional status was improved and analgesic medication requirements were decreased in all three patients. There were no complications associated with the procedure. Because of the unique anatomy of the sacrum, it was difficult to monitor instrument placement and PMMA injection by using conventional fluoroscopy. BrainLAB image guidance was used in one case, and was helpful in guiding instrument placement and assuring accurate PMMA deposition at the fracture site. Balloon kyphoplasty may be a treatment alternative in selected patients with sacral insufficiency fractures. BrainLAB image guidance may offer some advantages over conventional fluoroscopy with regard to the monitoring of instrument placement and PMMA injection.

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Bilateral Insufficiency Fracture of the Pelvis Following THA: A Case Report

Case Reports in Medicine ◽

10.1155/2012/170736 ◽

2012 ◽

Vol 2012 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Shinya Hayashi ◽

Takayuki Nishiyama ◽

Takaaki Fujishiro ◽

Shingo Hashimoto ◽

Masahiro Kurosaka

Keyword(s):

Groin Pain ◽

Insufficiency Fracture ◽

Stress Fractures ◽

Insufficiency Fractures ◽

Pubic Rami ◽

First Case ◽

Fragile Bone ◽

Repetitive Stress ◽

Postoperative Stress ◽

Pelvic Insufficiency Fracture

Insufficiency fracture is of the stress fractures and is caused by repetitive stress on fragile bone. Insufficiency fractures of pubic rami are rare occurrences in association with total hip arthroplasty (THA). Postoperative stress fractures occur due to increase of patients activity following years of disability. The physician should consider the possibility of a pelvic insufficiency fracture in patients with RA after THA, if the patients present with groin pain. We demonstrate here the first case of bilateral insufficiency fracture of pubic rami and iliac bone following THA.

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Tarlov Cyst Causing Sacral Insufficiency Fracture

Operative Neurosurgery ◽

10.1093/ons/opw025 ◽

2017 ◽

Vol 13 (3) ◽

pp. E4-E7 ◽

Cited By ~ 1

Author(s):

Ross C. Puffer ◽

Marcus J. Gates ◽

William Copeland ◽

William E. Krauss ◽

Jeremy Fogelson

Keyword(s):

Bone Erosion ◽

Insufficiency Fracture ◽

Bowel Dysfunction ◽

Insufficiency Fractures ◽

Large Area ◽

Nerve Roots ◽

Posterior Aspect ◽

Sacral Insufficiency Fracture ◽

Tarlov Cyst ◽

Tarlov Cysts

Abstract BACKGROUND AND IMPORTANCE: Tarlov cysts, also known as perineural cysts, have been described as meningeal dilations of the spinal nerve root sheath between the peri- and endoneurium at the dorsal root ganglion. Most often they are found in the sacrum involving the nerve roots. Normally asymptomatic, they have been reported to present with radiculopathy, paresthesias, and even urinary or bowel dysfunction. Sacral insufficiency has not been a well-documented presentation. CLINICAL PRESENTATION: The patient is a 38-year-old female who started to develop left low back pain and buttock pain that rapidly progressed into severe pain with some radiation down the posterior aspect of her left leg. There was no recent history of spine or pelvic trauma. These symptoms prompted her initial emergency department evaluation, and imaging demonstrated a large Tarlov cyst with an associated sacral insufficiency fracture. She was noted to have a normal neurological examination notable only for an antalgic gait. She was taken to surgery via a posterior approach and the cyst was identified eccentric to the left. The cyst was fenestrated and the nerve roots identified. Given her large area of bone erosion and insufficiency fractures, fixation of the sacroiliac joints was deemed necessary. Fusion was extended to the L5 vertebral body to buttress the fixation. She tolerated the procedure well and was discharged from the hospital on postoperative day 3. CONCLUSION: Tarlov cysts of the sacrum can lead to significant bone erosion and subsequent insufficiency fractures, requiring fenestration and in some cases, complex sacropelvic fixation.

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Bilateral Tibial Stress Fractures and Osteoporosis in a Young Patient

Sports Health A Multidisciplinary Approach ◽

10.1177/19417381211032127 ◽

2021 ◽

pp. 194173812110321

Author(s):

Ali Gürbüz ◽

Mustafa Gür

Keyword(s):

Case Report ◽

Young Patient ◽

Insufficiency Fracture ◽

The Elderly ◽

Stress Fractures ◽

The Other ◽

Insufficiency Fractures ◽

Normal Loading ◽

Bone Injury ◽

Fatigue Fractures

Stress fractures result from microscopic bone injury due to repetitive submaximal stress and include fatigue and insufficiency fracture components. Fatigue fractures generally occur in runners and athletes and are caused by abnormal physical load on the bone. On the other hand, insufficiency fractures are generally seen in the elderly secondary to osteoporosis, typically involving the pelvis and surrounding bones. Insufficiency fracture occurs as a result of normal loading in the abnormal bone. In this case report, we describe a young patient with bilateral tibial stress fractures with both fatigue and insufficiency components.

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Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm

Journal of Neurosurgery Spine ◽

10.3171/2019.12.spine191148 ◽

2020 ◽

Vol 33 (2) ◽

pp. 225-236 ◽

Cited By ~ 1

Author(s):

Thomas J. Buell ◽

Ulas Yener ◽

Tony R. Wang ◽

Avery L. Buchholz ◽

Chun-Po Yen ◽

...

Keyword(s):

Insufficiency Fracture ◽

Sacral Fracture ◽

Leg Pain ◽

Insufficiency Fractures ◽

Lower Extremity Weakness ◽

Sacral Insufficiency Fracture ◽

Lumbopelvic Fixation ◽

Iliac Screws ◽

Sacral Insufficiency Fractures

OBJECTIVESacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors’ operative experience managing this complication, review pertinent literature, and propose a treatment algorithm.METHODSThe authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication.RESULTSNine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8–96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score −1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8–90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to–lumbar lordosis (LL) mismatch.CONCLUSIONSA high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5–S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.

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Sacral Insufficiency Fracture Following Short-Segment Lumbosacral Fusion: Case Series and Review of the Literature

Global Spine Journal ◽

10.1177/2192568220950332 ◽

2020 ◽

pp. 219256822095033

Author(s):

Joshua M. Kolz ◽

Scott A. Mitchell ◽

Benjamin D. Elder ◽

Arjun S. Sebastian ◽

Paul M. Huddleston ◽

...

Keyword(s):

Lumbar Fusion ◽

Treatment Options ◽

Insufficiency Fracture ◽

Case Series ◽

Neurologic Deficit ◽

Retrospective Case ◽

Short Segment ◽

Sacral Insufficiency Fracture ◽

Lumbosacral Fusion ◽

Posterior Surgery

Study Design: Retrospective case series. Objective: Sacral insufficiency fracture is a rare and serious complication following lumbar spine instrumented fusion. The purpose of this study was to describe the patient characteristics, presentation, evaluation, treatment options, and outcomes for patients with sacral insufficiency fracture after short-segment lumbosacral fusion. Methods: Six patients from our institutional database and 16 patients from literature review were identified with a sacral insufficiency fracture after short-segment (L4-S1 or L5-S1) lumbar fusion within 1 year of surgery. Results: Patients were 55% female with a mean age of 58 years and body mass index of 30 kg/m2. Osteoporosis or osteopenia was the most common comorbidity (85%). Half of patients sustained a sacral fracture after surgery from a posterior approach, while the others had anterior or anterior-posterior surgery. Mean time to fracture was 42 days with patients clinically presenting with new sacral pain (86%), radiculopathy (60%), or neurologic deficit (5%). Ultimately, 73% of patients underwent operative fixation often involving extension of the construct (75%) and fusion to the pelvis (69%). Men ( P = .02) and patients with new radicular pain or neurologic deficit ( P = .01) were more likely to undergo revision surgical treatment while women over 50 years of age were more likely to be treated conservatively ( P = .003). Conclusions: Spine surgeons should monitor for sacral insufficiency fracture as a source of new-onset pain in the postoperative period in patients with a short segment fusion to the sacrum. The recognition of this complication should prompt an assessment of bone health and management of underlying bone fragility.

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Insufficiency Fractures vs. Low-Energy Pelvic Ring Fractures – Epidemiological, Diagnostic and Therapeutic Characteristics of Fragility Fractures of the Pelvic Ring

Zeitschrift für Orthopädie und Unfallchirurgie ◽

10.1055/a-1394-6502 ◽

2021 ◽

Author(s):

Manuel Sterneder ◽

Patricia Lang ◽

Hans-Joachim Riesner ◽

Carsten Hackenbroch ◽

Benedikt Friemert ◽

...

Keyword(s):

Pelvic Ring ◽

Diagnostic Testing ◽

Insufficiency Fracture ◽

Fragility Fractures ◽

Relative Increase ◽

Trauma Centre ◽

Low Energy ◽

Insufficiency Fractures ◽

Type Iv ◽

Pelvic Ring Fractures

Abstract Background Fragility fractures of the pelvis (FFP) encompass two fracture entities: fracture after low-energy trauma and insufficiency fracture without trauma. It is unclear whether the two subgroups differ in terms of diagnosis and therapy. The aim of this retrospective study was to evaluate insufficiency fractures with regard to defined parameters and to compare specific parameters with the fractures after low-energy trauma. Patients and Methods In the period from 2008 to 2017, 203 patients with FFP were recorded at our clinic (Level 1 Trauma Centre DGU, SAV approval). Of these, 25 had an insufficiency fracture and 178 had a pelvic ring fracture after low-energy trauma. Epidemiological, diagnostic and therapeutic parameters were examined. Results There was a relative increase in the insufficiency fracture within the FFP (2008 – 2009: 5.0% vs. 2015 – 2017: 17.8%). In these patients, osteoporosis tended to be more pronounced than in patients after low-energy trauma (t-value: − 3.66 vs. − 3.13). The diagnosis of insufficiency fractures showed increased use of MRI and DECT (60.9% vs. 26.0%) and a high proportion of type IV fractures after FFP (40.0% vs. 7.9%). In terms of therapy, surgical treatment of the insufficiency fracture was sought more often (68,2% vs. 52,1%), with a tendency towards increased use of combined osteosynthesis procedures (14.3% vs. 7.6%). Conclusion We were able to show that as the number of cases increases, the insufficiency fracture becomes more important within FFP. If these patients tend to have more pronounced osteoporosis, particular attention should be paid to the diagnosis and adequate therapy of the osteoporosis, especially in the case of an insufficiency fracture. In addition to the increased diagnostic testing using MRI and DECT to detect oedema and the increased surgical therapy for this type of fracture, it is also noteworthy that the insufficiency fracture can cause higher-grade fractures after FFP.

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