Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Sacral Insufficiency Fractures : How to Classify?

  • Bakker, Gesa (Hannover Region Public Health Department) ;
  • Hattingen, Joerg (Department for Radiology and Neuroradiology, KRH Nordstadt) ;
  • Stuetzer, Hartmut (Institute for Medical Statistics, Computer Science and Epidemiology IMSIE, University of Cologne) ;
  • Isenberg, Joerg (Department of Traumatology and Orthopedics, KRH Nordstadt)
  • Received : 2017.06.12
  • Accepted : 2017.08.18
  • Published : 2018.03.01
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Abstract

Objective : The diagnosis of insufficiency fractures of the sacrum in an elder population increases annually. Fractures show very different morphology. We aimed to classify sacral insufficiency fractures according to the position of cortical break and possible need for intervention. Methods : Between January 1, 2008 and December 31, 2014, all patients with a proven fracture of the sacrum following a low-energy or an even unnoticed trauma were prospectively registered : 117 females and 13 males. All patients had a computer tomography of the pelvic ring, two patients had a magnetic resonance imaging additionally : localization and involvement of the fracture lines into the sacroiliac joint, neural foramina or the spinal canal were identified. Results : Patients were aged between 46 and 98 years (mean, 79.8 years). Seventy-seven patients had an unilateral fracture of the sacral ala, 41 bilateral ala fractures and 12 patients showed a fracture of the sacral corpus : a total of 171 fractures were analyzed. The first group A included fractures of the sacral ala which were assessed to have no or less mechanical importance (n=53) : fractures with no cortical disruption ("bone bruise") (A1; n=2), cortical deformation of the anterior cortical bone (A2; n=4), and fracture of the anterolateral rim of ala (A3; n=47). Complete fractures of the sacral ala (B; n=106) : parallel to the sacroiliac joint (B1; n=63), into the sacroiliac joint (B2; n=19), and involvement of the sacral foramina respectively the spinal canal (B3; n=24). Central fractures involving the sacral corpus (C; n=12) : fracture limited to the corpus or finishing into one ala (C1; n=3), unidirectional including the neural foramina or the spinal canal or both (C2; n=2), and horizontal fractures of the corpus with bilateral sagittal completion (C3; n=8). Sixty-eight fractures proceeded into the sacroiliac joint, 34 fractures showed an injury of foramina or canal. Conclusion : The new classification allowes the differentiation of fractures of less mechanical importance and a risk assessment for possible polymethyl methacrylate leaks during sacroplasty in the direction of the neurological structures. In addition, identification of instable fractures in need for laminectomy and surgical stabilization is possible.

Keywords

References

  1. Albertsen AM, Egund N, Jurik AG : Fatigue fracture of the sacral bone associated with septic arthritis of the symphysis pubis. Skeletal Radiol 24 : 605-607, 1995
  2. Alnaib M, Waters S, Shanshal Y, Caplan N, Jones S, St Clair Gibson A, et al. : Combined pubic rami and sacral osteoporotic fractures: a prospective study. J Orthop Traumatol 13 : 97-103, 2012 https://doi.org/10.1007/s10195-012-0182-2
  3. Aretxabala I, Fraiz E, Perez-Ruiz F, Rios G, Calabozo M, Alonso-Ruiz A : Sacral insufficiency fractures. High association with pubic rami fractures. Clin Rheumatol 19 : 399-401, 2000 https://doi.org/10.1007/PL00011178
  4. Bayley E, Srinivas S, Boszczyk BM : Clinical outcomes of sacroplasty in sacral insufficiency fractures: a review of the literature. Eur Spine J 18 : 1266-1271, 2009 https://doi.org/10.1007/s00586-009-1048-z
  5. Choi KC, Shin SH, Lee DC, Shim HK, Park CK : Effects of percutaneous sacroplasty on pain and morbility in sacral insufficiency fracture. J Korean Neurosurg Soc 60 : 60-66, 2017 https://doi.org/10.3340/jkns.2016.0505.010
  6. Connolly LP, Drubach LA, Connolly SA, Treves ST : Young athletes with low back pain: skeletal scintigraphy of conditions other than pars interarticularis stress. Clin Nucl Med 29 : 689-693, 2004 https://doi.org/10.1097/00003072-200411000-00003
  7. Cooper KL, Beabout JW, Swee RG : Insufficiency fractures of the sacrum. Radiology 156 : 15-20, 1985 https://doi.org/10.1148/radiology.156.1.4001403
  8. Denis F, Davis S, Comfort T : Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 227 : 67-81, 1988
  9. Finiels H, Finiels PJ, Jacquot JM, Strubel D : Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases. Presse Med 26 : 1568-1573, 1997
  10. Fujii M, Abe K, Hayashi K, Kosuda S, Yano F, Watanabe S, et al. : Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 30 : 165-169, 2005 https://doi.org/10.1097/00003072-200503000-00004
  11. Gotis-Graham I, McGuigan L, Diamond T, Portek I, Quinn R, Sturgess A, et al. : Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 76 : 882-886, 1994
  12. Guilbeau JC, Arrive L, Maruice F, Nahum H : Spontaneous fracture of the sacrum due to “insufficiency”. An overlooked cause of low lumbago in elderly women. J Radiol 67 : 741-744, 1986
  13. Hak DJ, Baran S, Stahel P : Sacral fractures: current strategies in diagnosis and management. Orthopedics 32 : 752-757, 2009 https://doi.org/10.3928/01477447-20090818-18
  14. Hatgis J, Granville M, Jacobson RE, Berti A : Sacral insufficiency fractures: recognation and treatment in patients with current lumbar vertebral compression fractures. Cureus 9 : e1008, 2017
  15. Heo DH, Park CK : Percutaneus sacroplasty for non-neoplastic osteoporotic sacral insufficiency fractures. Pain Physician 20 : 89-94, 2017
  16. Isler B : Lumbosacral lesions associated with pelvic ring injuries. J Orthop Trauma 4 : 1-6, 1990 https://doi.org/10.1097/00005131-199003000-00001
  17. Judet R, Judet J, Letournel E : Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am 46 : 1615-1646, 1964 https://doi.org/10.2106/00004623-196446080-00001
  18. Linstrom NJ, Heiserman JE, Kortman KE, Crawford NR, Baek S, Anderson RL, et al. : Anatomical and biomechanical analyses of the unique and consistent locations of sacral insuffiency fractures. Spine (Phila Pa 1976) 34 : 309-315, 2009 https://doi.org/10.1097/BRS.0b013e318191ea01
  19. Longhino V, Bonora C, Sansone V : The management of sacral stress fractures: current concepts. Clin Cases Miner Bone Metab 8 : 19-23, 2011
  20. Lourie H : Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA 248 : 715-717, 1982 https://doi.org/10.1001/jama.1982.03330060055034
  21. Majo NM, Helms CA : Sacral stress fractures in long-distance runners. AJR Am J Roentgenol 174 : 727-729, 2000 https://doi.org/10.2214/ajr.174.3.1740727
  22. Richards AM, Coleman NW, Knight TA, Belkoff SM, Mears SC : Bone density and cortical thickness in normal, osteopenic, and osteoporotic sacra. J Osteoporos 2010 : 504078, 2010
  23. Rommens PM, Hofmann A : Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury 44 : 1733-1744, 2013 https://doi.org/10.1016/j.injury.2013.06.023
  24. Rommens PM, Wagner D, Hofmann A : Surgical management of osteoporotic pelvic fractures: a new challenge. Eur J Trauma Emerg Surg 38 : 499-509, 2012 https://doi.org/10.1007/s00068-012-0224-8
  25. Rousiere M, Kahan A, Job-Deslandre C : Postpartal sacral fracture without osteoporosis. Joint Bone Spine 68 : 71-73, 2001 https://doi.org/10.1016/S1297-319X(01)00262-7
  26. Roy-Camille R, Saillant G, Gagna G, Mazel C : Transverse fracture of the upper sacrum. Suicidal jumper's fracture. Spine (Phila Pa 1976) 10 : 838-845, 1985 https://doi.org/10.1097/00007632-198511000-00011
  27. Schindler OS, Watura R, Cobby M : Sacral insufficiency fractures. J Orthop Surg (Hong Kong) 15 : 339-346, 2007 https://doi.org/10.1177/230949900701500320
  28. Strange-Vognsen HH, Lebech A : An unusual type of fracture in the upper sacrum. J Orthop Trauma 5 : 200-203, 1991 https://doi.org/10.1097/00005131-199105020-00014
  29. Tile M : Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg 4 : 143-151, 1996 https://doi.org/10.5435/00124635-199605000-00004
  30. Totterman A, Glott T, Madsen JE, Roise O : Unstable sacral fractures: associated injuries and morbidity at 1 year. Spine (Phila Pa 1976) 31 : E628-E635, 2006 https://doi.org/10.1097/01.brs.0000231961.03527.00
  31. Weber M, Hasler P, Gerber H : Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine (Phila Pa 1976) 18 : 2507-2512, 1993 https://doi.org/10.1097/00007632-199312000-00021

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