AJR 2005; 184:1956-1959
© American Roentgen Ray Society
Percutaneous Sacroplasty for the Treatment of Sacral Insufficiency Fractures
Carina L. Butler1,
Curtis A. Given, II1,
Steven J. Michel1 and
Phillip A. Tibbs2
1 Department of Diagnostic Radiology, University of Kentucky Chandler Medical
Center, Rm. HX-311C, 800 Rose St., Lexington, KY 40536.
2 Department of Neurosurgery, University of Kentucky Chandler Medical Center
Lexington, KY.
Received July 15, 2004;
accepted after revision September 7, 2004.
Address correspondence to C. A. Given II
(cagive2{at}uky.edu).
Abstract
OBJECTIVE. The purpose of this article is to illustrate the
effectiveness and utility of percutaneous sacroplasty in the treatment of
sacral insufficiency fractures. We also outline the technical considerations
in performing the procedure.
CONCLUSION. Percutaneous sacroplasty is an effective treatment for
sacral insufficiency fractures. Most patients experience significant relief
within the first 48 hr.
Introduction
Sacral insufficiency fractures often are associated with severe,
debilitating pain. These fractures often are seen in patients similar to those
at risk for vertebral compression fractures, most commonly postmenopausal
women with osteoporosis. Additional risk factors include rheumatoid arthritis,
steroid therapy, previous hip replacement, and radiation therapy to the pelvis
[1]. Most sacral insufficiency
fractures heal with time; current medical therapy consists of bed rest and
pain management [1].
Percutaneous sacroplasty, a variation of percutaneous vertebroplasty, is an
alternative that may provide symptomatic relief and hasten recovery. Use of
percutaneous vertebroplasty to treat compression fractures secondary to
osteoporosis and other conditions can lessen or alleviate pain, provide
vertebral stabilization, and allow patients to become mobile more quickly than
can the use of medical therapy alone
[2]. Percutaneous sacroplasty
shows similar promise in the treatment of sacral insufficiency fractures
[3,
4]. We present a small series
of patients who had percutaneous sacroplasty for insufficiency fractures and
discuss the clinical results and technical considerations.
Subjects and Methods
From January 2003, to April 2004, six patients with sacral insufficiency
fractures had percutaneous sacroplasty (seven total treatments) at our
institution. The fractures were secondary to osteoporosis in four patients,
radiation necrosis in one patient, and multiple myeloma in one patient. The
patient with multiple myeloma received two treatments to the right sacrum
because cement distribution during the initial therapy was insufficient. All
patients were white women who ranged in age from 52 to 81 years (mean, 71
years).
All patients had MRI, technetium-99m methylene diphosphonate
(99mTc-MDP) bone scan, or both (Figs.
1A,
2A, and
2B). The images indicated the
presence of sacral insufficiency fracture, tumor involvement of the sacrum, or
a combination. Before the procedure, all patients had initial CT scans of the
pelvis, all of which showed insufficiency fractures. Conscious sedation was
achieved with IV midazolam and fentanyl citrate and local anesthesia, with 1%
lidocaine infiltration. Vital signs were monitored by the radiology nursing
staff. Under CT fluoroscopy guidance using a package available on a Somatom
Plus 4 helical scanner (Siemens Medical Solutions), 13-gauge trocar needles
(Parallax Medical) were placed into the sacrum. Attempts were made to place
two needles within each half (upper and lower positions) of the sacrum. In
several cases, however, only one needle could be placed into one side of the
sacrum because of needle "crowding," with apposition of the needle
hubs external to the patient. When possible, two needles were placed on the
side with the greatest pain or the side that appeared most abnormal on imaging
studies. In one patient, only one side of the sacrum was treated because
imaging of the contralateral side showed abnormalities and the pelvic pain was
unilateral.
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Fig. 1A. —71-year-old woman with history of cervical and colon cancer
and bedridden with pain and sacral insufficiency fracture secondary to
radiation necrosis (biopsy before treatment negative for tumor). Posterior
delayed image of pelvis from technetium-99m methylene diphosphonate bone scan
shows increased tracer uptake within sacrum, giving characteristic H shape
seen with bilateral sacral insufficiency fractures. Tracer uptake localizes
greater toward right side.
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Fig. 2A. —76-year-old woman with history of osteoporosis and severe
pelvic pain with sacral insufficiency fracture. Posterior delayed image of
pelvis from technetium-99m methylene diphosphonate bone scan shows increased
tracer uptake within sacrum and characteristic H sign of bilateral sacral
insufficiency fractures.
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Fig. 2B. —76-year-old woman with history of osteoporosis and severe
pelvic pain with sacral insufficiency fracture. Axial T1-weighted MR image
(TR/TE, 550/15) shows edema within bilateral sacrum (arrows)
consistent with sacral insufficiency fractures.
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Fig. 1B. —71-year-old woman with history of cervical and colon cancer
and bedridden with pain and sacral insufficiency fracture secondary to
radiation necrosis (biopsy before treatment negative for tumor). Axial CT
fluoroscopy image with patient in prone position shows proper placement of
trocar needle (arrow) within right sacrum, avoiding sacroiliac joint
and sacral foramina (arrowhead).
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Fig. 1C. —71-year-old woman with history of cervical and colon cancer
and bedridden with pain and sacral insufficiency fracture secondary to
radiation necrosis (biopsy before treatment negative for tumor).
Posteroanterior radiograph of sacrum after injection of polymethylmethacrylate
(PMMA) solution. PMMA fills bilateral sacrum in expected trabecular pattern,
with more PMMA distributed toward right side.
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Fig. 1D. —71-year-old woman with history of cervical and colon cancer
and bedridden with pain and sacral insufficiency fracture secondary to
radiation necrosis (biopsy before treatment negative for tumor). Axial CT
image after sacroplasty shows PMMA filling bilateral marrow spaces of
sacrum.
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Fig. 1E. —71-year-old woman with history of cervical and colon cancer
and bedridden with pain and sacral insufficiency fracture secondary to
radiation necrosis (biopsy before treatment negative for tumor). Anterior
maximum-intensity projection-reformatted CT image after sacroplasty shows PMMA
filling bilateral marrow spaces of sacrum.
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Under CT fluoroscopy guidance, near real-time positioning of the trocar
needle within the marrow cavity of the sacrum, midway between the sacroiliac
joint and the sacral foramina, was achieved (Figs.
1B and
2C). Five of the six patients
were then transferred in the prone position on a stretcher to the angiography
suite, where the remainder of the procedure was performed using single-plane
fluoroscopy (Fig. 2D). CT
guidance allowed precise needle positioning within the central portion of the
sacrum, minimizing the risk for cement extrusion into the soft tissues and
obviating venography and biplane fluoroscopy during injection of the cement.
Similar to the vertebroplasty technique
[3], polymethylmethacrylate
(PMMA) was mixed with sterile barium (Tracers, Parallax Medical) and injected
through the indwelling trocar needles. Under fluoroscopy, approximately 4-8 mL
of the PMMA solution was placed in each side of the sacrum through the trocar
needles. The PMMA filled the marrow space in the expected trabecular pattern
(Figs. 1C and
2E). The weight of one patient
exceeded the weight capacity of our angiography tables. In this case, the
cement was injected under CT fluoroscopy with the patient on the CT table.
After the procedure, a CT scan of the pelvis confirmed the PMMA solution was
properly placed within the marrow space of the sacrum (Figs.
1D,
1E,
2F, and 2G).
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Fig. 2C. —76-year-old woman with history of osteoporosis and severe
pelvic pain with sacral insufficiency fracture. Axial CT fluoroscopy image
with patient in prone position shows proper placement of trocar needle
(arrow) within right sacrum. The patient had complicating chronic
right iliac wing fracture (arrowhead).
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Fig. 2D. —76-year-old woman with history of osteoporosis and severe
pelvic pain with sacral insufficiency fracture. Posteroanterior radiograph of
sacrum after placement of four 13-gauge trocar needles within sacrum.
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Fig. 2E. —76-year-old woman with history of osteoporosis and severe
pelvic pain with sacral insufficiency fracture. Posteroanterior radiograph of
sacrum after injection of polymethylmethacrylate (PMMA) solution shows PMMA
filling sacrum in expected trabecular pattern.
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Fig. 2F. —76-year-old woman with history of osteoporosis and severe
pelvic pain with sacral insufficiency fracture. Axial CT image (through
superior sacrum) after sacroplasty illustrates PMMA (arrows) filling
marrow space of sacrum.
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All patients were assessed for relief of pain 2 days after the procedure
and were followed for 2-8 weeks. At each follow-up, the patients were asked to
grade their pain as unchanged, mildly improved, significantly improved, or
completely resolved.
Results
Technical success with adequate distribution of cement throughout the
marrow spaces of the sacrum on imaging was achieved in five (83%) of the six
patients, with technical success achieved in the sixth patient after a second
treatment. Three patients (50%) reported at least mild relief pain within 2
days after the sacroplasty, and four (66%) reported significant or complete
relief of pain/symptoms at least 2 weeks after the treatment. Five patients
(83%) experienced at least a mild degree of pain relief at least 2 weeks after
the procedure. The sacroplasty was effective (four of five patients) in
significantly reducing or eliminating pain in patients with insufficiency
fractures attributable to osteoporosis or radiation necrosis. The patient with
multiple myeloma reported only mild pain relief 2 weeks after the treatment.
No patient had worse symptoms after the procedure, and none of the neural
foramina was compromised by the PMMA solution. Minimal venous intravasation of
the PMMA occurred in one patient and a small amount of extension into the
sacroiliac joint in another patient; neither event was clinically
significant.
Discussion
Percutaneous sacroplasty is an attractive alternative to traditional
medical therapy for sacral insufficiency fractures. Few case reports or series
of sacroplasty have been published
[3,
4]. To our knowledge, there is
only one previous description of sacroplasty performed using CT guidance
[4]. Similar to the authors of
these case reports [3,
4], we believe that accurate
needle placement within the sacrum can be challenging under fluoroscopic
guidance, often because of difficulty assessing needle depth or positioning
relative to the sacral foramina. In our experience, the axial images provide
improved visualization of the sacral foramen and the sacroiliac joints,
permitting more precise needle placement within the central portions of the
sacrum and away from the cortical margin. Also, with CT fluoroscopy, needle
depth and trajectory into the marrow cavity are easily determined and easily
manipulated. Improved visualization should reduce the risk for inappropriate
needle placement into the sacral foramen, the sacroiliac joints, or adjacent
soft tissues. As in our cases, the precise needle placement afforded by CT
guidance avoids placing the needle near the cortical margin and minimizes the
risk for soft-tissue extrusion of the cement, possibly eliminating the need
for confirmatory venography
[4]. Continuous fluoroscopic
surveillance to assess for venous extension remains necessary during the
cement injection. CT guidance also may enhance operator confidence during the
procedure and permit extrusion of larger volumes of PMMA into the sacrum,
potentially improving the clinical outcome. In our experience, it is better to
assess cement extrusion during injection with conventional fluoroscopy (rather
than CT fluoroscopy), because the cement mixture usually distributes
preferentially in the craniocaudal and lateral directions away from the needle
tip. For these reasons, attempting to follow the cement extrusion with CT
fluoroscopy is cumbersome and suboptimal. Combined CT (with fluoroscopy) and
conventional fluoroscopy units would provide the optimal setting for
percutaneous sacroplasty procedures.
Our results agree with those in previous case reports
[3,
4] and illustrate the
effectiveness of sacroplasty in the treatment of sacral insufficiency
fractures. Treatment of the one patient with osteoporosis who failed to
respond to sacroplasty was likely complicated by an unknown insufficiency
(stress) fracture of the femoral shaft, a fracture that completed 1 day after
the procedure. Most patients experienced pain relief within the first 48 hr
after treatment, indicating that the relief was a direct result of the
sacroplasty rather than the natural healing process of the fracture.
Potential complications of sacroplasty include venous intravasation with
pulmonary embolism, infection, and extension into and compromise of the neural
foramina. We believe, as do authors of previous reports
[4], that the use of CT
guidance for needle placement will reduce the complication rate and likely
improve clinical outcomes. In conclusion, percutaneous sacroplasty is a
promising alternative to conventional medical therapy alone in patients with
sacral insufficiency fractures, with early reports suggesting high efficacy
and low complication rates.
References
- De Smet AA, Neff JR. Pubic and sacral insufficiency fractures:
clinical course and radiologic findings. AJR1985; 145:601
-606[Abstract/Free Full Text]
- Jensen ME. Percutaneous vertebroplasty: a new therapy for the
treatment of painful vertebral body compression fractures. Appl
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- Garant M. Sacroplasty: a new treatment for sacral insufficiency
fracture. J Vasc Interv Radiol2002; 13:1265
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- Pommersheim W, Huang-Hellinger F, Baker M, Morris P. Sacroplasty: a
treatment for sacral insufficiency fractures. Am J
Neuroradiol 2003;24:1003
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Abstract
Introduction
