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Iwate Medical University School of Medicine Morioka 020-8505, Japan
In a recent issue of the AJR, Dr. Butler and colleagues [1] reported the use of percutaneous sacroplasty for the treatment of sacral insufficiency fracture secondary to osteoporosis (four cases), radiation necrosis (one patient), and multiple myeloma (one patient).
This procedure may be used to treat an insufficiency fracture with either a delayed union or prolonged severe pain. However, as Butler et al. [1] pointed out, the prognosis for patients with a sacral insufficiency fracture due to osteoporosis is generally good and patients respond well to conservative therapy [2, 3]. The injection of polymethylmethacrylate cement into the fracture cleft may contribute to temporary pain relief, but the cement also inhibits osseous fracture union, which usually occurs only with conservative therapy.
Fractures with a poor clinical outcome using conservative therapy, including those caused by pseudoarthrosis or osteonecrosis and pathologic fractures, are good indications for this procedure, but I wonder when this procedure should be performed in the patient with an osteoporotic insufficiency fracture.
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University of Kentucky Chandler Medical Center Lexington, KY 40536
Traditional management of sacral insufficiency fractures, including those related to osteoporosis, emphasizes pain control and bed rest [1, 2]. Prolonged immobilization of an elderly patient, those most frequently afflicted with osteoporosis, poses several potential risks and complications. Deep venous thrombosis is one of the most feared complications, occurring in as many as 61% of patients with pelvic fractures [1]. Early mobilization of patients with pelvic fractures, including sacral insufficiency fractures, decreases the risk of venous thrombosis and subsequently the risk of life-threatening pulmonary embolus [1]. Other risks associated with immobilization include pneumonia, urinary tract infections, pressure ulcers, and so on.
Preliminary results from sacroplasty procedures show effective pain relief in most patients—including those with osteoporotic fractures, thereby permitting earlier ambulation [2-4]. The therapeutic effect of sacroplasty is thought to be similar to that of vertebroplasty and the result of fracture stabilization, the thermal effects of the cement mixture, or both [2, 5].
We do not wish to attempt to quantify the financial burden of sacral insufficiency fractures on the health care system except to point out that Taillandier et al. [6] reported an average hospital stay of 45 days in 60 patients with pelvic insufficiency fractures. The average stay was even longer in the subset of patients with sacral insufficiency fractures. Sacroplasty offers earlier pain control and mobilization, with an expectant reduction in hospital stay.
We appreciate Dr. Ehara's comments about our article [3], and we agree that, as with vertebral compression fractures, the initial treatment for osteoporotic sacral insufficiency fractures remains conservative therapy. But how long is an elderly patient expected to remain on bed rest with intractable pain? Sacral insufficiency fractures may take as long as 12 months to heal [5]. The elderly osteoporotic patient already has a limited life expectancy and is more likely to develop the aforementioned complications. The effectiveness of sacroplasty in relieving pain and permitting earlier patient mobilization has been shown, and sacroplasty is associated with little risk of complication [2-5]. As a result, we think that the threshold to refer patients who are refractory to conservative management for sacroplasty will continue to decrease over time. Some clinicians no longer require failure of conservative management before performing vertebroplasty procedures [7], rendering it the initial treatment for some vertebral fractures. There may be a similar role for sacroplasty in the future, with it being offered as initial therapy for sacral insufficiency fractures.
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