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We greatly appreciate the comments of Drs. Tsiridis and Giannoudis with regard to our article [1] about the utility of percutaneous sacroplasty in the treatment of patients with sacral insufficiency fractures. Although traditional management of sacral insufficiency fractures involves immobilization, some authors have advocated early mobilization of patients in an attempt to reduce known complications such as deep venous thrombosis and pulmonary embolism, decline in muscle strength, and pneumonia [2, 3]. In contrary to Tsiridis and Giannoudis' suggestion of immobilization for 1-2 months, one of our goals with the sacroplasty procedure (in addition to pain relief) was to permit early mobilization and restore patient independence. Because most sacral insufficiency fractures are stable, we choose to allow patients to return to daily activities as tolerated, thereby reducing the complications of immobilization. Although admittedly the initial follow-up period was rather short, we are pleased to report that follow-up of at least 1 year is available in most of the patients, with the patients reporting either a stable condition or further improvement. None of the patients has reported worsening of symptoms.

Although pain is an extremely subjective way to assess treatment response, it was the chief complaint of all patients. Thus, the goals of the sacroplasty procedures in our subset of patients focused on pain relief and improving quality of life (e.g., early mobilization, restoration of independence). Deen and Nottmeier [4] reported a small case series of patients undergoing balloon kyphoplasty, a variation of sacroplasty, in which the therapeutic effect of the procedure was validated by improvement in patients' scores on a visual analogue pain scale and a reduction in analgesic consumption, both of which are less subjective methods of validation, as suggested by Tsiridis and Giannoudis. Certainly, future prospective trials, possibly comparing conservative management and screw fixation, should incorporate these less subjective measures. Other case reports and small case series [5-7] have shown similar results with regard to pain relief, patient satisfaction, and improvement in quality of life.

Most of the patients in our case series had failed to benefit from conservative medical management. All patients were referred from or their case was discussed with experienced spine neurosurgeons or orthopedic surgeons before the procedure was performed in an attempt to determine the best therapeutic option for each individual patient. Although the exact mechanism for pain relief after a sacroplasty procedure is not clearly established, some authors have postulated that stabilization of the fracture with subsequent reduction in micro-motion accounts for the therapeutic effect [5, 7].

With regard to Tsiridis and Giannoudis' concern of impaired fracture healing by the deposition of cement at the fracture site, we merely point out that chronic nonunion (and thus impaired healing) of the fractures was present in our patients and thought to be a contributing factor to their symptoms. Nonunion at the fracture site is not a rare finding in patients with chronic pain from sacral insufficiency fractures.

Sacroplasty, as a procedure, is still in the infancy stage with numerous technical variations already described [1, 4-7]. Preliminary data suggest that sacroplasty is a safe procedure (we are aware of no reported symptomatic complications) with promising results with regard to pain relief, early mobilization, and improvement in quality of life. Although sacroplasty may not be the ideal procedure for all patients with sacral insufficiency fractures, it should be considered as a therapeutic option along with conservative medical management and screw fixation.