Download PDF
Osteologie 2012; 21(03): 168-173
DOI: 10.1055/s-0037-1621680
Osteoplasty of the spine
Schattauer GmbH

Treatment of Denis 1, 2 and 3 insufficiency fracture zones of the os sacrum

Individual approaches adapted to the course of the fracture in CT-assisted balloon sacroplastyVersorgung von Denis-1-, -2- und -3-Insuffizienzfrakturzonen des Os sacrumIndividuelle dem Frakturverlauf angepasste Zugangswege bei der CT-gesteuerten Ballon-Sakroplastie zur
R. Andresen
1   Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide/Germany
,
S. Radmer
2   Center of Orthopedics, Berlin
,
P. Kamusella
1   Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide/Germany
,
C. Wissgott
1   Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide/Germany
,
J. Banzer
3   Radiology, Charité University Berlin, Campus Benjamin Franklin, Berlin/Germany
,
H.-C. Schober
4   Department of Internal Medicine, Municipal Hospital Suedstadt Rostock, Academic Teaching Hospital of the University of Rostock/Germany
› Author Affiliations
Further Information

Publication History

received: 18 August 2012

accepted: 22 August 2012

Publication Date:
04 January 2018 (online)

    Permissions and Reprints

Zusammenfassung

Beiälteren Patienten mit reduzierter Knochenqualität sind Insuffizienzfrakturen des Os sacrum relativ häufig und typischerweise mit starken, invalidisierenden Schmerzen verbunden. Ziel unserer Studie war die Durchführbarkeit der Zementaugmentation mittels Ballonkatheterüber individuelle, die komplexe Anatomie des Os sacrum und die Ausrichtung des Frakturgeschehens berücksichtigende Zugangswege sowie die postinterventionelle Erfassung von Leckagen und Darstellung des klinischen Outcomes. Bei 40 Patienten mit schwerer Osteoporose (24 Frauen mit einem Durchschnittsalter von 74,4 Jahren, 16 Männer mit einem Durchschnittsalter von 69,7 Jahren) wurde im CT und MRT eine Ossacrum-Fraktur detektiert. Bei 17 Frauen und neun Männern war diese Fraktur unilateral, bei sieben Frauen und sieben Männern bilateral. Die Frakturen wurden nach Denis eingeteilt. Um eine Zementverteilung in Längsrich-tung zur Fraktur zu erreichen, wurde der Ballonkatheterüber eine Hohlnadel in das Os sacrum entweder von dorsal nach ventral, von caudal nach cranial oder von lateral nach medial transiliacal eingebracht. Der Ballonkatheter wurde daraufhin entlang der Fraktur in der entsprechenden Richtung einbis dreimal in-und deflatiert. Der dadurch geschaffene Hohlraum wurde dann mit PMMA-Zement im Niederdruckverfahren aufgefüllt. Anschließend erfolgte eine konventionelle Röntgenaufnahme in zwei Ebenen sowie ein Kontroll-CT. Die Schmerzintensität wurde prä interventionem, am zweiten Tag sowie sechs und zwölf Monate post interventionem mittels visueller Analogskala (VAS) bestimmt. Zusätzlich wurde die Patientenzufriedenheit nach zwölf Monaten abgefragt. Bei allen Patienten ließ sich die Ballon-Sakroplastie technisch gut anwenden. In der Röntgen-und CT-Kontrolle fand sich im Os sacrum entlang der Frakturausdehnung eine ausreichende Zementverteilung, wobei eine Leckage ausgeschlossen werden konnte. Der Mittelwert für Schmerzen lag nach VAS vor Intervention bei 8,9, die Patienten mit einer Denis-2-Fraktur hatten tendenziell die stärksten Schmerzen. Am zweiten postoperativen Tag zeigte sich eine signifikante Schmerzreduktion (p < 0,001) mit einem Durchschnittswert von 2,7; dieser war mit 2,5 nach sechs Monaten und mit 2,3 nach zwölf Monaten stabil. Nach zwölf Monaten fand sich eine hohe Patientenzufriedenheit. Zugangswege, welche die Anatomie des Os sacrum und die Frakturausrichtung im Os sacrum berücksichtigen, erlauben eine mengenoptimierte und sichere Zementaugmentation. Die Ballon-Sakroplastie wird hierdurch zu einer effektiven, komplikationsarmen Behandlungsmethode zur schnellen und signifikanten Schmerzreduktion bei Patienten mit einer Os-sacrum-Fraktur.

Summary

In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically associated with severe and debilitating pain. The objective of our study was to determine the practicability of cement augmentation using a balloon catheter via individual approaches taking into consideration the complex anatomy of the sacrum and the course of the fracture, as well as the post-interventional determination of leakages and representation of the clinical outcome. In 40 patients with severe osteoporosis (24 women with an average age of 74.4 years, 16 men with an average age of 69.7 years), a sacral fracture was detected by CT and MRI. This fracture was unilateral in 17 women and 9 men and bilateral in 7 women and 7 men. The fractures were classified according to Denis. In order to achieve a cement distribution longitudinally in relation to the fracture, the balloon catheter was inserted into the sacrum via a hollow needle either from dorsal to ventral, from caudal to cranial, or from lateral to medial using the transiliac approach. The balloon catheter was then inflated and deflated 1–3 times along the fracture in the respective direction, and the hollow space created was then filled with PMMA cement using a low-pressure procedure. A conventional radiograph in two planes and a control CT were then performed. Pain intensity was determined pre-intervention, on the 2nd day post-intervention and 6 and 12 months post-intervention, using a visual analogue scale (VAS). In addition, the patients were asked to state how satisfied they were after 12 months. The balloon sacroplasty was performed successfully from a technical point of view in all patients. The radiographic and CT control showed sufficient cement distribution in the sacrum along the course of the fracture, whereby leakage could be ruled out. According to the VAS, the mean pain score was 8.9 before the intervention, while the patients with a Denis 2 fracture tended to have the strongest pain. There was a significant reduction in pain on the 2nd postoperative day, with an average value of 2.7 (p < 0.001), which was stable at 2.5 after 6 months and 2.3 after 12 months. A high level of patient satisfaction was found after 12 months. Approaches that take into account the anatomy of the sacrum and the course of the sacral fracture enable reliable augmentation with an optimum amount of cement. This makes balloon sacroplasty an effective treatment that has few complications, for rapid and significant pain reduction in patients with a sacral fracture.

Schlüsselwörter

Ballon-Sakroplastie - Insuffizienzfraktur - Ossacrum-Fraktur - Schmerztherapie - Zementaugmentation

Keywords

Balloon sacroplasty - insufficiency fracture - sacral fracture - pain therapy - cement augmentation
 

  • References

  • 1 Lourie H. Spontaneous osteoporotic fracture of the sacrum. An unrecognised syndrome of the elderly. JAMA 1982; 248 (06) 715-717.
    CrossrefPubMedGoogle Scholar
  • 2 Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthopaedic Surg 2007; 15 (03) 339-346.
    Google Scholar
  • 3 De Smet AA, Neffxy JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 1985; 145 (03) 601-606.
    CrossrefPubMedGoogle Scholar
  • 4 Grasland A, Pouchot J, Mathieu A. et al. Sacral insufficiency fractures: an easily overlooked cause of back pain in elderly women. Arch Intern Med 1996; 156 (06) 668-674.
    CrossrefPubMedGoogle Scholar
  • 5 West SG, Troutner JL, Baker MR. et al. Sacral insufficiency fractures in rheumatoid arthritis. Spine 1994; 19 (18) 2117-2121.
    CrossrefPubMedGoogle Scholar
  • 6 Lin J, Lachmann E, Nagler W. Sacral insufficiency fractures: a report of two cases and a review of the Literature. J Womens Health Gend Based Med 2001; 10 (07) 699-705.
    CrossrefPubMedGoogle Scholar
  • 7 Dasgupta B, Shah N, Brown H. et al. Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 1998; 37 (07) 789-793.
    CrossrefPubMedGoogle Scholar
  • 8 Gotis-Graham I, McGuigam L, Diamond T. et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 1994; 76 (06) 882-886.
    PubMedGoogle Scholar
  • 9 Fujii M, Abe K, Hayashi K. et al. Honda sign and variants in patients suspected of having a sacral insufficiency fracture. Clin Nucl Med 2005; 30 (03) 165-169.
    CrossrefPubMedGoogle Scholar
  • 10 Peh WC, Khong PL, Ho WY. et al. Imaging of pelvic insufficiency fractures. Radiographics 1996; 16 (02) 335-348.
    CrossrefPubMedGoogle Scholar
  • 11 Cabarrus NC, Ambekar A, Lu Y. et al. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol 2008; 191 (04) 995-1001.
    CrossrefPubMedGoogle Scholar
  • 12 Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227: 67-81.
    CrossrefPubMedGoogle Scholar
  • 13 Babayev M, Lachmann E, Nagler W. The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate?. Am J Phys Med Rehabil 2000; 79 (04) 404-409.
    CrossrefPubMedGoogle Scholar
  • 14 Lin JT, Lane JM. Sacral stress fractures. J Womens Health 2003; 12 (09) 879-888.
    CrossrefPubMedGoogle Scholar
  • 15 Routt Jr ML, Simonian PT. Closed reduction and percutaneous skeletal fixation of sacral fractures. Clin Orthop Relat Res 1996; 329: 121-128.
    CrossrefPubMedGoogle Scholar
  • 16 Butler CL, Given 2nd CA, Michel SJ. et al. Percutaneous sacroplasty for the treatment of sacral insufficiency fractures. AJR Am J Roentgenol 2005; 184 (06) 1956-1959.
    CrossrefPubMedGoogle Scholar
  • 17 Cho CH, Mathis JM, Ortiz O. Sacral fractures and sacroplasty. Neuroimaging Clin N Am 2010; 20 (02) 179-186.
    CrossrefPubMedGoogle Scholar
  • 18 Frey ME, DePalme MJ, Cifu DX. et al. Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine 2008; 8 (02) 367-373.
    CrossrefPubMedGoogle Scholar
  • 19 Pommersheim W, Huang-Hellinger F, Baker M. et al. Sacroplasty: a treatment for sacral insufficiency fractures. AJNR Am J Neuroradiol 2003; 24 (05) 1003-1007.
    PubMedGoogle Scholar
  • 20 Whitlow CT, Mussat-Whitlow BJ, Mattern CWT. et al. Sacroplasty versus vertebroplasty: comparable clinical outcomes for the treatment of fracture-related pain. AJNR Am J Neuroradiol 2007; 28 (07) 1266-1270.
    CrossrefPubMedGoogle Scholar
  • 21 Garant M. Sacroplasty: a new treatment for sacral insufficiency fracture. J Vasc Interv Radiol 2002; 13 (12) 1265-1267.
    CrossrefPubMedGoogle Scholar
  • 22 Heron J, Connell DA, James SL. CT-guided sacroplasty for the treatment of sacral insufficiency fractures. Clin Radiol 2007; 62 (11) 1094-1100.
    CrossrefPubMedGoogle Scholar
  • 23 Heß GM. Sacroplasty for the treatment of sacral insufficiency fractures. Unfallchirurg 2006; 109 (08) 681-686.
    CrossrefPubMedGoogle Scholar
  • 24 Lyders EM, Whitlow CT, Baker MD. et al. Imaging and treatment of sacral insufficiency fractures. AJNR Am J Neuroradiol 2010; 31 (02) 201-210.
    CrossrefPubMedGoogle Scholar
  • 25 Bastian JD, Keel MJ, Heini PF. et al. Complications related to cement leakage in sacroplasty. Acta Orthop Belg 2012; 78 (01) 100-105.
    PubMedGoogle Scholar
  • 26 Deen HG, Nottmeier EW. Balloon kyphoplasty for treatment of sacral insufficiency fractures. Report of three cases. Neurosurg Focus 2005; 18 (03) 1-5.
    PubMedGoogle Scholar
  • 27 Shah RV. Sacral kyphoplasty for the treatment of painful sacral insufficiency fractures and metastases. Spine J 2012; 12 (02) 113-120.
    CrossrefPubMedGoogle Scholar
  • 28 Andresen R, Radmer S, Kamusella P. et al. Interventional pain relief using Balloon-Kyphoplasty in patients with osteoporotic-based fatigue fractures of the os sacrum. Fortschr Röntgenstr 2012; 184 (01) 32-36.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 DVO Guideline 2009 for Prevention, Diagnosis and Therapy of Osteoporosis in Adults. Osteologie 2011; 20 (01) 55-74.
    Article in Thieme ConnectGoogle Scholar
  • 30 Smith DK, Dix JE. Percutaneous sacroplasty: long axis injection technique. AJR Am J Roentgenol 2006; 186 (05) 1252-1255.
    CrossrefPubMedGoogle Scholar
  • 31 Strub WM, Hoffmann M, Ernst RJ. et al. Sacroplasty by CT and fluoroscopic guidance: is the procedure right for your patient?. AJNR Am J Neuroradiol 2007; 28 (01) 38-41.
    PubMedGoogle Scholar
  • 32 Kamel EM, Binaghi S, Guntern D. et al. Outcome of long-axis percutaneous sacroplasty for the treatment of sacral insufficiency fractures. Eur Radiol 2009; 19 (12) 3002-3007.
    CrossrefPubMedGoogle Scholar
  • 33 Sciubba DM, Wolinsky JP, Than KD. et al. CT fluoroscopically guided percutaneous placement of transiliosacral rod for sacral insufficiency fracture: case report and technique. AJNR Am J Neuroradiol 2007; 28 (08) 1451-1454.
    CrossrefPubMedGoogle Scholar
  • 34 Andresen R, Radmer S, Banzer D. Bone mineral density and spongiosa architecture in correlation to vertebral body insufficiency fractures. Acta Radiol 1998; 39 (05) 538-542.
    CrossrefPubMedGoogle Scholar
  • 35 Trouvin AP, Alcaix D, Somon T. et al. Analgesic effect of sacroplasty in osteoporotic sacral fractures: A study of six cases. Joint Bone Spine. 2012 [Epub ahead of print].
    PubMedGoogle Scholar
  • 36 Pohlmann T, Tscherne H. Fixation of sacral fractures. Tech Orthop 1995; 9: 315-326.
    Google Scholar
  • 37 Mehling I, Hessmann MH, Rommens PM. Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome. Injury 2012; 43 (04) 446-451.
    CrossrefPubMedGoogle Scholar
  • 38 Garfin SR, Yuan HA, Riley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 2001; 26: 1511-1515.
    CrossrefPubMedGoogle Scholar
  • 39 Kortman K, Ortiz O, Miller T. et al. Multicenter study to assess the efficacy and safety of sacroplasty in patients with osteoporotic sacral insufficiency fractures or pathologic sacral lesions. J Neurointerv Surg. 2012 June 8 [Epub ahead of print]
    PubMedGoogle Scholar
  • 40 Bayley E, Srinivas S, Boszczyk BM. Clinical outcomes of sacroplasty in sacral insufficiency fractures: a review of the Literature. Eur Spine J 2009; 18 (09) 1266-1271.
    CrossrefPubMedGoogle Scholar
  • 41 Dehdashti AR, Martin JB, Jean B. et al. PMMA cementoplasty in symptomatic metastatic lesions of the S1 vertebral body. Cardiovasc Intervent Radiol 2000; 23 (03) 235-237.
    CrossrefPubMedGoogle Scholar
  • 42 Lüdtke CW, Kamusella P, Andresen R. Pain management in pathologic sacrum fracture with CT guided balloon sacral vertebroplasty. Fortschr Röntgenstr 2012; 184 (06) 578-580.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Georgy BA. Percutaneous cement augmentations of malignant lesions of the sacrum and pelvis. AJNR Am J Neuroradiol 2009; 30 (07) 1357-1359.
    CrossrefPubMedGoogle Scholar
  • 44 Whitlow CT, Yazdani SK, Reedy ML. et al. Investigating sacroplasty: technical considerations and finite element analysis of polymethylmethacralate infusion into cadaveric sacrum. AJNR Am J Neuroradiol 2007; 28 (06) 1036-1041.
    CrossrefPubMedGoogle Scholar
  • 45 Anderson DE, Cotton JR. Mechanical analysis of percutaneous sacroplasty using CT image based finite element model. Med Eng Phys 2007; 29 (03) 316-325.
    CrossrefPubMedGoogle Scholar
  • 46 Grossterlinden L, Begemann PGC, Lehmann W. et al. Sacroplasty in a cadaveric trial: comparison of CT and fluoroscopic guidance with and without ballon assistance. Eur Spine J 2009; 18 (08) 1226-1233.
    CrossrefPubMedGoogle Scholar
  • 47 Binaghi S, Guntern D, Schnyder P. et al. A new, easy, fast, and safe method for CT-guided sacroplasty. Eur Radiol 2006; 16 (12) 2875-2878.
    CrossrefPubMedGoogle Scholar
  • 48 Gjertsen O, Schellhorn T, Nakstad PH. Fluoroscopy-guided sacroplasty: special focus on preoperative planning from three-dimensional computed tomography. Acta Radiol 2008; 49 (09) 1042-1048.
    CrossrefPubMedGoogle Scholar
  • 49 Briem D, Grossterlinden L, Begemann PG. et al. CTguided balloon-assisted sacroplasty. Preliminary results of a feasibility study. Unfallchirurg 2008; 111 (06) 381-386.
    CrossrefPubMedGoogle Scholar
  • 50 Layton KF, Thielen KR, Wald JT. Percutaneous sacroplasty using CT fluoroscopy. AJNR Am J Neuroradiol 2006; 27 (02) 356-358.
    PubMedGoogle Scholar