Sacroplasty by CT and fluoroscopic guidance: is the procedure right for your patient?

Abstract

Background and purpose: Sacral insufficiency fractures are an infrequent but often disabling cause of severe low back pain. We report our results of a sacroplasty technique, using CT for needle placement and fluoroscopy to monitor the polymethylmethacrylate injection in a group of patients with sacral insufficiency fractures.

Methods: All patients had a history of chronic back pain and had an osteoporotic sacral insufficiency fracture documented by imaging before the procedure. With the patient under conscious sedation, a bone biopsy needle was placed under CT guidance; the patient was then transferred to the fluoroscopy suite, where a polymethylmethacrylate mixture was injected into the sacrum under real-time fluoroscopy. Clinical outcome was assessed by telephone.

Results: The procedure was performed on 13 female patients with an average age of 76 years (range, 60-88 years). A bilateral procedure was performed in 11 patients and a unilateral procedure was performed in 2 patients. An average of 4.1 mL of cement was injected for each treatment. There were no instances of cement extravasation into the central canal or sacral foramina. Long-term follow-up, averaging 15 months, was available in 6 patients. Five patients (83%) reported no symptoms of pain at all. The final patient, in whom a bilateral procedure was performed, was completely asymptomatic on the left side but reported persistent unilateral pain on the right.

Conclusion: Sacroplasty is a safe and effective procedure in the treatment of sacral insufficiency fractures that can provide substantial pain relief and lead to a better quality of life.

Fig 1.

CT images from needle placement in 2 different patients with sacral insufficiency fractures illustrating the possible orientation for the bone biopsy needle(s) in the sacrum. A, Axial image showing vertical orientation of the bone biopsy needles in a patient with bilateral fractures. B. Axial image showing an oblique orientation, paralleling the sacroiliac joint of the bone biopsy needle, in a patient with a unilateral fracture.

Fig 2.

Fluoroscopic spot films taken during the PMMA injection in a 65-year-old woman with bilateral sacral insufficiency fractures. A, Frontal projection allows for monitoring of extravasation into the sacral foramina. B, Lateral projection allows for monitoring for any cement extravasation into the soft tissues.