Trans-iliac-sacral-iliac-bar procedure to treat insufficiency fractures of the sacrum

Abstract

Background: Osteoporosis is an increasing problem attributed to the greater longevity of the population and the incidence of fractures related to osteoporosis. The presence of osteoporotic bone, comorbidities, and functional status of the patient require adequate solutions to improve the clinical outcome of sacral insufficiency fractures. Conservative treatment by means of prolonged bed rest and analgesics are associated with increased risks and complications. A sacroplasty significantly improves the functional outcome. We describe the trans-iliac-sacral-iliac-bar (TISIB) procedure and our clinical experience to treat insufficiency fractures of the sacrum.

Materials and methods: The records of 19 consecutive patients with a mean age of 71.7 years (range: 57-82 years) who had been managed with a TISIB procedure from 2005 till 2007 were reviewed retrospectively. There were 15 females and 4 males. Predisposing factors for sacral insufficiency fractures were osteoporosis (n = 12, 63%), radiotherapy (n = 6, 32%), and rheumatoid arthritis (n =1). Diagnosis with a mean delay of 3.7 months was mainly made by CT. All patients were preoperatively and at follow-up assessed by means of the visual analogue score (VAS), analgesic consumption, and the ability to perform activities of daily living (ADLs) using a 5-point pain scale: 1, without pain; 2, mild pain; 3, moderate pain; 4, severe pain and, 5 unable to perform ADLs because of pain.

Results: The average duration of postoperative follow-up was 9 months (range: 3-24.5 months). No neurological complications occurred during the surgery. A postoperative radiographic study showed a well-positioned bar in every case. The mean VAS improved 44.7 mm (preoperative: 67.8; at follow-up: 23.2). Fifteen patients (79%) consumed narcotic analgesics before surgery, and only one (5%) at follow-up; two patients (10%) consumed NSAIDS before surgery and three (15%) after. Two patients (10%) consumed minor analgesics before, and 11 (58%) after the procedure. Finally, four patients (21%) were not taking any analgesics at follow-up. Before surgery, 9 patients (47%) were able to perform ADLs with a pain score of 4; 6 (32%) with a score of 3, and 4 (21%) a score of 2. At follow-up 1 (5%) did have a score of 4; 1 (5%) a score of 3, 8 (42%) a score of 2 and 9 (47%) a pain score of 1.

Conclusion: A TISIB PROCEDURE RELIES ON THE PRINCIPLES OF FRACTURE TREATMENT: fracture stabilisation and compression. The incapacitating problem of an insufficiency fracture of the sacrum can be elegantly solved by means of this minimally invasive procedure. A near-immediate improvement is noticed when looking at the VAS score, analgesics consumption, and the ability to perform ADLs.

Keywords: Elderly; bar; fracture; insufficiency; minimally invasive; osteoporosis; sacrum.

Figure 1

StealthStation™, Treatment Guidance Platform. Tri-axial reformats (coronal, sagittal and axial anatomical planes) and a three-dimensional reconstruction are displayed. The optimal Iliac-sacral-iliac path (white bar) is indicated, diameter 5.5mm. According to the preoperative plan, a path can be drilled using the Sure Track (blue)

Figure 2

TISIB procedure with fluoroscopic guidance. In prone position, a lateral view is obtained to mark the entry point at the level of the skin and bone (a) An iliac-sacral-iliac path is progressively drilled under control of inlet (b) and outlet views (c) of the pelvis

Figure 3

76 years old women with complaint of incapacitating low back pain radiating to the left lower extremity (S1 topography). Plain radiographs were unhelpful to make a diagnosis (a). An axial CT scan with coronal and sagittal reconstructions showed bilateral insufficiency fractures of the sacrum (b). A bone scan using 99mTc-MDP tracer showed an increased uptake at the level of both sacro-iliac joints (c). A TISIB-procedure has been performed since the insufficiency fractures occurred bilaterally (d). A postoperative CT scan with axial reconstructions showed a well-positioned bar at the level of S1 (e). A postoperative CT scan with coronal reconstructions showed a well-positioned bar at the level of S1 (f).