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Journal of Orthopaedic Research :... Jun 2018With increasing life expectancy, fragility fractures of the pelvic ring are seen more frequently. Although their osteosynthesis can be very challenging, specific...
With increasing life expectancy, fragility fractures of the pelvic ring are seen more frequently. Although their osteosynthesis can be very challenging, specific biomechanical studies for investigation of the fixation stability are still lacking. The aim of this study was to biomechanically evaluate four different fixation methods for sacrum Denis type II fractures in osteoporotic bone. Unstable Denis type II vertical sacrum fractures were created in 16 human pelves. Their osteosynthesis was performed with one sacro-iliac screw, posterior sacral plating, triangular fixation, or spino-pelvic fixation. For that purpose, each pelvis was randomly assigned to two paired groups for treatment with either SI-screw/posterior sacral plating or triangular fixation/spino-pelvic fixation. Each hemi-pelvis was cyclically tested under progressively increasing axial compression. Relative interfragmentary movements were investigated via optical motion tracking analysis. Axial stiffness of triangular fixation was significantly higher versus posterior sacral plating and spino-pelvic fixation (p ≤ 0.022), but not significantly different in comparison to SI-screw fixation (p = 0.337). Cycles to 2, 3, 5, and 8 mm fracture displacement, as well as to 3°, 5°, and 8° gap angle at the fracture site were significantly higher for triangular fixation compared to all other groups (p ≤ 0.041). Main failure mode for all osteosynthesis techniques was screw cutting through the bone, leading loss of fixation stability. From a biomechanical point of view, triangular fixation in sacrum Denis type II fractures demonstrated less interfragmentary movements and should be considered in unstable fragility fractures of the sacrum. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1624-1629, 2018.
Topics: Biomechanical Phenomena; Bone Density; Bone Screws; Female; Fracture Fixation, Internal; Humans; Male; Sacrum; Spinal Fractures
PubMed: 29106756
DOI: 10.1002/jor.23798 -
Journal of Orthopaedics and... Sep 2023There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.
BACKGROUND
There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.
MATERIALS AND METHODS
The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.
RESULTS
Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.
CONCLUSIONS
This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients.
LEVEL OF EVIDENCE
IV.
TRIAL REGISTRATION
not applicable (consensus paper).
Topics: Humans; Consensus; Fractures, Bone; Traction; Sacrum; Decompression, Surgical; Fracture Fixation
PubMed: 37665518
DOI: 10.1186/s10195-023-00726-2 -
European Spine Journal : Official... Dec 2020A systematic review and meta-analysis. (Meta-Analysis)
Meta-Analysis Review
STUDY DESIGN
A systematic review and meta-analysis.
OBJECTIVE
The purpose of this study was to evaluate the clinical outcome and safety of sacroplasty for patients with secondary metastatic lesions to the sacrum.
METHODS
Several databases, including the Cochrane library, PubMed and EMBASE, were systematically searched to identify potentially eligible articles in English language. All the above databases were searched until December 2019. The search strategy was based on the combination of the following keywords: sacroplasty AND secondary tumours OR metastasis OR metastases. The reference list of the selected literature was also reviewed and a standard PRISMA template utilised.
RESULTS
From a total of 102 articles initially identified, a final seven studies were identified as meeting the inclusion criteria. A total of 107 patients from these studies were included. The follow-up ranged from immediate post-operatively to 30.5 months. The mean preoperative VAS was 8.38 (range 6.9-9.3), which improved significantly to 3.01 (range 1.12-4.7) post-operatively (p < 0.001). The most frequent complication reported was cement leakage, which occurred in 26 patients (25.4%), but without any neurological or other adverse sequelae.
CONCLUSIONS
Sacroplasty in the management of secondary sacral tumours is a safe procedure that can achieve a significant reduction in pain, as quantified by VAS scores, and low complication rate.
Topics: Bone Cements; Humans; Sacrococcygeal Region; Sacrum; Spinal Fractures; Treatment Outcome
PubMed: 32772170
DOI: 10.1007/s00586-020-06562-w -
Spine Jun 1992A load-to-failure test was used to study the biomechanical properties of sacral screw fixation in human cadaveric specimens. The goals of this study were 1) to determine...
A load-to-failure test was used to study the biomechanical properties of sacral screw fixation in human cadaveric specimens. The goals of this study were 1) to determine the effects of the two commonly chosen sacral screw orientations of fixation characteristics; 2) to determine the effects of selected screw-instrumentation linkages on the biomechanics of sacral screw fixation; 3) to correlate the biomechanical properties with a noninvasive assessment of sacral bone density; and 4) to correlate the torque during screw insertion with these biomechanical properties. The bone density of each specimen was measured with quantitative computed tomography. A screw was inserted from the dorsal surface either anteromedially or anterolaterally into the body of S1, and the torque needed to insert each screw was measured. The screw head was attached to a constrained or semiconstrained loading linkage. Force was applied to the screw in an inferior direction until the maximum load was achieved. The maximum load, screw translation, rotation at maximum load, and initial compliance of the bone-screw interface were determined. It was found that the anteromedial screw orientation, combined with a rigidly constrained loading linkage, resulted in the greatest maximum load to failure, the least screw rotation, and the least initial compliance of the four groups studied. The maximum load and the initial stiffness of bone-screw fixation increased significantly with bone density. Torque measurements correlated significantly with maximum load to failure, initial interface stiffness, and bone density. It was therefore concluded that bone density and torque measurements can be useful in assessing sacral screw fixation.
Topics: Aged; Aged, 80 and over; Biomechanical Phenomena; Bone Density; Bone Screws; Cadaver; Equipment Failure; Female; Humans; Male; Middle Aged; Sacrum; Stress, Mechanical; Tomography, X-Ray Computed
PubMed: 1631718
DOI: 10.1097/00007632-199206001-00023 -
The Journal of Bone and Joint Surgery.... Nov 1979A review of seventy-one children with sacral anomalies is presented. The aetiology is discussed and a classification of sacral anomalies is suggested, with three groups...
A review of seventy-one children with sacral anomalies is presented. The aetiology is discussed and a classification of sacral anomalies is suggested, with three groups of patients: agenetic, dysgenetic and dysraphic. The clinical presentation of each group is discussed and the high incidence of congenital visceral and skeletal abnormalities is indicated in the dysgenetic group. The need for constant urological assessment is emphasised, particularly in the agenetic and dysraphic children.
Topics: Abnormalities, Multiple; Adolescent; Child; Child, Preschool; Congenital Abnormalities; Diabetes Complications; Female; Humans; Infant; Male; Radiography; Sacrum; Spine
PubMed: 500747
DOI: 10.1302/0301-620X.61B4.500747 -
Skeletal Radiology 1984The sacral foramina, particularly the first three, are not simple fenestrations. Each foramen is a Y-shaped complex of canals, all with indefinite margins. The complexes...
The sacral foramina, particularly the first three, are not simple fenestrations. Each foramen is a Y-shaped complex of canals, all with indefinite margins. The complexes lie obliquely at approximately 45 degrees to the coronal plane. An appreciation of these facts facilitates the recognition of the anatomy of plain films, tomographs, and computerized scans.
Topics: Fractures, Bone; Humans; Sacrum; Tomography, X-Ray; Tomography, X-Ray Computed; Wounds, Gunshot
PubMed: 6729502
DOI: 10.1007/BF00351354 -
Neurosurgery Nov 2002We discuss the anatomy of the thoracic, lumbar, and sacral levels of the spinal cord. Given the nature of endoscopic surgery, it is recommended that the surgeon have... (Review)
Review
We discuss the anatomy of the thoracic, lumbar, and sacral levels of the spinal cord. Given the nature of endoscopic surgery, it is recommended that the surgeon have thorough knowledge not only of the bony architecture but also of important visceral and other soft tissue structures. It is essential to understand the normal anatomy to recognize the abnormal and anatomic variations. We present the so-called normal anatomic configurations and illustrate how these structures vary at the different levels of the spinal column.
Topics: Blood Vessels; Endoscopy; Humans; Lumbar Vertebrae; Nervous System; Neurosurgical Procedures; Sacrum; Thoracic Vertebrae
PubMed: 12234432
DOI: No ID Found -
The Journal of Bone and Joint Surgery.... Apr 2016Fragility fractures of the sacrum are increasing in prevalence due to osteoporosis and epidemiological changes and are challenging in their treatment. They exhibit...
BACKGROUND
Fragility fractures of the sacrum are increasing in prevalence due to osteoporosis and epidemiological changes and are challenging in their treatment. They exhibit specific fracture patterns with unilateral or bilateral fractures lateral to the sacral foramina, and sometimes an additional transverse fracture leads to spinopelvic dissociation. The goal of this study was to assess sacral bone mass distribution and corresponding changes with decreased general bone mass.
METHODS
Clinical computed tomography (CT) scans of intact pelves in ninety-one individuals (mean age and standard deviation, 61.5 ± 11.3 years) were used to generate three-dimensional (3D) models of the sacrum averaging bone mass in Hounsfield units (HU). Individuals with decreased general bone mass were identified by measuring bone mass in L5 (group 1 with <100 HU; in contrast to group 2 with ≥100 HU).
RESULTS
In group 1, a large zone of negative Hounsfield units was located in the paraforaminal lateral region from S1 to S3. Along the trans-sacral corridors, a Hounsfield unit peak was observed laterally, corresponding to cortical bone of the auricular surface. The lowest Hounsfield unit values were found in the paraforaminal lateral region in the sacral ala. An intermediate level of bone mass was observed in the area of the vertebral bodies, which also demonstrated the largest difference between groups 1 and 2. Overall, the Hounsfield units were lower at S2 than S1.
CONCLUSIONS
The models of averaged bone mass in the sacrum revealed a distinct 3D distribution pattern.
CLINICAL RELEVANCE
The negative values in the paraforaminal lateral region may explain the specific fracture patterns in fragility fractures of the sacrum involving the lateral areas of the sacrum. Transverse fractures located between S1 and S2 leading to spinopelvic dissociation may occur because of decreased bone mass in S2. The largest difference between the studied groups was found in the vertebral bodies and might support the use of transsacral or cement-augmented implants.
Topics: Adult; Aged; Aged, 80 and over; Female; Fractures, Bone; Humans; Male; Middle Aged; Models, Anatomic; Retrospective Studies; Sacrum; Tomography, X-Ray Computed; Young Adult
PubMed: 27053587
DOI: 10.2106/JBJS.15.00726 -
Neuroimaging Clinics of North America May 2010Pain from sacral insufficiency fractures or metastatic tumor to the sacrum, refractory to radiation and/or chemotherapy, can be extremely debilitating to affected... (Review)
Review
Pain from sacral insufficiency fractures or metastatic tumor to the sacrum, refractory to radiation and/or chemotherapy, can be extremely debilitating to affected patients. Conservative medical therapy with rest, limited ambulation, and pain medication has been the mainstay of treatment. Open surgical fixation is reserved for severe fracture that does not heal with rest. A minimally invasive treatment, sacroplasty, is gaining popularity and uses image-guided, percutaneous injection of surgical cement into the fracture. This article reviews the incidence, causes, diagnosis, presentation, and treatment options for sacral fractures, and describes detailed technical steps of the sacroplasty procedure.
Topics: Fractures, Bone; Humans; Sacrum; Vertebroplasty
PubMed: 20439013
DOI: 10.1016/j.nic.2010.02.004 -
European Spine Journal : Official... Dec 2016Sacrectomy is a highly demanding surgery representing the main treatment for primary tumors arising in the sacrum and pelvis. Unfortunately, it is correlated with loss... (Review)
Review
PURPOSE
Sacrectomy is a highly demanding surgery representing the main treatment for primary tumors arising in the sacrum and pelvis. Unfortunately, it is correlated with loss of important function depending on the resection level and nerve roots sacrificed. The current literature regarding residual function after sacral resection comes from several small case series. The goal of this review is to appraise residual motor function and gait, sensitivity, bladder, bowel, and sexual function after sacrectomies, with consideration to the specific roots sacrificed.
METHODS
An exhaustive literature search was conducted. All manuscripts published before May 2015 regarding residual function after sacrectomy were considered; if a clear correlation between root level and functioning was not present, the paper was excluded. The review identified 15 retrospective case series, totaling 244 patients; 42 patients underwent sacrectomies sparing L4/L4, L4/L5 and L5/L5; 45 sparing both L5 and one or both S1 roots; 8 sparing both S1 and one S2; 48 sparing both S2; 11 sparing both S2 and one S3, 54 sparing both S3, 9 sparing both S3 and one or both S4, and 27 underwent unilateral variable resection.
RESULTS
Patients who underwent a sacrectomy maintained functionally normal ambulation in 56.2 % of cases when both S2 roots were spared, 94.1 % when both S3 were spared, and in 100 % of more distal resections. Normal bladder and bowel function were not present when both S2 were cut. When one S2 root was spared, normal bladder function was present in 25 % of cases; when both S2 were spared, 39.9 %; when one S3 was spared, 72.7 %; and when both S3 were spared, 83.3 %. Abnormal bowel function was present in 12.5 % of cases when both S1 and one S2 were spared; in 50.0 % of cases when both S2 were spared; and in 70 % of cases when one S3 was spared; if both S3 were spared, bowel function was normal in 94 % of cases. When even one S4 root was spared, normal bladder and bowel function were present in 100 % of cases. Unilateral sacral nerve root resection preserved normal bladder function in 75 % of cases and normal bowel function in 82.6 % of cases. Motor function depended on S1 root involvement.
CONCLUSION
Total sacrectomy is associated with compromising important motor, bladder, bowel, sensitivity, and sexual function. Residual motor function is dependent on sparing L5 and S1 nerve roots. Bladder and bowel function is consistently compromised in higher sacrectomies; nevertheless, the probability of maintaining sufficient function increases progressively with the roots spared, especially when S3 nerve roots are spared. Unilateral resection is usually associated with more normal function. To the best of our knowledge, this is the first comprehensive literature review to analyze published reports of residual sacral nerve root function after sacrectomy.
Topics: Defecation; Humans; Neurosurgical Procedures; Sacrum; Spinal Nerve Roots; Urinary Bladder
PubMed: 26914097
DOI: 10.1007/s00586-016-4450-3