Diagnostics and treatment of sacral insufficiency fractures with special attention to cement augmentation procedures - an overview

Insufficiency fractures of the sacrum are being detected increasingly frequently, whereby their incidence will no doubt increase further as a result of the rise in life expectancy. Some of the patients are disabled by the severe fracture pain and cannot be treated adequately by means of conservative treatment. A marked pain reduction and clinical improvement can be achieved by inserting cement into the respective fracture zone. The objective of this review article is to present the different cement augmentation procedures, balloon, radiofrequency, vertebro- and cement sacroplasty, with regard to their correct indication, technical feasibility, possible complications and clinical outcome. A literature search was conducted in PubMed and Google Scholar using the keywords: pelvic insufficiency fracture, fragility fractures of the pelvic ring, sacral insufficiency fracture, sacrum, osteoporosis, interventional pain therapy, sacroplasty, cement augmentation and pelvic osteosyntheses. Experience gained from our own interdisciplinary, multicentric working group, which has been in existence for many years, was also taken into consideration. New classifications in the categorisation of pelvic insufficiency fractures must be taken into account when determining the appropriate therapeutic procedure, while making allowance for the individual clinical situation. Conservative therapy is of primary importance initially, although not all patients achieve freedom from pain here and cannot be mobilised adequately, subsequently leading to comorbidities and increased mortality. In the case of non-dislocated fractures, sacroplasty can be performed to achieve rapid and sustained pain reduction. With regard to cement augmentation, the osteoplastic procedures such as balloon, radiofrequency and cement sacroplasty can be differentiated from the non-osteoplastic procedure of vertebrosacroplasty. In the case of vertebrosacroplasty, a higher rate of cement leakage is to be expected. The complex sacral anatomy, the osteopenic bone structure, the alignment of the fracture zones, the differences in technical approach, the properties of the cements and the experience of the surgeons have an influence on the occurrence of possible complications. If conservative measures do not lead to a clinical improvement, patients with painful, non-dislocated sacral insufficiency fractures achieve an effective and sustained benefit from cement augmentation. Through the use of individually adaptable sacroplasty procedures, relevant complications are generally very rare. Patients with unstable fractures benefit from osteosynthesis performed at an early stage.