E2300. Insufficiency Fractures: Is nothing Sacrum? Identification and Treatment of Sacral Insufficiency Fractures
  1. Nicholaus Monsma; Rochester Regional Health
  2. Rebecca Le; Rochester Regional Health
  3. Evan Basha; Rochester Regional Health
  4. Robert Brooks; Rochester Regional Health
  5. Garrett Schneider; Rochester Regional Health
Sacral insufficiency fractures are an overlooked etiology of back pain that can also be difficult to diagnose radiographically. Advanced imaging, including MR and scintigraphy, are useful modalities for diagnosis, as these fractures are frequently missed on plain films. Management is often conservative, particularly to avoid surgical fixation, a rarely completed surgery due to its high morbidity. In addition to diagnosing fractures, radiologists are also able to provide symptomatic relief via sacroplasty, a minimally invasive, percutaneous, image-guided procedure, first described in 2002.

Educational Goals / Teaching Points
Highlight high-risk populations for sacral insufficiency fractures and list key symptoms of those who may develop such fractures. Describe key findings across multiple modalities for insufficiency fractures. Discuss sacral vertebroplasty as a possible treatment strategy and outline key procedural strategies to minimize complications.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The most common sites of pelvic insufficiency fractures include the sacral ala and parasymphyseal region of the os pubis. The butterfly or “H-shaped” pattern is a classic sign of this fracture on scintigraphy, best appreciated posteriorly. MR is considered the gold standard in diagnosing insufficiency fractures and is characterized by low T1 band like signal intensity with corresponding high T2/T2 STIR signal intensity. Such fractures can be treated via sacroplasty by carefully injecting polymethylmethacrylate bone cement via one or more trocar needles. Knowledge of sacral anatomy is critical during the procedure to not violate specific sacral zones or traverse any of the neural foramina.

Sacral insufficiency fractures may be subtle on certain imaging modalities and can cause significant morbidity due to delayed diagnosis and care. There are multiple imaging modalities that can be pursued to promote timely diagnosis. Likewise, sacral vertebroplasty is a safe and effective treatment for select patients.