Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm

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  • 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
  • 2 Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
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OBJECTIVE

Sacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors’ operative experience managing this complication, review pertinent literature, and propose a treatment algorithm.

METHODS

The authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication.

RESULTS

Nine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8–96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score −1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8–90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to–lumbar lordosis (LL) mismatch.

CONCLUSIONS

A high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5–S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.

ABBREVIATIONS DEXA = dual energy x-ray absorptiometry; DF = dorsiflexion; LL = lumbar lordosis; LS = lumbosacral; PF = plantarflexion; PI = pelvic incidence; PJK = proximal junctional kyphosis; rhBMP-2 = recombinant human bone morphogenetic protein-2; TLIF = transforaminal lumbar interbody fusion; UIV = upper-most instrumented vertebra.

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Contributor Notes

Correspondence Thomas J. Buell: University of Virginia Health System, Charlottesville, VA. tjb4p@hscmail.mcc.virginia.edu.

INCLUDE WHEN CITING Published online March 27, 2020; DOI: 10.3171/2019.12.SPINE191148.

Disclosures Dr. Buell reports receiving honoraria from Wolters Kluwer. Dr. Buchholz reports being a consultant for Medtronic, NuVasive, and Siemens. Dr. Yen reports being a consultant to NuVasive. Dr. Shaffrey reports being a consultant to Medtronic, NuVasive, Zimmer-Biomet, and K2M; receiving royalties from Medtronic, NuVasive, and Zimmer-Biomet; and being a stock holder in NuVasive. Dr. Smith reports receiving royalties from Zimmer Biomet and NuVasive; being a consultant for Zimmer Biomet, Cerapedics, NuVasive, K2M, and AlloSource; receiving honoraria from Zimmer Biomet, NuVasive, and K2M; receiving research support from DePuy Synthes, AOSpine, and ISSGF; receiving fellowship support from the NREF and AOSpine; being a stockholder for Alphatec; and being on the editorial boards of the Journal of Neurosurgery: Spine, Neurosurgery, and Operative Neurosurgery.

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