Mini Review - Sacral Fractures After Lumbosacral Fusions

Andrei F. Joaquim

Andrei F. Joaquim, Neurosurgeon – Spine Division, Department of Neurology, Discipline of Neurosurgery, State University of Campinas (UNICAMP), Campinas SP, Brazil.

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Andrei F. Joaquim, Neurosurgeon – Spine Division, Department of Neurology, Discipline of Neurosurgery, State University of Campinas (UNICAMP), Campinas SP, Brazil.
Email: andjoaquim@yahoo.com
Telephone: +55-19-35217905

Received: April 27, 2017
Revised: May 15, 2017
Accepted: May 16 2017
Published online: August 28, 2017


Sacral fractures may be complication of lumbar and lumbosacral fusions, increasing costs and morbidity of spinal surgeries. The most common risk factors for sacral fractures are obesity, sagittal unbalance, poor bone quality and a long fusion. Clinical presentation generally consists of a new low back or buttock pain after some days/ weeks or months after an index lumbar procedure. Although plain radiographs may diagnosis sacral fractures, CT scan with reconstruction is the image modality of choice for these injuries. Treatment may consist in pain management in mild and aligned fractures or surgical revision, including extending the posterior fusion with iliac fixation. Understand the nuances involved in sacral fractures after fusions are important to try to avoid this complication and, when it happens, performed the adequate diagnosis and management.

Key words: Sacral fractures; Diagnosis; Management; Treatment

© 2017 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Joaquim AF. Mini Review - Sacral Fractures After Lumbosacral Fusions. International Journal of Orthopaedics 2017; 4(4): 786-787 Available from: URL: http: //www.ghrnet.org/index.php/ijo/article/view/2051

Mini Review

Lumbar fusions to treat degenerative lumbar disease are one of the most common spinal procedures performed around the world[1]. Lumbar and lumbosacral (LS) fusions may result in higher stress forces at the spinal levels near the fusion segments, which increase the risks of adjacent spinal stenosis, disc degeneration and also junctional fractures[2,3]. Potential causes for the higher risk of spinal changes in the adjacent fusion areas are the abnormal distribution of the forces (such as the body weight), overloading the normal or near normal spine below and above the fusion levels. The risk of spinal fractures after LS fusions increases in patients with osteoporosis, obesity, sagittal spine unbalance and long fusions (more than five levels) without iliac fixation[2,4,5,6]. The estimate incidence of sacral fractures is about 1.3% after short segmental fusions and up to 3.1% in long fusions[7].

Sacral fractures after fusion should be suspected in patients who had unspecific new buttock or low back pain after some days, weeks or even months of the index surgery[2,3,4]. Radiculopathy may also occur. The pain intensity is variable, from mild to severe, sometimes with intractable pain. Diagnosis of sacral fractures after lumbar fusions can be made using simple plain radiographs. However, the best radiological method for diagnosing sacral fractures is CT scan with reconstruction, especially in the setting of previous instrumentation[7].

Conservative treatment of sacral fractures after LS fusions has been reported with or without using a brace with thigh extension, in patients without severe misalignment and mild or controlled pain. However, the majority of the cases were treated successfully with a posterior revision surgery and extension of the instrumentation to the pelvis, with fracture healing[7,8]. Lag screws directly to the sacral fractures were also reported anecdotally by some authors[9,10].

By this time, the best way to prevent sacral fractures is to understand the risk factors, avoiding, for instance, stopping long fusions at S1 and adequate correction of sagittal unbalance. Additionally, it is important to treat osteoporosis and obesity to potentially decrease complications. Further comparative studies are also necessary to clarify the best treatment options.


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Peer reviewer: Mohamed Abdel-Wanis


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