Sacral insufficiency fractures: a case of mistaken identity

Figures & data

Figure 1 Bone scintigraphy showing increased sacral uptake bilaterally (hollow arrows) and pubic bone (solid arrow).

Figure 2 Axial T1-weighted MRI image of sacrum.

Note: Patchy, low-intensity edema evident (arrows).
Abbreviation: MRI, magnetic resonance imaging.

Figure 3 CT images of sacrum.

Notes: (A) axial and (B) sagittal views demonstrating cortical breaks with mottled sclerosis/lucency (arrows).
Abbreviation: CT, computed tomography.

Table 1 Summary of articles published on the imaging modalities utilized for the investigation of SIFs

Author	Study type	Number of patients	Imaging method	Findings
Gotis-Graham et al^Citation7	CS/MA	110	Plain films	Images reviewed retrospectively. Vertical bands of sclerosis (50%) or fracture lines (11%) present.
Schneider et al^Citation38	CS	23	Nuclear medicine	Described three patterns of radionuclide uptake. H-shaped was the most common (78%). Other patterns include, uptake in a single alar (13%) or a T-shaped uptake, involving the sacral body and only one alar (9%).
Finiels et al^Citation13	MA	508		H-shaped pattern present in only 42% of reported cases.
Fujii et al^Citation22	CS	26		Sensitivity of NM for diagnosis of SIFs was 96% and PPV 92%.
Cabarrus et al^Citation24	CS	64	MRI	Images reviewed retrospectively. Marrow edema demonstrated in 100% and a fracture line in 94%.
Grangier et al^Citation16	CS	17		Use of IV gadolinium and/or fat suppression may improve detection of fracture lines.
Byun et al^Citation39	CS	22		Diffusion-weighted MRI may help differentiate between marrow edema from fracture or metastasis.
Gotis-Graham et al^Citation7	CS	12	CT	Images reviewed retrospectively. Fracture lines (42%) or sclerosis (17%) present.
Cabarrus et al^Citation24	CS	64		Images reviewed retrospectively. Fractures detected in 75% of proven SIFs.

Abbreviations: CS, case series; CT, computed tomography; IV, intravenous; MA, meta-analysis; MRI, magnetic resonance imaging; NM, nuclear medicine; PPV, positive predictive value; SIFs, sacral insufficiency fractures.

Table 2 A selection of previously reported case series on the various treatments of SIFs

Authors	Study type	Number of patients	Treatment	Outcome
Aretxabala et al^Citation15	CS	9	Bed rest + analgesia	Mean recovery time of 3.3 months.
Weber et al^Citation28	CS	20	Analgesia and early physical therapy	100% of patients pain-free at 9 weeks.
Leroux et al^Citation40	CS	10	Bed rest + analgesia	Mean time to symptomatic improvement of 4 weeks.
Gotis-Graham et al^Citation7	CS	20	Analgesia ± bed rest	85% reported complete resolution of pain and return to independence at 9 months.
Brook et al^Citation41	CS	2	CT-guided sacroplasty	Improvement in pre-procedure VAS. Improvement sustained at 8–16 months.
Frey et al^Citation32	CS	52	CT-guided sacroplasty	Improvement in pre-procedure VAS. Improvement sustained at 1 year.
Strub et al^Citation42	CS	13	CT-guided sacroplasty	Improvement in pre-procedure pain. Improvement sustained at 15 months.

Abbreviations: CS, case series; CT, computed tomography; SIFs, sacral insufficiency fractures; VAS, visual analog scale.

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