This column summarizes patient cases posted to SIR Connect (SIR’s popular online member community), the responses from other SIR members and how that feedback helped the original poster. To see how SIR’s online community can help you, visit SIR Connect at connect.sirweb.org.
Original Post, lightly edited for flow:
I performed CT-guided sacroplasty on a patient with bilateral trocars at S1, 2, 3 and used 13.4 cc of cement. That is more than my usual four trocars and 8–10 ccs of cement. The patient has reported no pain relief and claims that pain is worse. He wants to know if he can have it done again. I have been doing kyphoplasties and sacroplasties for almost 20 years and my partners thought I went above and beyond on this case. Any advice would be appreciated. I had pre-op CT and MRI which was positive for subacute sacral insufficiency fractures.
What challenges have you faced in performing CT guided sacroplasty with bilateral trocars?
CT-guided sacroplasty has several challenges including delays with CT-fluoro and the cement drying too quickly. I usually use two trocars at S1 bilaterally and two trocars bilaterally at S2–3. Due to the short axis of CT, the large handles of the trocars end up touching each other or deflecting each other unless I try to stay slightly off the same axial level on same level trocars. The advantage of CT is easier guidance of placement of the trocars in the fractures more precisely. Many IRs use cone-beam CT with newer fluoro angio rooms, which we do not have available yet.
What specifically prompted you to reach out regarding this case/topic?
This was the first time I have not achieved any clinical improvement after sacroplasaty. I wanted to know from experienced operators if repeat treatment would be reasonable.
What post or posts were most valuable to you and why?
The most helpful post was from Douglas Beall, MD, FSIR, who is a world expert on vertebral procedures. He sent articles and pictures of long axis techniques. Doug suggested I try again and add more cement.
Will you, or have you changed your practice patterns based off of responses on SIR Connect? Please describe any changes you are considering.
I did repeat the sacroplasty procedure within a week and added almost the same amount of cement as the first time. However, the patient did not show any improvement clinically. Do I have regrets? No. The patient then knew I had tried everything. I will learn how to perform the long-axis fluoro technique that most other IRs do these days and have reached out to my device manufacturer’s rep to ask about training.
Additional commentary:
Percutaneous sacral vertebroplasty (sacroplasty) is a safe and effective procedure for patients suffering from back pain due to compression fractures secondary to osteoporosis, malignancy and hemangiomas.1,2,3,4,5 Analogous to vertebroplasty, which was highlighted by Dr. Beall in the summer 2019 issue of IR Quarterly (bit.ly/31U6Wnx), sacroplasty provides pain relief and improved mobility in select patients.1,3,6
A cement acrylic polymer such as polymethylmethacrylate (PMMA)1 is injected under short- and long-axis techniques that utilize image guidance with fluoroscopy or CT,1,5 as described by the OP who attempted re-treatment in a patient who received sacroplasty for pain control. While an appropriateness algorithm for vertebroplasty has been presented and could be extrapolated for sacroplasty, a dedicated algorithm does not exist.6 Repeat sacroplasty can be performed for patients with recurrent insufficiency fractures, though challenges may include the sacral medullary volume, access approach, placing trocars into fracture locations that do not bear cement, or hardening artifacts due to CT imaging.7
Percutaneous sacroplasty yields favorable outcomes for pain management, with 50% immediate post-op, pre-discharge pain relief in one prospective analysis.1,8 According to a vendor-sponsored study referenced in the SIR Connect post, a retrospective multicenter analysis of CT-guided sacroplasty in patients with sacral insufficiency fractures and lesions demonstrated a reduction in pain scores (31% complete relief with average cement volume 4.1 ml).9,10 Another multicenter prospective study demonstrated pain relief seen in some patients within 30 minutes.10,11 A portion of patients see immediate relief, gradual pain improvement during a 1- to 2-week period, and up to 6–12 months to see complete symptom resolution and improved mobility.11–15
The complication rate of sacroplasty is low; risks include cement extravasation and leakage associated with tissue damage, nerve and circulatory problems.9,10 The long-axis sacroplasty technique cited in the AJR article on the SIR Connect post mitigates risk by improving cement distribution and risk of its leakage into surrounding structures.15 One limitation to all of these articles is that there is a lack of randomized controlled studies to date regarding percutaneous sacroplasty for insufficiency fractures.10,14
The patient in this case was treated under CT-guidance for sacral insufficiency fractures with satisfactory postprocedure sacroplasty images. A few respondents on SIR Connect recommended waiting and seeing the patient in clinic 2 weeks post-op, which is a similar standard follow-up time per the clinical care pathway reviewed in Dr. Beall’s vertebroplasty article.6 Others commented regarding repeat sacroplasty and bupivacaine joint nerve blocks with pre- and postprocedure NSAIDs.
This discussion may highlight a potential role for repeat sacroplasty in combination with other treatment modalities for refractory pain and patient education on underlying osteoporosis.6
Additional commentary from Douglas Beall, MD, FSIR
Sacroplasty is a critically important treatment option for patients suffering from sacral insufficiency fractures and sacral metastatic disease and is highly effective at relieving pain and improving function as has been shown in numerous manuscripts. Sacroplasty is similar to vertebroplasty but is not the same, as it requires more cement and has different anatomy which requires that you treat these cases as a sacroplasty, not as a vertebroplasty of the sacrum.
The goal of sacroplasty is the civil engineering of the sacrum to be able withstand the compression and shear forces that are placed upon it while the individual is ambulating. Patients with sacral fractures tend to be older, more osteoporotic and more debilitated than the typical patient suffering from a painful vertebral compression fracture. This should remind us that we are physicians, not technicians, and the additional attention to the patient should include adequate follow-up, additional interventional pain procedures as is necessary, and treating the underlying disorder that gave rise to the fractures.
SIR Foundation is collecting data for a sacroplasty registry that will showcase patient-reported outcomes and the response to treatment in regard to improvements in pain and patient function. Learn more at bit.ly/30Y8MUz.
References
- Radvany, et al. “Vertebroplasty and Kyphoplasty.” Handbook of Interventional Radiologic Procedures, by Krishna Kandarpa et al., Lippincott Williams & Wilkins, 2016.
- Ortiz, A. Orlando, and Allan L. Brook. “Sacroplasty.” Techniques in Vascular and Interventional Radiology, vol. 12, no. 1, Mar. 2009, pp. 51–63. org (Crossref), doi:10.1053/j.tvir.2009.06.006.
- Baerlocher, Mark O., et al. “Quality Improvement Guidelines for Percutaneous Vertebroplasty.” Journal of Vascular and Interventional Radiology, vol. 25, no. 2, Feb. 2014, pp. 165–70. org (Crossref), doi:10.1016/j.jvir.2013.09.004.
- Maynard, A. Stanley, et al. Value of Bone Scan Imaging in Predicting Pain Relief from Percutaneous Vertebroplasty in Osteoporotic Vertebral Fractures. 2000, p. 6.
- Health, Center for Devices and Radiological. “Polymethylmethacrylate (PMMA) Bone Cement - Class II Special Controls Guidance Document for Industry and FDA.” FDA, FDA, Feb. 2020. fda.gov, https://www.fda.gov/medical-devices/guidance-documents-medical-devices-and-radiation-emitting-products/polymethylmethacrylate-pmma-bone-cement-class-ii-special-controls-guidance-document-industry-and-fda.
- Beall, Douglas P. “Feature: Pain Points. Improving the Treatment Pathway for Painful Vertebral Compression Fractures.” IR Quarterly, Summer 2019.
- Simon, Jeremy I., et al. “Successful Repeat Sacroplasty in a Patient With a Recurrent Sacral Insufficiency Fracture: A Case Presentation.” PM&R, vol. 9, no. 11, 2017, pp. 1171–74. Wiley Online Library, doi:10.1016/j.pmrj.2017.04.002.
- Frey, Michael E, et al. “Sacroplasty: A Ten-Year Analysis of Prospective Patients Treated with Percutaneous Sacroplasty: Literature Review and Technical Considerations.” Pain Physician, p. 10.
- Medtronic data on file: 31100918
- Sacroplasty for Sacral Insufficiency Fractures. www.medtronic.com, https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/sacroplasty.html. Accessed 16 July 2020.
- Frey, Michael E., et al. “Percutaneous Sacroplasty for Osteoporotic Sacral Insufficiency Fractures: A Prospective, Multicenter, Observational Pilot Study.” The Spine Journal, vol. 8, no. 2, Mar. 2008, pp. 367–73. org (Crossref), doi:10.1016/j.spinee.2007.05.011.
- Gotis-Graham, I, et al. “Sacral Insufficiency Fractures in the Elderly.” The Journal of Bone and Joint Surgery. British Volume, 76-B, no. 6, 1994, pp. 882–, doi: 10.1302/0301-620x. 76b6.7983111.
- Lin, Julie, et al. “Sacral Insufficiency Fractures: A Report of Two Cases and a Review of the Literature.” Journal of Women’s Health & Gender-Based Medicine, vol. 10, no. 7, Sept. 2001, pp. 699–705. org (Crossref), doi:10.1089/15246090152563588.
- Talmadge, Jennifer, et al. “Clinical Impact of Sacroplasty on Patient Mobility.” Journal of Vascular and Interventional Radiology, vol. 25, no. 6, June 2014, pp. 911–15. org (Crossref), doi:10.1016/j.jvir.2014.02.007.
- Smith, Douglas K., and James E. Dix. “Percutaneous Sacroplasty: Long-Axis Injection Technique.” American Journal of Roentgenology, vol. 186, no. 5, May 2006, pp. 1252–55. org (Crossref), doi:10.2214/AJR.05.0823.
