Sacral Insufficiency CHAPTER 9

Fracture Repair/
Sacroplasty
Michael E. Frey and Michael B. Furman

Sacral insufficiency fractures are a common cause of low back pain. They are
often underdiagnosed as a result of low clinical suspicion. These fractures are a
consequence of the imposition of physiologic stresses onto weakened bones.
Spontaneous fracture of the osteoporotic sacrum was first described in 1982. It
clinically manifests as back and/or buttock pain with or without lower limb pain
referral.
The traditional therapeutic algorithm for sacral insufficiency fractures consists of
limited bed rest, partial weight bearing, and early mobilization. The overall 1-year
mortality rate associated with pelvic insufficiency fractures is 14.3%, and 50% of
affected patients will not return to their prior level of functioning. Despite a favor-
able natural history, more aggressive treatments may benefit patients who are
incapacitated by painful sacral insufficiency fractures.
The percutaneous injection of polymethylmethacrylate (PMA) into fractured
vertebral bodies (i.e., vertebroplasty) has been safely performed to success-
fully treat painful osteoporotic compression fractures. A natural extension of the
application of vertebroplasty is the percutaneous injection of synthetic bone
cement into the fractured sacrum (i.e., sacroplasty) to treat persistent symptoms
and disability.
Several articles have documented the efficacy of sacroplasty, including two
large prospective studies. Sacroplasty appears to be a safe and effective treat-
ment for painful sacral insufficiency fractures. The rate of improvement is rapid,
with more than 50% reduction in pain achieved before the post-procedure dis-
charge of the patient. Pain reduction primarily occurs within the first 3 months, but
it is sustained through 12 months after treatment.
Complications of this procedure include (but are not limited to) bleeding,
infection, bowel perforation, cement emboli, and neuritis. With the use of the
technique described here, bowel perforation and neuritis can be minimized by
using appropriate safety considerations and views.

Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.

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 Chapter 9  Sacral Insufficiency Fracture Repair/Sacroplasty

Trajectory View

Confirm the level (with the anteroposterior view) before obtaining the trajectory view. 

n The fluoroscope is obliqued contralaterally from the side being treated until one can superimpose the medial and lat-
II

eral aspects of the sacroiliac joint. This could be approximately 5- to 25-degree contralateral oblique. If the posterior
iliac crest is in the way, caudal or cephalad tilts of 0 to 25 degrees may be necessary.
n The needle tip destination is at the midpoint of the imaginary line drawn between the lateral aspect of the dorsal

sacral foramina and the sacroiliac joint.

n Use an 18-gauge needle to first penetrate the skin. Use a mallet to gently tap either a 13- or 11-gauge trocar into

the periosteum.
n Because this is the trajectory view, the needle entry position should be parallel to the C-arm beam (Fig. 9.1). 

Epidural
space
Trajectory Trajectory Ilium L5 VB
view view

Sacrum
S1 foramen
SI joint S2 foramen

Imaginary
target line

B
A

Sacral
nerve roots
Trajectory View Safety
Considerations
Trajectory Ilium
L5 VB
view n Avoid the nerve root and spinal nerve by staying
Epidural space lateral to the lateral aspect of the foramen.  

S1 foramen Sacrum
Safety view

S2 foramen

C
Fig. 9.1.  A, Trajectory view with S1 and S2 needle being placed. The fluoroscope is obliqued contralaterally from the side being
treated until one can line up the sacroiliac joint. This could involve an approximately 5- to 25-degree oblique tilt. If the posterior iliac
crest is in the way, caudal or cephalic tilts of 0 to 25 degrees may be necessary. B, Radiopaque structures, trajectory view.
C, Radiolucent structures, trajectory view.

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 Optimal Needle Position in Multiplanar Imaging

   ptimal Needle Position

O
in Multiplanar Imaging

Use anteroposterior and lateral views to confirm trocar placement before placing the PMA. 

II
OPTIMAL NEEDLE POSITIONING IN THE LATERAL VIEW (FIG. 9.2)

Check a lateral view to confirm that the needle tip is located within the S1 and S2 vertebral segments and not ventral to them.
The C-arm should be oriented to obtain a true lateral view (see Chapter 3). 

Multiplanar Multiplanar
view view L5
VB

Sacrum

S2 segment

A B


Lateral View Safety
Multiplanar
Considerations
view L5
VB Do not penetrate the anterior third of the S1
Sacral
nerve roots Sacrum Danger
segment (i.e., the “danger zone”). There is a
zone high probability that a needle can pass outside
Safety view of the ventral sacrum if it gets near this region.
Distal Possible complications include bowel perforation
colon
and cement near the bowel or in the presacral
Caudal S2 segment space.
space

Rectum

C
Fig. 9.2.  A, Fluoroscopic lateral view of the S1 needle placed. Slowly advance the trocar under continuous imaging to the middle
third of the sacrum with the use of the lateral view. B, Radiopaque structures, lateral view. C, Radiolucent structures, lateral view.
This view is used to advance ventrally. The anteroposterior (AP) view (see Fig. 9.1) confirms that the trocars are actually lateral to the
nerves.

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 Chapter 9  Sacral Insufficiency Fracture Repair/Sacroplasty

OPTIMAL NEEDLE POSITIONING IN THE ANTEROPOSTERIOR

VIEW (FIG. 9.3)

Return to the anteroposterior view to properly visualize the sacral foramen and to confirm needle tip placement. Some
physicians may consider placing contrast at the S1 nerve root for the proper visualization of the nerve.
The same process is repeated at S2. For most patients, needle placement at the S1 and S2 segments is sufficient.
Depending on the extent of the fracture based on magnetic resonance imaging, computed tomography, or bone scan
findings, the process may need to be repeated at S3 and S4. 
II

Multiplanar Multiplanar
view view L5 VB

Ilium
Sacrum

Sacral
foramen

Clamp

B
A

Sacral
nerve
Anteroposterior View
Multiplanar roots Safety Considerations
L5
view VB
n Beware of spread toward the sacral nerve roots
Ilium that is too medial.  
Sacrum

Safety view
Sacral
foramen

Clamp

C
Fig. 9.3.  A, Fluoroscopic image of the anteroposterior view with the needle tip in position. B, Radiopaque structures, anteropos-
terior view. C, Radiolucent structures, anteroposterior view. Although the S2 trocar appears close to the S1 ventral nerve, lateral
imaging (Fig. 9.2) confirms appropriate ventral depth and safety.

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 Optimal Cement Patterns

Optimal Cement Patterns

When injecting the cement, first slowly inject using anteroposterior imaging to watch for medial spread of the
cement toward the nerve roots. Some physicians may first want to place the contrast along the sacral nerve root,
but this may obscure the proper placement of the cement. Fill most of the S1 and S2 segments where most of

II
the weight-bearing occurs. Consider injecting the S2 segment first because most of the cement travels both down
toward the lower sacrum and up toward the S1 segment. As a result of lordosis, the sacrum is in a caudad posi-
tion when the patient is lying prone. Place approximately 5 to 10 cc of cement in each sacral ala. As described for
almost all techniques, multiplanar imaging is recommended and employed in this procedure to monitor the cement
spread. This is accomplished by alternating between the lateral and anteroposterior views (Fig. 9.4) or through
biplanar fluoroscopy (if available).
Optimal cement patterns travel into most of the sacral alae. The goal is to achieve safe optimum filling of the sacral
alae. 

Optimal Optimal

A B

Optimal Optimal

C D
Fig. 9.4.  Optimal cement patterns within the sacrum. A and B, With trocars. C and D, Without trocars.

167
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 Chapter 9  Sacral Insufficiency Fracture Repair/Sacroplasty

Suboptimal Cement Patterns

Suboptimal cement patterns occur when too much cement migrates outside the sacrum (i.e., too medial toward the
nerve roots or too anterior into the presacral space). Injecting smaller volumes of approximately 3 to 4 cc of cement per
level can reduce the incidence of these suboptimal occurrences (Fig. 9.5). The cement should not traverse the sacral
II

foramen where it can jeopardize, irritate, or compromise the sacral nerve roots (Fig. 9.6).

Cement
outside
Suboptimal Suboptimal Cement not sacrum
optimally placed L5 VB

Sacral
foramen
SI
joint Cement near
nerve root
Cement
Cement
too medial
too medial

A B
Fig. 9.5.  A and B, There is a suboptimal cement spread of 3 cc into the bilateral sacral ala. On the patient’s right, there is migration
of cement outside of the sacrum on the upper lateral aspect of the sacrum, and the cement is also too medial on both sides since it
crosses the sacral foramen.

Dorsal
Suboptimal Suboptimal extravasation

Cement in
presacral space

A B
Fig. 9.6.  A, Lateral fluoroscopic view demonstrating suboptimal polymethylmethacrylate (PMA) filling after sacroplasty. There is
suboptimal spread of the PMA (with contrast) into the presacral space. There is also a small amount of contrast that extends out of
the dorsal surface of the sacrum at S2. B, Drawing of the fluoroscopic image seen in A.

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Suggested Reading
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Suboptimal Cement Patterns
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