Percutaneous Sacroplasty

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Chapter 20 Percutaneous Sacroplasty

Kyung-Hoon Kim, MD, PhD, Ji-Young Yoon, MD

Sacral insufficiency fractures, which are commonly associated with osteoporosis, rheumatoid arthritis, and radiation therapy–related cancer bony metastasis, can be treated with percutaneous sacroplasty under fluoroscopic and CT guidance; procedure is the same in the vertebrae as in the sacrum [1]. Pain caused by sacral insufficiency fractures can be relieved immediately with percutaneous sacroplasty, and patients can be allowed to ambulate immediately after the procedure.

The possible mechanisms for the pain relief experienced after sacroplasty are as follows:

Thermal neural ablation from the injected polymethylmethacrylate (PMMA), or thermal neurolysis

Neurotoxic materials from the injected PMMA, or chemical neurolysis

Stabilization and fixation of the sacral fracture site, which achieves mechanical augmentation and stabilization

Indications

Indications for sacroplasty are as follows:

Prolonged difficulty in weight-bearing with severe tenderness on the median sacral crest and/or lateral sacral crest, and/or sacral ala on physical examination

Radiologic evidence of sacral fractures on computed tomography or magnetic resonance imaging, and radioactive lesions on the sacrum demonstrated on a bone scan

Possible complications

The possible complications of sacroplasty are as follows:

Cement leakage into the sacral foramen or epidural space and venous system

Neural damage due to needle insertion

Procedure

1. The patient’s written informed consent is obtained.

2. The patient is placed in the prone position with padding beneath the upper chest and pelvis.

3. An intravenous injection of 30 mg ketorolac and 50 μg fentanyl with or without 2 to 3 mg midazolam is administered for anesthesia.

4. A 22-gauge, 10-cm block needle is placed in each sacral foramen, and contrast medium is injected under fluoroscopic guidance (Fig. 20-1A).

. If needed, the contrast medium is injected to confirm correct placement of the needle past the root and epidural space (Fig. 20-1B).

6. A 1% solution of lidocaine is infiltrated with another block needle to the targeted periosteum (Fig. 20-2).

7. A skin incision is made with a No. 15 scalpel along the skin crease.

. An 11-gauge, 10-cm vertebral needle is inserted into the skin incision and anchored to the targeted periosteum (Fig. 20-3).

9. The targeted depth is the anterior ⅓ to ¼ of the sacrum.

10. The contrast medium is injected to ensure that there is no leakage into the epidural space, transforaminal space, or the venous system after the stylet of the vertebral needle is removed.

11. To reduce the pain from expanding the periosteum, an injection of less than 2 mL of 1% lidocaine can be given before the insertion of PMMA.

12. PMMA mixed with a radiopaque contrast agent, antibiotic, and barium powder is injected with the aid of the injector under continuous fluoroscopic vision in the lateral projection to ensure adequate filling of the lesions and to avoid PMMA leakage (Fig. 20-4).

13. The stylet is re-inserted, and the vertebral needle is removed under continuous fluoroscopic vision.

14. The preceding procedures are repeated for multiple affected areas as needed (Figs. 20-5 to 20-8).

15. The wound is dressed with an adhesive dressing such as a Steri-Strip, and a piroxicam patch is applied.

16. The patient is placed in the supine position and instructed to remain immobile for the next 2 hours.

Figure 20–1 (A) Placement of block needle on the left S1 foramen. (B) Injection of contrast medium under fluoroscopy.

Figure 20–2 Local infiltration of 1% lidocaine into the targeted periosteum which is just above the left S1 foramen and identified on AP fluoroscopic view (A) and lateral view (B).

Figure 20–3 Insertion of an 11-gauge, 10-cm vertebral needle to the pre-anesthetized targeted periosteum as Fig. 20-2 and identified on AP fluoroscopic view (A) and lateral view (B).

Figure 20–4 After injection of contrast medium, the mixture of bone cement with antibiotic and barium powder is injected on the left sacral ala and identified on AP fluoroscopic view (A) and lateral view (B).

Figure 20–5 The vertebral needle on the left sacral ala is placed after injection of bone cement and identified on AP fluoroscopic view (A) and lateral view (B).

Figure 20–6 Local infiltration of 1% lidocaine on the right sacral periosteum and identified on AP fluoroscopic view (A) and lateral view (B).

Figure 20–7 Injection of contrast medium into the vertebral needle and confirmation of leakage into the L5-S1 intervertebral disc space and identified on AP fluoroscopic view (A) and lateral view (B).

Figure 20–8 Injection of the mixture of bone cement and barium powder into the right sacral ala, upper S1 body, and L5-S1 intervertebral disc space and identified on AP fluoroscopic view (A) and lateral view (B).

Postoperative follow-up

After 3 days, the patient may take a shower.

The patient is instructed to return after 1 week for an examination of the wound. If the wound is clean, the dressing is removed.

Related anatomy and physiology

Figure 20-9 illustrates the anatomy and physiology related to sacroplasty.

Figure 20–9 Sacrum and coccyx. (A) anterior (pelvic) view; (B) posterior view; (C) left lateral view; (D) Sacrum, superior view; (E) Transverse section through the sacrum (the level of section is shown in A.)

(From Ross LM, Lamperti ED. Atlas of Anatomy: General Anatomy and Musculoskeletal System. Stuttgart, Thieme, 2006, pp 90-91.)

Caveat

It is helpful to inject contrast medium or to place the needles into the foramen near the dorsal ganglion of S1 and/or S2 through the posterior approach before performing percutaneous sacroplasty, especially when the procedure is performed under fluoroscopic guidance.

CASE STUDY 20.1

A 38-year-old woman with breast cancer was suffering from intractable low back pain, especially in weight-bearing positions. There were tumor infiltrations on the L5 vertebra and both sacral alae of the S1 and S2 vertebrae as seen in preoperative magnetic resonance imaging and bone scan (Fig. 20-10). It was determined that sacroplasty would be performed and there was no cement leakage into the L5-S1 intervertebral space during the procedure (Fig. 20-11). Two hours after completion of the sacroplasty, the patient experienced pain relief when standing and sitting, and was discharged.

Figure 20–10 Case Study 20.1: Preoperative magnetic resonance image shows the pathologic compression fracture of S1 and S2 vertebrae which is mixed signal at T2WI (A and C) and hypointense at T1WI (B and D). Bone scan reveals hot uptake of S1 and S2 vertebrae (E and F).

Figure 20–11 Case Study 20.1: Postoperative sacrum anteroposterior (A) and lateral plain films (B) shows no cement leakage into the L5-S1 intervertebral space.and it is also revealed by CT scans (E, F and G) and three-dimensional computed tomography scans (B, C, H, I, J and K).