Percutaneous Sacroplasty

Published on 10/03/2015 by admin

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Last modified 10/03/2015

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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:

image Thermal neural ablation from the injected polymethylmethacrylate (PMMA), or thermal neurolysis
image Neurotoxic materials from the injected PMMA, or chemical neurolysis
image Stabilization and fixation of the sacral fracture site, which achieves mechanical augmentation and stabilization

Indications

Indications for sacroplasty are as follows:

image 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
image 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:

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