What are the indications for bilateral sacroplasty?

Indications for Bilateral Sacroplasty

Bilateral sacroplasty is primarily indicated for patients with bilateral sacral insufficiency fractures who have persistent, severe, disabling pain despite conservative management for at least 3 weeks. 1

Patient Selection Criteria

Primary Indications

• Bilateral sacral insufficiency fractures confirmed by imaging (MRI preferred) 2, 1
• Severe, disabling low back pain unresponsive to conservative treatment 1
• Osteoporotic patients, particularly elderly women 3
• Patients with limited mobility due to pain 3

Clinical Presentation

• Chronic, severe low back pain
• Pain that limits mobility and quality of life
• Pain that persists despite adequate conservative management (typically 3+ weeks) 1

Imaging Findings

• Bilateral sacral insufficiency fractures confirmed on MRI or CT
• No evidence of malignancy or infection

Contraindications

• Active infection at the procedure site
• Uncorrectable coagulopathy
• Allergy to bone cement components
• Fractures with significant displacement requiring surgical stabilization 4
• Asymptomatic fractures

Pre-Procedure Considerations

Patient Optimization

• Bone health should be assessed and optimized with appropriate pharmacotherapy 3
• Anabolic agents prior to or in conjunction with sacroplasty may improve outcomes 3
• Interdisciplinary case conference is recommended to establish indication for intervention 1

Technical Approaches

Several technical approaches can be used for bilateral sacroplasty:

1. Short-axis approach: Needle advancement from dorsal to ventral 1
2. Long-axis approach: Needle placement along the sacral ala 5
3. Transiliac approach: Lateral to medial needle placement 1

Both long-axis and short-axis techniques have shown similar safety profiles with high-viscosity cement, with no significant differences in cement extravasation rates 5.

Procedural Details

• Performed under conscious sedation or general anesthesia 1
• CT guidance for needle placement provides precise targeting 2
• Fluoroscopy monitoring during cement injection allows real-time visualization 2
• Creation of a cavity using a flexible osteotome before cement injection may help reduce extravasation risk 1
• High-viscosity PMMA cement is recommended to minimize extravasation risk 5
• Average cement volume: 4-6 mL per fracture 2, 1
• Single-shot antibiotic prophylaxis immediately prior to intervention 1

Expected Outcomes

Pain Relief

• Significant pain reduction typically occurs within 2 days post-procedure 1
• Average pre-procedure pain scores of 8.8/10 reduced to 2.1/10 by day 2 1
• Pain relief is typically sustained long-term (18+ months) 1

Functional Improvement

• Improved mobility and quality of life 2
• Reduced need for pain medications
• Earlier return to activities of daily living
• Full remobilization in most patients 1

Complications

• Cement extravasation rate: approximately 12% of treated fractures 1
• Most extravasations are asymptomatic 1
• Rare complications include nerve root compression, infection, and pulmonary embolism

Post-Procedure Care

• CT scan on the day after intervention to assess cement distribution and detect leakage 1
• Early mobilization is encouraged
• Continued management of underlying osteoporosis 3

Clinical Pearls

• Bilateral procedures are commonly needed (11 of 13 patients in one study) 2
• Patient positioning after the procedure may help prevent cement extravasation 5
• Careful patient selection is critical for optimal outcomes
• Interdisciplinary approach involving pain management, radiology, and orthopedics is recommended

Bilateral sacroplasty represents an effective minimally invasive treatment option for patients with bilateral sacral insufficiency fractures who have failed conservative management, offering rapid, significant, and sustained pain relief with high patient satisfaction.