Diagnostik und Behandlung von sacralen Insuffizienzfrakturen unter besonderer Berücksichtigung der Zementaugmentationsverfahren – eine Übersicht

Zusammenfassung

Insuffizienzfrakturen des Os sacrum werden in letzter Zeit immer häufiger detektiert, wobei aufgrund der steigenden Lebenserwartung die Inzidenz weiter zunehmen wird. Ein Teil der Patienten ist, bedingt durch die starken Frakturschmerzen, invalidisiert und lässt sich durch eine konservative Behandlung nicht suffizient therapieren. Mittels Zementeinbringung in die entsprechende Frakturzone lässt sich eine deutliche Schmerzreduktion und klinische Verbesserung herbeiführen. Ziel dieser Übersichtsarbeit ist eine Darstellung der unterschiedlichen Zementaugmentationsverfahren Ballon-, Radiofrequenz-, Vertebro- und Zementsakroplastie hinsichtlich der richtigen Indikation, der technischen Durchführbarkeit, den möglichen Komplikationen und des klinischen Outcomes. Die Grenzen der Sakroplastie und die Indikation zur Durchführung unterschiedlicher Osteosyntheseverfahren werden aufgezeigt.

Eine Literaturrecherche in PubMed und GoogleScholar wurde zu den Stichworten durchgeführt: Beckeninsuffizienzfraktur, Fragilitätsfrakturen des Beckenrings, sacrale Insuffizienzfraktur, Os sacrum, Osteoporose, interventionelle Schmerztherapie, Sakroplastie, Zementaugmentation und Beckenosteosynthesen. Erfahrungen aus der seit Jahren bestehenden eigenen interdisziplinären und multizentrischen Arbeitsgruppe wurden mitberücksichtigt.

Neue Klassifikationen in der Einteilung von Beckeninsuffizienzfrakturen sind bei der Festlegung des therapeutischen Vorgehens unter Beachtung der individuellen Klinik zu berücksichtigen. Eine konservative Therapie steht zunächst im Vordergrund, jedoch werden hier nicht alle Patienten schmerzfrei und lassen sich nicht adäquat mobilisieren, konsekutiv folgen Komorbiditäten und eine erhöhte Mortalität. Bei nichtdislozierten Frakturen lässt sich mittels Sakroplastie eine schnelle und nachhaltige Schmerzreduktion herbeiführen. Hinsichtlich der Zementaugmentation lassen sich osteoplastische Verfahren wie die Ballon-, Radiofrequenz- und Zementsakroplastie von dem nichtosteoplastischen Verfahren der Vertebrosakroplastie unterscheiden. Bei der Vertebrosakroplastie muss man mit einer höheren Zementleckagerate rechnen. Die komplexe sacrale Anatomie, die osteopene Knochenstruktur, die Ausrichtung der Frakturzonen, das unterschiedlich technische Vorgehen, die Eigenschaften der Zemente und die Erfahrung des Operateurs haben einen Einfluss auf das Auftreten möglicher Komplikationen.

Wenn konservative Maßnahmen zu keiner klinischen Verbesserung führen, profitieren Patienten mit schmerzhaften, nichtdislozierten sacralen Insuffizienzfrakturen von einer Zementaugmentation effektiv und nachhaltig. Durch den Einsatz von individuell anzupassenden Sakroplastieverfahren sind relevante Komplikationen insgesamt sehr selten. Patienten mit instabilen Frakturen profitieren von einer rechtzeitig durchgeführten Osteosynthese.

Abstract

Insufficiency fractures of the sacrum are being detected increasingly frequently, whereby their incidence will no doubt increase further as a result of the rise in life expectancy. Some of the patients are disabled by the severe fracture pain and cannot be treated adequately by means of conservative treatment. A marked pain reduction and clinical improvement can be achieved by inserting cement into the respective fracture zone. The objective of this review article is to present the different cement augmentation procedures, balloon, radiofrequency, vertebro- and cement sacroplasty, with regard to their correct indication, technical feasibility, possible complications and clinical outcome.

A literature search was conducted in PubMed and Google Scholar using the keywords: pelvic insufficiency fracture, fragility fractures of the pelvic ring, sacral insufficiency fracture, sacrum, osteoporosis, interventional pain therapy, sacroplasty, cement augmentation and pelvic osteosyntheses. Experience gained from our own interdisciplinary, multicentric working group, which has been in existence for many years, was also taken into consideration.

New classifications in the categorisation of pelvic insufficiency fractures must be taken into account when determining the appropriate therapeutic procedure, while making allowance for the individual clinical situation. Conservative therapy is of primary importance initially, although not all patients achieve freedom from pain here and cannot be mobilised adequately, subsequently leading to comorbidities and increased mortality. In the case of non-dislocated fractures, sacroplasty can be performed to achieve rapid and sustained pain reduction. With regard to cement augmentation, the osteoplastic procedures such as balloon, radiofrequency and cement sacroplasty can be differentiated from the non-osteoplastic procedure of vertebrosacroplasty. In the case of vertebrosacroplasty, a higher rate of cement leakage is to be expected. The complex sacral anatomy, the osteopenic bone structure, the alignment of the fracture zones, the differences in technical approach, the properties of the cements and the experience of the surgeons have an influence on the occurrence of possible complications.

If conservative measures do not lead to a clinical improvement, patients with painful, non-dislocated sacral insufficiency fractures achieve an effective and sustained benefit from cement augmentation. Through the use of individually adaptable sacroplasty procedures, relevant complications are generally very rare. Patients with unstable fractures benefit from osteosynthesis performed at an early stage.

Schlüsselwörter

Beckenosteosynthesen - Os sacrum - Osteoporose - sakrale Insuffizienzfraktur - Sakroplastie - Schmerztherapie - Zementaugmentation

Key words

Pelvic osteosynthesis - sacrum, osteoporosis - sacral insufficiency fracture - sacroplasty - pain therapy - cement augmentation

Publication History

Article published online:
27 July 2020

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