Vergleich von konservativer Therapie vs. CT-gesteuerter Ballon -sakroplastie bei der Behandlung von Insuffizienz frakturen des Os sacrum

Zusammenfassung

Ziel der Studie

Bei älteren osteoporotischen Patienten sind Insuffizienzfrakturen des Os sacrum relativ häufig und typischerweise mit invalidisierenden Schmerzen verbunden. In unserer Studie sollte das Outcome für die konservative Behandlung und die Ballon -sakroplastie retrospektiv überprüft werden. Material und Methoden: Bei 90 Patienten wur-de mittels MRT eine Os sacrum-Fraktur detek-tiert. Die konservative Behandlung beinhaltete Schmerztherapie und physio therapeutische Maßnahmen. Die Ballon sakroplastie erfolgte CT-gesteuert. Die Schmerzen wurden nach vi-sueller Analog skala (VAS) dokumentiert, die Patienten zufriedenheit wurde nach zwölf Mo-naten erfragt.

Ergebnisse

Bei dem Vergleich der Patienten in den konservativ behandelten Gruppen zeigt sich, dass Patienten mit einem Schmerzniveau bis 5 klinisch deutlich bessere Ergebnisse auf-weisen als Patienten mit Werten > 5. In der In-terventionsgruppe zeigte sich postinterventio-nell eine schnelle, signifikante und nachhaltige Schmerzreduktion. Nach zwölf Monaten fand sich eine hohe Patienten zufriedenheit.

Fazit

Der Erfolg der konservativen Therapie ist stark von der Schmerzausgangsintensität abhängig. Patienten mit VAS-Werten > 5 sollten aufgrund der schnellen und signifikanten Schmerzreduktion nach Zement augmentation einer Ballonsakroplastie zugeführt werden.

Summary

Objective

In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically associated with intense, disabling pain. The standard therapy for sacral insufficiency fractures remains conservative today. Balloon sa-croplasty represents an alternative treatment option. Our study was designed to examine the outcome of the different treatment forms retrospectively.

Material and methods

In 90 patients with an average age of 80.3 years, a sacral fracture was detected by MRI. Depending on the pain intensity, the conservative treatment given involved bed rest, adjuvant analgesic therapy, as well as mobilisation with pain-adapted weight-bearing. The cement augmentation was performed by CT guided balloon sacroplasty. Pain was documented on a visual analogue scale (VAS) on the day of in-patient admission, after 3 days, on the day of discharge, and after 6 and 12 months. Additionally occurring complications were recorded, and the patients were asked to state how satisfied they were after 12 months.

Results

Conservatively treated patients with a pain level of up to 5 could be discharged from inpatient treatment earlier and were less reliant on analgesics and supporting aids in everyday life than patients with values > 5. Conservatively treated patients with VAS values >5 showed a significantly higher rate of complications and mortality, and the pain level was significantly higher. In particular, a higher incidence of newly occurring anterior pelvic ring fractures was observed over the course in this group of patients. In the inter-ventional group, an average pain value of 8.7 was observed prior to the intervention. There was a significant pain reduction on the second postoperative day (p < 0.001) with an average value of 2.5, and this was stable at 2.5 after 6 months and 2.4 after 12 months. A high patient satisfaction was found after 12 months.

Conclusion

The success of conservative therapy is strongly dependent upon the pain intensity at baseline, whereby patients with a high level of pain require longer periods of treatment and show much higher complication rates. On the basis of the rapid and significant reduction in pain after cement augmentation, patients with VAS values >5 should be treated by balloon sacroplasty.

Schlüsselwörter

Ballonsakroplastie - Insuffizienzfraktur - kon-servative Behandlung - Os sacrum-Fraktur - Schmerztherapie - Zementaugmentation

Keywords

Balloon sacroplasty - insufficiency fracture - conservative treatment - sacral fracture - pain therapy - cement augmentation

• Literatur

• 1 Lourie H. Spontaneous osteoporotic fracture of the sacrum. An unrecognised syndrome of the elderly. JAMA 1982; 248 (06) 715-717.
• 2 Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthopaedic Surg 2007; 15 (03) 339-346.
• 3 Dasgupta B, Shah N, Brown H. et al. Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 1998; 37 (07) 789-793.
• 4 Grasland A, Pouchot J, Mathieu A. et al. Sacral insufficiency fractures: an easily overlooked cause of back pain in elderly women. Arch Intern Med 1996; 156 (06) 668-674.
• 5 Blake SP, Conners AM. Sacral insufficiency fracture. Br J Radiol 2004; 77 (922) 891-896.
• 6 Alnaib M, Waters S, Shanshal Y. et al. Sacral insufficiency fractures. J Orthopaedic Surg 2007; 15 (03) 339-346.
• 7 Gotis-Graham I, McGuigam L, Diamond T. et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 1994; 76 (06) 882-886.
• 8 Lin JT, Lane JM. Sacral stress fractures. J Womens Health 2003; 12 (09) 879-888.
• 9 West SG, Troutner JL, Baker MR. et al. Sacral insufficiency fractures in rheumatoid arthritis. Spine 1994; 19 (18) 2117-2121.
• 10 Lips P. Vitamin D deficiency and secondary hyperthyroidism in elderly: consequences for bone and fractures and therapeutic implications. Endocr Rev 2001; 22 (04) 477-501.
• 11 Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227: 67-81.
• 12 De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. Am J Roentgenol 1985; 145 (03) 601-606.
• 13 Peh WC, Khong PL, Ho WY. et al. Imaging of pelvic insufficiency fractures. Radiographics 1996; 16 (02) 335-348.
• 14 Alnaib M, Waters S, Shanshal Y. et al. Combined pubic rami and sacral osteoporotic fractures: a prospective study. J Orthop Traumatol 2012; 13 (02) 97-103.
• 15 Fuchs T, Rottbeck U, Hofbauer V. et al. Beckenringfrakturen im Alter. Die unterschätzte osteoporotische Fraktur.. nfallchirurg 2011; 114 (08) 663-670.
• 16 Vanderschot P, Kuppers M, Sermon A. et al. Transiliac-sacral-iliac-bar procedure to treat insufficiency fractures of the sacrum. Indian J Orthop 2009; 43 (03) 245-252.
• 17 Tjardes T, Paffrath T, Baethis H. et al. Computer assisted percutaneous placement of augmented iliosacral screws: a reasonable alternative to sacroplasty. Spine (PhilaPa 1976) 2008; 33 (13) 1497-1500.
• 18 Whitlow CT, Yazdani SK, Reedy ML. et al. Investigating sacroplasty: technical considerations and finite element analysis of polymethylmethacralate infusion into cadaveric sacrum. AJNR Am J Neuroradiol 2007; 28 (06) 1036-1041.
• 19 Garant M. Sacroplasty: a new treatment for sacral insufficiency fracture. J Vasc Interv Radiol 2002; 13 (12) 1265-1267.
• 20 Butler CL, Given 2nd CA, Michel SJ. et al. Percutaneous sacroplasty for the treatment of sacral insufficiency fractures. AJR Am J Roentgenol 2005; 184 (06) 1956-1959.
• 21 Frey ME, DePalme MJ, Cifu DX. et al. Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine 2008; 08 (02) 367-373.
• 22 Heron J, Connell DA, James SL. CT-guided sacroplasty for the treatment of sacral insufficiency fractures. Clin Radiol 2007; 62 (11) 1094-1100.
• 23 Heß GM. Sakroplastie zur Behandlung von Insuffizienzfrakturen des Sakrums. Unfallchirurg 2006; 109 (08) 681-686.
• 24 Bayley E, Srinivas S, Boszczyk BM. Clinical outcomes of sacroplasty in sacral insufficiency fractures: a review of the literature. Eur Spine J 2009; 18 (09) 1266-1271.
• 25 Kortman K, Ortiz O, Miller T. et al. Multicenter study to assess the efficacy and safety of sacroplasty in patients with osteoporotic sacral insufficiency fractures or pathologic sacral lesions. J Neurointerv Surg 2013; 05 (05) 461-466.
• 26 Bastian JD, Keel MJ, Heini PF. et al. Complications related to cement leakage in sacroplasty. Acta Orthop Belg 2012; 78 (01) 100-105.
• 27 Deen HG, Nottmeier EW. Balloon kyphoplasty for treatment of sacral insufficiency fractures. Report of three cases. Neurosurg Focus 2005; 18 (03) 1-5.
• 28 Briem D, Grossterlinden L, Begemann PG. et al. CT-gesteuerte Sakroplastie unter Verwendung insufflierbarer Ballons: Ergebnisse einer Machbarkeitsstudie. Unfallchirurg 2008; 111 (06) 381-386.
• 29 Andresen R, Radmer S, Kamusella P. et al. Interventionelle Schmerztherapie mittels Ballon-Kyphoplastie bei Patienten mit osteoporosebedingten Insuffizienzfrakturen des Os sacrum. Fortschr Röntgenstr 2012; 184 (01) 32-36.
• 30 Shah RV. Sacral kyphoplasty for the treatment of painful sacral insufficiency fractures and metastases. Spine J 2012; 12 (02) 113-120.
• 31 Andresen R, Radmer S, Kamusella P. et al. Treatment of Denis 1, 2 and 3 insufficiency fracture zones of the os sacrum. Individual approaches adapted to the course of the fracture in CT-assisted balloon sacroplasty. Osteol 2012; 21 (03) 168-173.
• 32 Babayev M, Lachmann E, Nagler W. The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate?. Am J Phys Med Rehabil 2000; 79 (04) 404-409.
• 33 DVO Guideline 2009 for Prevention, Diagnosis and Therapy of Osteoporosis in Adults. Osteol 2011; 20 (01) 55-74.
• 34 Finiels H, Finiels PJ, Jacquot JM. et al. Fractures of the sacrum caused by bone insufficiency. Metaanalysis of 508 cases. Presse Med 1997; 26 (33) 1568-1573.
• 35 Andresen R, Radmer S, Banzer D. Bone mineral density and spongiosa architecture in correlation to vertebral body insufficiency fractures. Acta Radiol 1998; 39 (05) 538-542.
• 36 Byrnes DP, Russo GL, Ducker TB. et al. Sacrum fractures and neurological damage. Report of two cases. J Neurosurg 1977; 47 (03) 459-462.
• 37 Leroux JL, Denat B, Thomas E. et al. Sacral insufficiency fractures presenting as acute low-back pain. Biomechanical aspects. Spine 1993; 18 (16) 2502-2506.
• 38 Richards AM, Mears SC, Knight TA. et al. Biomechanical analysis of sacroplasty: does volume or loacation of cement matter?. AJNR Am J Neuroradiol 2009; 30 (02) 315-317.
• 39 Anderson DE, Cotton JR. Mechanical analysis of percutaneous sacroplasty using CT image based finite element model. Med Eng Phys 2007; 29 (03) 316-325.
• 40 Trouvin AP, Alcaix D, Somon T. et al. Analgesic effect of sacroplasty in osteoporotic sacral fractures: a study of six cases. Joint Bone Spine 2012; 79 (05) 500-503.
• 41 Thomas EN, Cyteval C, Herisson C. et al. Osteoporotic fracture of the sacrum: sacroplasty and physical medicine. Ann Phys Rehabil Med 2009; 52 (05) 427-435.
• 42 Newhouse KE, El-Khoury GY, Buckwalter JA. Occult sacral fractures in osteopenic patients. J Bone Joint Surg (Am) 1992; 74 (10) 1472-1477.
• 43 Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine 1993; 18 (16) 2507-2512.
• 44 Aretxabala I, Fraiz E, Perez-Ruiz F. et al. Sacral insufficiency fractures. High association with pubic rami fractures. Clin Rheumatol 2000; 19 (05) 399-401.