Treatment for sacral insufficiency fractures: A systematic review.

Intro: Sacral insufficiency fractures after lumbosacral fusion continue to establish themselves as a rare complication after surgery. The diagnosis can often be missed due to inconclusive imaging and non-specific symptoms. In the literature, the treatment of sacral insufficiency fractures varies from non-operative and conservative management to surgical intervention with lumbopelvic fixation. Methods: We performed a systematic review searching the PubMed database using sacral insufficiency fracture treatment after lumbosacral fusion and sacral insufficiency fracture after posterior spinal instrumentation as keywords. Results: This search strategy identified 32 publications from the PubMed database for literature review. After evaluating the inclusion and exclusion criteria, a total of 17 articles were included in the review. 65% of sacral insufficiency fractures were managed surgically with 35% of patients proceeding with non-operative, conservative management only. Revision surgery always involved sacropelvic fixation which typically led to immediate resolution or reduction of symptoms, with the exception of 2 cases that did not receive adequate reduction of symptoms. Five cases reported failed non-operative management that subsequently responded to revision surgery. Conclusion: Outcomes after non-operative management usually leads to symptom resolution; however has a slower symptom relief time as well as a higher chance of failed treatment. Operative outcomes, generally with a variation of sacropelvic fixation lead to immediate symptom resolution and very rarely failed treatment. Clinicians must always maintain a high index of suspicion of new onset lower back or sacral pain after lumbosacral surgery and order a CT scan to rule out a potential insufficiency fracture. Objectives: The objective of this study was to review the literature to examine treatment options for sacral insufficiency fractures after lumbosacral fusion in order to improve clinical practice and management. This systematic review of the literature regarding treatment of sacral insufficiency fractures will assist clinicians in making the accurate diagnosis and devise a strategic treatment plan for patients with sacral insufficiency fractures after spinal instrumentation.