Advertisement

Skeletal Radiology

, Volume 24, Issue 1, pp 31–35 | Cite as

Vacuum phenomena in insufficiency fractures of the sacrum

  • Axel Stäbler
  • Reiner Beck
  • Reiner Bartl
  • Dorothea Schmidt
  • Maximilian Reiser
Article

Abstract

Objective. Insufficiency fractures of the sacrum are found in women who have undergone radiation therapy to the lower abdomen as well as those suffering from osteoporosis of postmenopausal, steroid-induced, or primary biliary cirrhosis-related origin. Increased up-take in bone scintigraphy and osteolytic changes in these fractures can be misinterpreted as bone metastases, leading to unnecessary biopsies and other procedures in the ensuing search for non-existent primary tumor.Patients. In eight female patients averaging 69.4 years of age, insufficiency fracture of the sacrum was diagnosed by computed tomography (CT) and bone scintigraphy. Three underwent a total of five MRI examinations. Malignancy was excluded by histology in two patients and follow-up of at least 6 months in the remainder. Retrospective analysis of CT scans of 13 patients with metastases in the sacrum revealed no vacuum phenomena.Results. In seven of eight patients with insufficiency fracture of the sacrum, vacuum phenomena were shown on CT examination. The gas was localized centrally within the ventral part of the fracture in three patients; gas was located in ten adjacent sacro-iliac joints of six patients.Conclusions. The vacuum phenomenon may be an incidental finding in osteoarthritis of the sacro-iliac joint, but it has not been previously recognized in IFS. The presence of intra-articular vacuum phenomena in the sacro-iliac joints in combination with a sacral fracture and vacuum phenomena located within the sacral fracture supports a diagnosis of insufficiency fracture or may indeed be the clue by which this diagnosis is established. Insufficiency fractures of the sacrum are a well-known complication in women who have undergone radiation therapy of the pelvis or are suffering from postmenopausal, steroid-induced, or primary biliary cirrhosis-related osteoporosis [1–11]. These fractures are characterized by increased activity on radionuclide bone scans. The lateral masses of the sacrum contain large amounts of hematopoetic bone marrow and are therefore often the site of bone metastasis. Increased uptake in bone scintigraphy in lateral masses of the sacrum and osteolytic destructions on radiographs and computed tomography (CT), especially in patients with a history of a tumor elsewhere, are suggestive of skeletal metastasis, prompting biopsies and additional diagnostic procedures to find a primary tumor [2]. We present seven out of eight patients with insufficiency fractures of the sacrum, in whom we observed vacuum phenomena within the fracture or in the adjacent sacroiliac joints, indicating the benignity of the lesion. This phenomenon has not been recognized previously.

Key words

Computed tomography Insufficiency fractures Osteoporosis Sacro-iliac joint Radiation, complications Sacral bone 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Abe H, Nakamura M, Takahashi S, Maruoka S, Ogawa Y, Sakamoto K. Radiation-induced insufficiency fractures of the pelvis: evaluation with99mTc-methylene diphosphonate scintigraphy. AJR 1992; 158: 599–602.CrossRefGoogle Scholar
  2. 2.
    Blomlie V, Lien HH, Iversen T, Winderen M, Tvera K. Radiation-induced insufficiency fractures of the sacrum: evaluation with MR imaging. Radiology 1993; 188: 241–244.CrossRefGoogle Scholar
  3. 3.
    Buchard P-A, Gerster J-C. Fractures par insuffisance osseuse du sacrum. Schweiz Med Wochenschr 1991; 121: 1008–1013.PubMedGoogle Scholar
  4. 4.
    Cooper KL, Beabout JW, Swec RG. Insufficiency fractures of the sacrum. Radiology 1985; 156: 15–20.CrossRefGoogle Scholar
  5. 5.
    De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR 1985; 145: 601–606.CrossRefGoogle Scholar
  6. 6.
    Lien HH, Blomlie V, Talle K, Tveit KM. Radiation-induced fracture of the sacrum: findings on MR (letter). AJR 1992; 159: 227.CrossRefGoogle Scholar
  7. 7.
    Lock SH, Mitchell SC. Osteoporotic sacral fracture causing neurological deficit. Br J Hosp Med 1993; 49: 210.PubMedGoogle Scholar
  8. 8.
    Lundin B, Björkholm E, Lundell M, Jacobsson H. Insufficiency fractures of the sacrum after radiotherapy for gynaecological malignancy. Acta Oncol 1990; 29: 211–215.CrossRefGoogle Scholar
  9. 9.
    Lourie H. Spontaneous osteoporotic fracture of the sacrum: unrecognized syndrome of the elderly. JAMA 1982; 248: 715–717.CrossRefGoogle Scholar
  10. 10.
    Khorasami R, Nagel JS, Tumeh SS. Radiologic vignette. Sacral insufficiency fracture. Arthritis Rheum 1991; 34: 1387–1390.CrossRefGoogle Scholar
  11. 11.
    Newhouse KE, El-Khoury GY, Buckwalter JA. Occult sacral fractures in osteopenic patients. J Bone Joint Surg 1992; 74A: 1472–1477.Google Scholar
  12. 12.
    Atwell AE, Jackson DW. Stress fractures of the sacrum in runners. Am J Sports Med 1991; 19: 531–533.CrossRefGoogle Scholar
  13. 13.
    Schils J, Hauzeur J-P. Stress fracture of the sacrum. Am J Sports Med 1992; 20: 769–770.CrossRefGoogle Scholar
  14. 14.
    Volpin G, Milgrom C, Goldsher D, Stein H. Stress fractures of the sacrum following strenuous activity. Clin Orthop 1989; 68: 184–188.Google Scholar
  15. 15.
    Ries T. Detection of osteoporotic sacral fractures with radionuclides. Radiology 1983; 146: 783–785.CrossRefGoogle Scholar
  16. 16.
    Schneider R, Yacovone J, Ghelman B. Unsuspected sacral fractures: detection by radionuclide bone scanning. AJR 1985; 144: 337–341.CrossRefGoogle Scholar
  17. 17.
    Kumpan W, Salomonowitz E, Seidl G, Wittich GR. The intervertebral vacuum phenomen. Skeletal Radiol 1986; 15: 444–447.CrossRefGoogle Scholar
  18. 18.
    Resnick D, Niwayama G, Guerra J Jr, Vint V, Usselman J. Spinal vacuum phenomena: anatomical study and review. Radiology 1981; 139: 341–348.CrossRefGoogle Scholar
  19. 19.
    Harverson G. Intravertebral vacuum phenomen. Clin Radiol 1988; 39: 69–72.CrossRefGoogle Scholar
  20. 20.
    Maldague BE, Noel HM, Malghem JJ. The intravertebral vacuum cleft: a sign of ischemic vertebral collapse. Radiology 1978; 129: 23–29.CrossRefGoogle Scholar
  21. 21.
    Schabel SI, Moore TE, Rittenberg GM. Vertebral vacuum phenomenon. A radiographic manifestation of metastatic malignancy. Skeletal Radiol 1979; 4: 154–156.CrossRefGoogle Scholar
  22. 22.
    Wendling D, Cassou M, Guidet M. L’image de clarté gazeuse intra-vertebrale. A propos de 7 nouvelles observations. Rev Rhum Mal Osteoartic 1983; 50: 607–612.PubMedGoogle Scholar
  23. 23.
    Rafii M, Firooznia H, Golimbu C, Horner N. Radiation induced fractures of sacrum: CT diagnosis. J Comput Assist Tomogr 1988; 12: 231–235.CrossRefGoogle Scholar
  24. 24.
    Jones JW. Insufficiency fracture of the sacrum with displacement and neurologic damage: a case report and review of the literature. J Am Geriatr Soc 1991; 39: 280–283.CrossRefGoogle Scholar
  25. 25.
    Peh WC, Evans NS. Tarlov cysts — another cause of sacral insufficiency fractures? Clin Radiol 1992; 46: 329–330.CrossRefGoogle Scholar
  26. 26.
    Bronkovsky HL, Hawkins M, Steinberg K, Hersh T, Galambos JT, Henderson JM, Millikan WJ, Galloway JR. Prevalence and prediction of osteopenia in chronic liver disease. Hepatology 1990; 12: 273–280.CrossRefGoogle Scholar
  27. 27.
    Porayko MK, Wiesner RH, Hay JE, Krom RA, Dickson ER, Beaver S, Schwerman L. Bone disease in liver transplant recipients: incidence, timing, and risk factors. Transplant Proc 1991; 23: 462–465.Google Scholar
  28. 28.
    Peris P, Navasa M, Guanabens N, Monegal A, Moya F, Brancós MA, Rimola A, Munoz-Gómez. Sacral stress fracture after liver transplantation. Br J Rheumatol 1993; 32: 702–704.CrossRefGoogle Scholar
  29. 29.
    Brahme SK, Cervilla V, Vint V, Cooper K, Kortmann K, Resnik D. Magnetic resonance appearance of sacral insufficiency fractures. Skeletal Radiol 1990; 19: 489–493.CrossRefGoogle Scholar

Copyright information

© International Skeletal Society 1995

Authors and Affiliations

  • Axel Stäbler
    • 1
  • Reiner Beck
    • 1
  • Reiner Bartl
    • 2
  • Dorothea Schmidt
    • 1
  • Maximilian Reiser
    • 1
  1. 1.Institute of Diagnostic Radiology, Klinikum GrosshadernLudwig Maximilian UniversityMunichGermany
  2. 2.III Medical Clinic, Klinikum GrosshadernLudwig Maximilian UniversityMunichGermany

Personalised recommendations