Treatment of Sacral Fractures with Neurologic Injuries

Sacral fractures occur in two distinctly different patient populations: in individuals with healthy bone as a result of high-energy injury mechanism and in patients with morbid osteopenia that results in insufficiency fractures. Both patient groups share the relatively high propensity for delayed diagnosis of the sacral fracture. In the trauma group, this is due to overriding concerns for care of the multiply injured; in the insufficiency group, it is due to difficulty in interpreting bony landmarks. Both groups share the risk of incurring neurologic deficits and are at significant risk for posttraumatic deformity if sacral fractures are missed or underestimated in the treatment paradigm. Clear diagnostic pathways consisting of systematic physical examination and imaging modalities as well as electrodiagnostics enable the clinician to correctly identify the injury at hand and classify it according to useful systems. Nonoperative care can be successful for patients with minimally displaced fractures and predominately intact lumbosacral ligamentous structures in the presence of little or no neurologic deficits. Most patients with neurologic deficits and sacral disruption will benefit from a timely surgical intervention within the first 2 weeks from injury but rarely on an emergent basis. Surgical stabilization techniques after decompression of neurologic elements where indicated has evolved dramatically from highly morbid procedures with largely improvisational instrumentation techniques to either percutaneous stabilization techniques or devices that allow for comprehensive stabilization of the lumbosacral region as a whole.