4 Sacral
4.1 Trauma
4.1.1 Sacral Fusion
Symptoms and Signs
Diminished control/dysfunction of bladder/bowel, rectum, urinary system, and external genitalia (men: problems with erection and ejaculation; women: problems with lubrication)
Moderate/Severe numbness in perianal area (saddle anesthesia)
Loss of sensation along S2–S5 dermatomes
Muscle weakness in perianal/perineal region, including difficulty in voluntarily contracting the anus
Moderate/Severe pain in the sacral region (including peripelvic pain)
Bruising of the pelvic and buttocks regions
Pelvic ring injury
Spondylolisthesis
Cauda equina symptoms
Deficits in lower extremities
Refractory lower back pain
Surgical Pathology
Sacral spine benign/malignant trauma
Diagnostic Modalities
Physical/Neurologic examination and patient history
CT of sacrum without contrast (coronal and sagittal reconstruction views)
MRI of sacrum without contrast (when neural compromise may be indicated)
X-ray of sacrum (best views: AP, lateral, inlet, and outlet)
CT or X-ray of pelvis (not typically necessary)
Differential Diagnosis
Zone 1 fracture (lateral to foramina)
Most common
Zone 2 fracture (through foramina)
Very unstable with shear component
Zone 3 fracture (medial to foramina into spinal canal)
Frequently results in neurologic deficit
Transverse fracture
Frequently results in nerve dysfunction
U-type fracture
Frequently results in neurologic deficit
Treatment Options
Acute pain control with medications and pain management
Physical/Occupational/Rehabilitation therapy and rehabilitation
Progressive weight bearing with or without orthosis (if no neurologic deficit and little displacement)
If symptomatic without neurologic injury:
Urgent surgical fixation of implicated segments if deemed suitable candidate for surgery
If poor surgical candidate with poor life expectancy, medical management recommended
Percutaneous screw fixation
Posterior tension band plating
Iliosacral and lumbopelvic fixation
If symptomatic with cord compression:
Urgent surgical decompression and fusion of implicated segments if deemed suitable candidate for surgery
If poor surgical candidate with poor life expectancy, medical management recommended
Surgery may be done indirectly through axial traction or directly (posteriorly)
May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Laminotomy (section of lamina and ligament removed), Foraminotomy (expanding space of neural foramen by removing soft tissues, small disk fragments, and bony spurs in the locus), Laminoplasty (expanding space within spinal canal by repositioning lamina), Diskectomy (removal of section of herniated disk), Corpectomy (removal of vertebral body and disks), Bony Spur Removal
This may be accompanied by fusion for added stabilization (see ▶Fig. 4.1)
Fig. 4.1 A teenage boy who suffered a complete spinal cord injury, accompanied by severe kyphosis (a, b), received a posterior spinal fusion with instrumentation at T2-Sacrum/Pelvis (c, d). Prevalence. In: Samdani A, Newton P, Sponseller P, et al, eds. Neuromuscular Spine Deformity: A Harms Study Group Treatment Guide. 1st ed. Thieme; 2018
Indications for Surgical Intervention
No improvement after nonoperative therapy (physical therapy, pain management)
Fracture displacement greater than 1 cm
Fracture displacement after nonoperative therapy
Soft tissue is compromised
Unstable patterns of fracture
Neurologic dysfunction and/or instability resulting from sacral trauma
Surgical Procedure for Posterior Sacral Spine (Instrumentation without Fusion)
Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
Patient placed prone on OSI spine table, with pillows placed under thighs
Neuromonitoring not needed
Apply bifemoral skeletal traction
Femoral traction can be applied in two ways:
i. Traction bow posterior to thighs (extends pelvis and reduces kyphotic deformity)
ii. Traction bow anterior to thighs (longitudinal traction, reducing traumatic spondyloptosis)
Visualize the sacral fracture using fluoroscopy
Traction is applied to reduce it
Prepare pedicle screws placement into L4 and L5 (bilateral percutaneous pedicle screws with 6–7 mm diameters; four in total):
Make 2 to 3 cm bilateral incisions above the L4 and L5 levels of vertebrae, 1 to 2 cm lateral to the lateral L4 and L5 pedicle walls
Insert introducer needles and subsequently place guide wires, under fluoroscopic guidance
Hold the guide wires out of the way using hemostats
Place iliac screws (bilateral iliac screws with 8–9 mm diameters and 80–100 mm lengths; two in total):
Make 2 cm bilateral incisions, at the level of and 0.1 to 1 cm medial to posterior superior iliac spine (PSIS)
Perform sharp dissection to expose fascia on the iliac crest
Split fascia longitudinally over iliac crest using electrocautery, halfway between medial and lateral border, and elevate it off the medial side
Perform digital dissection to elevate the muscle off the medial side of iliac crest and expose the posterior sacral cortex (use retractors as necessary)
Remove sufficient iliac bone, including medial part of dorsal cortex, using gouges, to place iliac screws and provide enough room for the rods
Use curved tip of blunt curved probe, in conjunction with fluoroscopic imaging, to confirm the trajectory of screw placement
Place the iliac screws through the established pathway, continuing until the screw heads make contact with the sacrum
Sufficient proximal and distal clearance across the iliac crest bone from the iliac screws must be made in preparation for rod placement, using a straight osteotome
Bilateral rods (two in total) with 5.5 mm diameters are used
Once accomplished, place pedicle screws over the previously established guidewires
Reduce the fracture:
Reduce the fracture using direct manipulation of the iliac screws, by handling the left-in-place screws with insertion drivers
Hold the fracture in place through the screws on one side of spine, while removing screwdrivers on other side of spine
Pass the rod and place set screws, tightening them
Remove the contralateral screwdrivers and pass the other rod, placing and tightening the remaining set screws
When the rod is placed into the L4 and L5 screws, the iliac screw heads pivot
Tighten the iliac screws
After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion
Instrumentation can be removed 4 to 6 months after surgery after the healing of the fracture is confirmed via CT
Pitfalls
Intraoperative cerebrospinal (CSF) leak
Damage to spinal nerves and/or cord (especially thecal sac injury and dural tear)
Postoperative weakness or numbness or continued pain
Postoperative wound infection
Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
Progressive kyphosis
Problems with bowel/bladder control
Venous thromboembolism (frequently from immobility)
Iatrogenic nerve injury (frequently from fracture overcompression)
Malreduction (frequently associated with vertically displaced fractures)
Surgical Procedure for Anterior Sacral Spine (Anterior Lumbar Interbody Fusion with Transperitoneal Approach)
Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
Preoperative antibiotics delivered via IV injection
Appropriate intubation and sedation and lines (if necessary) as per the anesthetist (endotracheal tube and ventilator-assisted breathing)
Patient placed in supine position on radiolucent table, enabling use of C-arm fluoroscope
Place sterile drapes after properly cleansing the abdominal region
Neuromonitoring not needed
Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
Make midline abdominal skin incision over the L5–S1 level
Open the linea alba by performing another midline incision
Spread abdominal muscles apart without cutting them
Retract the peritoneal sac (including the intestines) and large blood vessels to the left side using retractors
Visualize the anterior aspect of the intervertebral disks using retractors
Once the bone of interest is exposed, it is recommended to localize and verify it via fluoroscopic imaging and confirming with at least two people in the room
Remove the intervertebral disk using Pituitary rongeurs, Kerrison rongeurs, and curettes (diskectomy)
Restore normal height of disk using distractor instruments and determine the size required for cage using fluoroscopy
Implant metal, plastic, or bone cage (with bone graft material) into the intervertebral disk space, under fluoroscopic guidance
Confirm that the location is correct using fluoroscopy
Add stability by adding instrumentation (a plate or screws/rods to hold the cage in place)
After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion
Pitfalls
Reduction in range of motion and mobility of fused spinal segments
Intraoperative CSF leak
Urethral injury
Bowel perforation
Incision hernia
Ileus
Retrograde ejaculation in men
Vascular injury
Damage to spinal nerves and/or cord
Postoperative weakness or numbness or continued pain
Postoperative wound infection
Prognosis
Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
Pain medications for postsurgical pain
Physical therapy and occupational therapy will be needed postoperatively, immediately and as outpatient to regain strength
Brace placed after discharge to immobilize to increase rate of healing
4.1.2 Tarlov Cyst Treatment
Symptoms and Signs
Diminished control/dysfunction of bladder/bowel, rectum, urinary system, and external genitalia (men: problems with erection and ejaculation; women: problems with lubrication)
Moderate/Severe numbness in perianal area (saddle anesthesia)
Loss of sensation along S2–S5 dermatomes
Muscle weakness in perianal/perineal region, including difficulty in voluntarily contracting the anus
Moderate/Severe pain in the sacral region (including peripelvic pain)
Bruising of the pelvic and buttocks regions
Pelvic ring injury
Spondylolisthesis
Cauda equina symptoms
Deficits in lower extremities
Refractory lower back pain
Radicular pain in lower body
Sciatica
Impaired reflexes
Coccydynia
Surgical Pathology
Sacral spine benign/malignant cyst
Sacral spine benign/malignant trauma
Diagnostic Modalities
Physical/Neurologic examination and patient history
CT myelography
MRI of lumbosacral spine without contrast (when neural compromise may be indicated) (see ▶Fig. 4.2)
Fig. 4.2 An MRI scan demonstrating a sacral Tarlov cyst (a) is compared with a control lumbosacral MRI (b). Xie C, Zheng X, Zhang N. Tarlov cyst is correlated with a short broad terminal of the thecal sac. J Neurol Surg A Cent Eur Neurosurg 2017;78(3):245–249
X-ray of sacrum (best views: AP, lateral, inlet, and outlet)
CT or X-ray of pelvis (not typically necessary)
Urological testing (urodynamics, cystoscopy, kidney ultrasound)
Differential Diagnosis
Fracture
Zone 1 fracture (lateral to foramina)
Most common
Zone 2 fracture (through foramina)
Very unstable with shear component
Zone 3 fracture (medial to foramina into spinal canal)
Frequently results in neurologic deficit
Transverse fracture
Frequently results in nerve dysfunction
U-type fracture
Frequently results in neurologic deficit
Tarlov cyst (see ▶Fig. 4.3)
Fig. 4.3 Cross-section images of lower lumbar Tarlov cyst patients (a, b) compared with normal controls (c, d). Xie C, Zheng X, Zhang N. Tarlov cyst is correlated with a short broad terminal of the thecal sac. J Neurol Surg A Cent Eur Neurosurg 2017;78(3):245–249
Disk herniation(s)
Gynecological conditions
Meningeal diverticula
Meningoceles
Arachnoiditis
Neurofibroma, Schwannoma
Treatment Options
Acute pain control with medications and pain management
Physical/Occupational/Rehabilitation therapy and rehabilitation
If symptomatic but poor surgical candidate (symptomatic cyst recurrence remains possible):
If poor surgical candidate with poor life expectancy, medical management recommended
Lumbar drainage of CSF
Cyst aspiration under CT guidance
CSF removal from interior of cyst, to be injected with fibrin sealant
If symptomatic cyst with cord/nerve root compression (treatments including, but not limited to):
Surgical decompression with cyst removal of implicated segments if deemed suitable candidate for surgery
If poor surgical candidate with poor life expectancy, medical management recommended
Laminectomy, cyst/nerve root removal, microsurgical cyst fenestration, and imbrication
Laminectomy, cyst resection
Microsurgical resection and defect closure with fibrin glue
Complete cyst removal and defect closure with fibrin glue
Cyst removal with neck occlusion
If symptomatic fracture with severe central canal compression:
Urgent surgical decompression and fusion of implicated segments if deemed suitable candidate for surgery
If poor surgical candidate with poor life expectancy, medical management recommended
Surgery may be done indirectly through axial traction or directly (posteriorly)
May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Laminotomy (section of lamina and ligament removed), Foraminotomy (expanding space of neural foramen by removing soft tissues, small disk fragments, and bony spurs in the locus), Laminoplasty (expanding space within spinal canal by repositioning lamina), Diskectomy (removal of section of herniated disk), Corpectomy (removal of vertebral body and disks), Bony Spur Removal
This may be accompanied by fusion for added stabilization
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