Postpartum Sacral Stress Fracture: An Unusual Case of Low-Back and Buttock Pain

ACR Appropriateness Criteria® Stress (Fatigue-Insufficiency) Fracture Including Sacrum Excluding Other Vertebrae: 2024 Update

Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in a variety of patients (athletes, older patients, and patients with predisposing conditions). Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Nuclear medicine scintigraphy and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go on to healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential to progress to completion, necessitating surgery. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated differently (ie, metastatic disease). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Pregnancy-Related Sacral Stress Fractures: A Single Center Experience of 23 Cases

Purpose

This study aims to find out the incidence, etiology, and risk factors, define clinical features, show the magnetic resonance imaging (MRI) and laboratory findings, and share the experience of treatment and clinical outcome of pregnancy-related sacral stress fractures (SSFs).

Methods

In total, 29,291 (15,008 of them vaginal and 14,283 of them cesarean section delivery) women gave birth in our hospital between January 2016 and December 2021. Twenty-three of them (0.078%) who had low back and pelvic pain were diagnosed with SSFs using pelvic MRI. Dual-energy X-ray absorptiometry (DEXA) was used to rule out underlying osteopenia and osteoporosis and determine the type of SSFs.

Results

The incidence of pregnancy-related SSFs was 0.078% (23/29,291patients). Six patients (26%) experienced pain during the last trimester of pregnancy, remaining seventeen (74%) patients had pain during the postpartum period. 73.91% of the patients were primigravida. Thirteen patients (56.52%) were classified as fatigue SSFs, eight (34.78%) were insufficiency SSFs, and only two (8.7%) were defined as a mixed type of SSFs. MRI imaging showed that nine patients (39.13%) had a left-sided fracture, seven patients (30.43%) had a right-sided fracture, and seven patients (30.43%) had bilateral fractures. Vitamin D deficiency (less than 20 ng/mL) was detected in seven patients (30.44%). One case had hypothyroidism in which thyroid stimulating hormone (TSH) was 5.41 μIU/mL.

Conclusion

Pregnancy-related SSFs are uncommon but should be considered by clinicians in the differential diagnosis of low back and pelvic pain during pregnancy and the postpartum period. We determined that first pregnancy is a risk factor for SSFs. The current study also revealed that laboratory investigation of vitamin D deficiency and DEXA investigation, which may lead to osteoporosis or osteopenia, were crucial in the diagnosis. Furthermore, some SSFs should be reclassified as mixed fractures, fatigue, and insufficiency fractures.

‘XX’–Sacroplasty: A Novel Technique for Management of “H-Type” Sacral Insufficiency Fractures

Objective

Examine the feasibility, safety, and results of a novel sacral percutaneous injection technique (“XX”) addressing both the vertical and horizontal aspects of sacral insufficiency fractures (SIF).

Methods

Prospective cohort study. Eight consecutive SIF patients with immobility and pain investigated using CT and nuclear imaging confirmed “H"-type fracture. Demographics, pain level, and ambulation status were recorded. The long-term quality of life was evaluated using the ODI questionnaire and pain VAS scores. Sacroplasty procedures in prone positioning using fluoroscopy were used to insert 2 bone trochars through the S1 pedicles and 2 trochars through the sacral ale aiming toward the SIJ, thus forming 2 “X” trochar formations. Balloon kyphoplasty was done through the trocars, and PMM was injected. Postoperative ambulation and VAS were recorded.

Results

Average age was 81.5 years (±3.4 years). The time from presenting symptoms to hospital admission was 2 days to 4 months. All patients were significantly limited with ambulation. None had a neurologic compromise. Sacroplasty was performed with 2 cases that required additional lumbar kyphoplasty. The mean operative time was 54 min (±14). The average exposure was 19 mGy (±12 mGy). Two patients had cement leaks. CT and X-rays revealed good cement filling of the fractures sacral alae and body of S1. The average postoperative hospitalization was 10 days. All patients reported postoperatively pain relief immediately and were able to walk better. Follow-up time was 17 ± 12 months. Follow-up VAS was 2.7 (±2) and ODI was 57.3% (±21%).

Conclusion

“XX” technique showed good outcomes for patients with higher complexity SIF, using the same principles as for lumbar VPL/KPL, and was found to be safe and effective.

Health Outcomes after Pregnancy in Elite Athletes: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to evaluate postpartum maternal health and training outcomes of females who were competing or training as elite athletes before or during pregnancy.

METHODS

Online databases were searched up to August 26, 2020. Studies of any design and language were eligible if they contained information on the relevant population (postpartum athletes [any period after pregnancy]), exposure (engaged in the highest level of sport immediately before or during pregnancy), comparators (sedentary/active controls), and outcomes: maternal (breastfeeding initiation and duration, postpartum weight retention or loss, bone mineral density, low back or pelvic girdle pain, incontinence [prevalence or severity of stress, urge or mixed urinary incontinence, fecal incontinence], injury, anemia, diastasis recti, breast pain, depression, anxiety) and training (<6 wk time to resume activity, training volume or intensity, performance level).

RESULTS

Eleven studies (n = 482 females, including 372 elite athletes) were included. We identified "very low" certainty evidence demonstrating a higher rate of return to sport before 6 wk postpartum among elite athletes compared with nonelite athletes (n = 145, odds ratio = 6.93, 95% confidence interval = 2.73-17.63, I2 = 11). "Very low" certainty evidence from three studies (n = 179) indicated 14 elite athletes obtained injuries postpartum (7 stress fractures, 9 "running injuries"). "Very low" certainty evidence from five studies (n = 262) reported that 101 (40.5%) elite athletes experienced improved performance postpartum.

CONCLUSION

Compared with controls, "very low" quality evidence suggests that elite athletes return to physical activity early in the postpartum period and may have an increased risk of injury. Additional high-quality evidence is needed to safely guide return to sport of elite athletes in the postpartum period.

Postpartum bilateral sacral stress fracture without osteoporosis-a case report and literature review

PURPOSE

Sacral stress fractures are rare complications which can arise during pregnancy or in the early postpartum period. We report a case and discuss the findings of a confirmed postpartum sacral stress fracture in a 39-year-old multiparous woman and review previous case reports in the literature of sacral stress fracture related to pregnancy.

METHODS

A review of the literature was conducted to examine the main characteristics of sacral stress fractures related to pregnancy. The Ovid/Medline, Embase and Google Scholar databases were searched with the inclusion criteria: human studies, English language, intrapartum, postpartum (within 6 months of parturition), sacrum and stress fracture. Our exclusion criteria included pubic fractures, vertebral fractures and non-English articles. The search terms included "stress fracture", "postpartum", "pregnancy", "atraumatic" and the wildcard "sacr*". Thirty-four cases were found and summarised in Table 2.

RESULTS

A total of 65% of patients had onset of symptoms postpartum. Most patients did not have risk factors for sacral stress fractures including macrosomia, excessive pregnancy weight gain, heparin exposure, rapid vaginal delivery or predisposition to accelerated osteoporosis. Lumbar radiculopathy can be a feature of sacral stress fracture and it is more common (17.6%) than reported in the literature (2%). MRI is the preferred imaging modality for its safety profile in pregnancy and high sensitivity. A total of 70% reported normal bone mineral density (BMD). The mainstay treatment for sacral stress fractures includes relative bed rest, analgesia and modified weight-bearing exercises. Most patients have favourable outcome with complete symptom resolution.

CONCLUSION

Sacral stress fractures in the absence of osteoporosis are rare complications of pregnancy that can present with lumbar radiculopathy. Conservative management often produces good clinical outcomes.

An Atraumatic Sacral Fracture with Lumbosacral Radiculopathy Complicating the Early Postpartum Period: A Case Report

Patient: Female, 26

Final Diagnosis: Atraumatic fatigue sacral fracture

Symptoms: Lumbar back pain with radiculopathy

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Postpartum sacral stress fracture associated with mechanical sacroiliac joint disease: A case report

RATIONALE

Stress fractures of the sacrum and mechanical sacroiliac joint disease can occur not only during pregnancy but also postpartum. Mechanical sacroiliac joint disease is common in patients with low back pain but often misdiagnosed by practitioners. The association of the 2 conditions has not been studied yet.

PATIENT CONCERNS

A 37-year-old woman physiatrist presented with 8-week history of persistent low back and left buttock pain that started in the third trimester of her pregnancy.

DIAGNOSES

Laboratory investigation, dual-energy x-ray absorptiometry, magnetic resonance imaging, and CT of the pelvic region were performed. The patient was diagnosed with postpartum sacral stress fracture associated with mechanical sacroiliac joint disease.

INTERVENTIONS

Treatment consisted in pain killers and tailored to a nonweight-bearing period of 3 months.

OUTCOMES

Painful symptoms disappeared and the patient was able to walk and perform other daily activities normally.

LESSONS

Clinician should be aware of the clinical context and the possible association of these 2 conditions in order to undertake an early and appropriate treatment.

Bencardino JT, Stone TJ, Roberts CC, Appel M, Baccei SJ, Cassidy RC, Chang EY, Fox MG, Greenspan BS, Gyftopoulos S, Hochman MG, Jacobson JA, Mintz DN, Mlady GW, Newman JS, Rosenberg ZS, Shah NA, Small KM, Weissman BN. ACR Appropriateness Criteria® Stress (Fatigue/Insufficiency) Fracture, Including Sacrum, Excluding Other Vertebrae

Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in both athletes and patients with predisposing conditions. Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Tc-99m bone scan and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go onto healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential of progressing to completion and requiring more invasive treatment or delay in return to activity. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated significantly different (ie, osteoid osteoma, osteomyelitis, and metastasis). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The postpartum triathlete

The postpartum period in a woman's life is filled with numerous changes, including physical changes, changes in sleep habits, and learning how to best care for a newborn. A common goal among postpartum women is to either begin or resume an active lifestyle, which often includes physical activity such as running, biking and swimming. The postpartum athlete may discover barriers that prevent her from returning to or beginning an exercise routine. These obstacles include muscle weakness, fatigue, depression and physical changes that require exercise modification. The physical therapist is well-suited to properly assess, treat and manage the care of the postpartum athlete. Postpartum athletes wishing to begin or resume training for triathlons require special consideration, as the triathlete must balance training to compete in three different sports. The purpose of the paper is to identify the unique physical and physiological changes that occur to the female during the postpartum period. In addition, injuries that are more commonly seen during the postpartum period will be discussed. Recommendations for beginning or resuming an exercise program will be reviewed. Lastly, sport-specific training for the postpartum triathlete, including challenges presented with each triathlon component, will be discussed.

Postpartum sacral stress fracture: a case report

BACKGROUND

Stress fractures are classified as insufficiency and fatigue fractures. Insufficiency fractures occur when normal stresses are placed on bone with decreased mineralization and elastic resistance; whereas fatigue fractures occur when abnormal forces are applied to normal bone.

CASE PRESENTATION

We report a case of postpartum bilateral sacral fracture in the absence of documented osteoporosis in a 30 year old Lebanese female, thus satisfying the classification of fatigue fractures. Clinical presentation was mainly low back pain, pelvic pain, and abnormal gait.

CONCLUSIONS

This case stresses the importance of including sacral fractures in the differential diagnosis of patients presenting with similar symptoms during pregnancy or the postpartum period.

Sacroiliitis or insufficiency fracture?

Sacral stress fracture and sacroiliitis are two conditions that present with pain. Sacral stress fractures are a rare cause of lumbar and hip pain. Sacral insufficiency fractures are a type of sacral stress fractures. Sacroiliitis represents inflammation of the sacroiliac joints. Coexistence of sacroiliitis and sacral insufficiency fracture (SIF) has not been reported before. Case 1: A 39-year-old woman reporting inflammatory back pain. Imaging revealed bilateral chronic sacroiliitis and bilateral SIF. Case 2: A 31-year-old woman presenting with left hip and inguinal pain. Imaging revealed left sacroiliitis and ipsilateral SIF. Calcium and vitamin D supplementation together with nonsteroidal anti-inflammatory drug (NSAID) treatment were given. Sulfasalazine was added to the treatment of the second patient who developed peripheral arthritis during follow-ups. Early diagnosis is best made with magnetic resonance imaging (MRI) since roentgenograms may be negative initially. Furthermore, MRI findings of both entities share common features leading to a diagnostic dilemma. Interpretation of radiological findings assisted by detailed history and clinical findings is crucial for diagnosis and treatment.

Postpartum sacral insufficiency fractures

Postpartum sacral insufficiency fracture is an uncommon occurrence that is often under-diagnosed because its symptoms of low back, buttock and groin pains may initially be attributed to physiologic biomechanical changes caused by pregnancy or to intervertebral disc disease. We present a case of bilateral sacral insufficiency fractures in a 37-year-old postpartum woman with osteopenic bone mineral density confirmed by dual energy X-ray absorptiometry. The symptoms were initially suspected to be of discogenic cause, and the fractures were incidentally appreciated at the edge of a lumbar spine magnetic resonance image. Therefore, it is important to keep in mind this potential diagnosis when examining imaging studies of postpartum patients. For women who present other risk factors of osteoporosis, imaging of the entire sacrum should be part of the imaging studies. If sacral stress fractures are diagnosed, further evaluation for bone mineral density and underlying metabolic bone disease is recommended.

Postpartum sacral fracture in a 30-year-old female

Possible causes of sacral and low back pain in the postpartum patient include sacroiliac joint dysfunction, sacroiliitis, lower lumbar diskitis, and irritation of the sciatic nerve. Postpartum stress fracture is a recognized cause of pain that should be considered in the differential diagnosis of the postpartum patient's low back pain. Several case reports of postpartum stress fracture are now in the literature (1, 2, 3, 4, 5, 6, 7, 8). A 30-year-old female presented postpartum with pain in the coccyx region that was most severe nine weeks after the uneventful spontaneous vaginal delivery of her first child. Imaging with computed tomography (CT) obtained 36 days after delivery demonstrated bilateral sclerosis in the lower sacrum. Plain film radiographs may not demonstrate this finding. Both magnetic resonance imaging (MRI) and CT are sensitive for sacral stress fracture.

Postpartum Sacral Stress Fracture: An Atypical Case Report

Sacral stress fractures are common in elderly people. However, sacral stress fracture should be always screened in the differential diagnoses of low back pain during the postpartum period. We present a case of sacral fracture in a thirty-six-year-old woman with low back pain and severe right buttock pain two days after cesarean section delivery of a 3.9 Kg baby. The diagnosis was confirmed by MRI and CT scan, while X-ray was unable to detect the fracture. Contribution of mechanical factors during the cesarean section is not a reasonable cause of sacral fracture. Pregnancy and lactation could be risk factors for sacral stress fracture even in atraumatic delivery such as cesarean section. Our patient had no risk factors for osteoporosis except for pregnancy and lactation. Transient or focal osteoporosis is challenging to assess and it cannot be ruled out even if serum test and mineral density are within the normal range.

Atraumatic Sacral Fracture in Late Pregnancy: A Case Report

Study Design Case report. Objective Sacral fractures, traumatic or atraumatic, are a rather rare cause of low back pain. The majority of the cases of pregnancy-related sacral fractures are reported as a postpartum complication, and only few cases of sacral atraumatic fractures have been reported in the last trimester of the pregnancy. The aim of this study is to report a rare case of atraumatic sacral fracture in the third trimester of pregnancy. Methods We report the case of a 30-year-old Caucasian European woman during her 37th week (36 weeks and 4 days) of gestation, who complained during her scheduled obstetric examination of continuous low back pain with no associated history of trauma. The patient performed activities of daily living with a normal level of fatigue and reported no running or walking long distances. She was examined in our department, and a magnetic resonance imaging scan was performed that showed a vertical nondisplaced fracture in her left sacrum. Results The patient was treated conservatively, and analgesics were administrated according to the consensus of the orthopedic and the anesthesiology departments. No further complications were recognized in the remaining period of her pregnancy, and a healthy child was born by caesarean section. Conclusions Atraumatic fractures of the sacrum should be included in the differentiated diagnosis of pregnant patients with low back pain.

Fragility fractures of the sacrum: how to identify and when to treat surgically?

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.

Sacral insufficiency fractures: an underdiagnosed injury during childbirth? : A case report and review of literature

Insufficiency fractures during pregnancy or childbirth are difficult to diagnose but holds high morbidity for a vulnerable patient group. In documenting the patient's pathway, diagnostic challenges and treatment options, it is hoped that pregnancy-related insufficiency fractures will be better diagnosed and treated.

INTRODUCTION

Sacral insufficiency fractures are a poorly understood phenomenon, which poses diagnostic and therapeutic challenges. Peripartum females who suffer from transient osteoporosis of pregnancy have been shown in several reports to be at particular high risk of these fractures.

METHOD

This case report details such a case and highlights some of the challenges that this condition presents. Furthermore, it draws on the current literature to offer options for improved techniques for diagnosis and up-to-date management for future practice.

Postpartum sacral stress fracture mimicking lumbar radiculopathy in a patient with pregnancy-associated osteoporosis

Postpartum sacral fracture is relatively rare, and its diagnosis is often delayed. We herein report such a case of a 28-year-old patient who presented with an insidious-onset lower back pain, left buttock pain, and radicular symptoms mimicking lumbar radiculopathy. Laboratory tests showed a decreased 25-hydroxy vitamin D level, and the bone mineral densitometry of both femurs was below the expected range. Plain radiographs of the lumbar spine and pelvis showed no definite abnormality, but lumbosacral spinal magnetic resonance imaging identified a left sacral fracture. Symptoms were alleviated with rest and oral analgesic treatment.

Intrapartum sacral stress fracture due to pregnancy-related osteoporosis: a case report

INTRODUCTION

Low back pain (LBP) and hip pain frequently occur during pregnancy and postpartum period. Although pelvic and mechanic lesions of the soft tissues are most responsible for the etiology, sacral fracture is also one of the rare causes.

CASE REPORT

A 32-year-old primigravid patient presented with LBP and right hip pain which started 3 days after vaginal delivery. Although direct radiographic examination was normal, magnetic resonance imaging of the sacrum revealed sacral stress fracture. Lumbar spine and femoral bone mineral density showed osteoporosis as a risk factor. There were no other risk factors such as trauma, excessive weight gain, and strenuous physical activity. It is considered that the patient had sacral fatigue and insufficiency fracture in intrapartum period. The patient's symptoms subsided in 3 months after physical therapy and rest.

CONCLUSION

In conclusion, sacral fractures during pregnancy and postpartum period, especially resulting from childbirth, are very rare. To date, there are two cases in the literature. In cases who even do not have risk factors related to vaginal delivery such as high birth weight infant and the use of forceps, exc., sacral fracture should be considered in the differential diagnosis of LBP and hip pain started soon after child birth. Pregnancy-related osteoporosis may lead to fracture during vaginal delivery.

Low back pain during pregnancy caused by a sacral stress fracture: a case report

INTRODUCTION

Sacral stress fractures are a rare but well known cause of low back pain. This type of fracture has also been observed as a postpartum complication. To date, no cases of intrapartum sacral stress fractures have been described in the literature.

CASE PRESENTATION

We report the case of a 26-year-old Caucasian European primigravid patient (30 weeks and two days of gestation) who presented to our outpatient clinic with severe low back pain that had started after a downhill walk 14 days previously. She had no history of trauma. A magnetic resonance imaging scan revealed a non-displaced stress fracture of the right lateral mass of her sacrum. Following her decision to opt for non-operative treatment, our patient received an epidural catheter for pain control. The remaining course of her pregnancy was uneventful and our patient gave birth to a healthy child by normal vaginal delivery.

CONCLUSIONS

We conclude that a sacral stress fracture must be considered as a possible cause of low back pain during pregnancy.

Low back pain post partum - a case report

Sacral stress fracture is an unusual source of low back pain and can be easily confused with a number of other clinical conditions seen in physiotherapy clinics. The purpose of this case report is to describe the case of a patient presenting with low back pain post partum illustrating pertinent aspects of differential diagnosis and issues of management. A 31 year old female presented complaining of low back pain since the birth of her second child 11 months earlier. Subjective and objective examination led the Therapist to consider a diagnosis of sacral stress fracture. This diagnosis was confirmed by MRI. Three months after presenting to physiotherapy the patient was pain free and had returned to all aspects of her daily life without any difficulties. Clinicians must be aware of the less common pathologies in any hypotheses development. A careful history and physical examination and broad hypotheses generation will ensure that patients are accurately diagnosed and receive appropriate and effective treatments.

Sacral insufficiency fracture, usually overlooked cause of lumbosacral pain

Sacral insufficiency fractures are usually known to develop in elderly patients with osteoporosis without definite trauma history. It is difficult to diagnose the sacral insufficiency fracture at an early stage because lower lumbar diseases, concurrently or not, may also be presented with similar symptoms and signs. We report a rare case of sacral insufficiency fracture who was not diagnosed initially but, instead, showed progressively worsening of clinical symptoms and radiological findings after decompression surgery for upper level lumbar stenosis.