Prijelom sakruma u oslabljenoj kosti – često neprepoznat uzrok križobolje i boli u zdjelici – prikaz bolesnice s pregledom literature

Danijela Veljković Vujaklija, Tea Schnurrer Luke-Vrbanić

Sacral stress fractures are divided into fatigue fractures and insufficiency fractures. Fatigue fractures occur in a normal bone exposed to abnormal or repetitive stresses, whereas insufficiency fractures occur in weakened bones under normal stress and with no underlying trauma. Sacral insufficiency fractures are often overlooked causes of nonspecific lumbosacral back pain, especially in
elderly women with underlying osteoporosis. In addition to old age and postmenopausal osteoporosis, other conditions which reduce bone mineral density and present risk factors for the occurrence of insufficiency fractures include: long-term glucocorticoid and bisphosphonates therapy, long-term vitamin D insufficiency and osteomalacia, renal osteodystrophy, primary hyperparathyroidism, Paget’s disease, long-term immobilisation and radiotherapy for the treatment of malignant diseases. There are no typical clinical signs to suggest sacral stress fracture. These fractures are often associated with degenerative diseases of the spine and intervertebral disc, and they are often accompanied by pre-existing osteoporotic vertebral compression fractures. Plain radiographs of the spine and pelvis, which are the first step in diagnostic imaging, are usually non-diagnostic when it comes to sacral fractures. Due to radicular pain symptoms, magnetic resonance imaging of the lumbosacral spine is the next step in diagnosis, in which sacral fractures are often revealed as accidental findings. In this paper, we shall present a case of an elderly patient with multiple comorbidities and multiple risk factors, in whose case physical therapy did not prove to be effective. During diagnostic
testing, a subsequent MRI showed an accidental finding confirming the sacral fracture. Furthermore, we shall highlight the importance of early detection of sacral stress fracture in high-risk patients, in order to avoid unnecessary, and sometimes invasive, diagnostic procedures and to reduce the possibility of possible complications. The imaging method of choice for the diagnosis of sacral stress fractures is MRI.

Stresne prijelome (engl. stress fractures) možemo podijeliti na prijelome zamora ili stresne prijelome u užem smislu (engl. fatigue fractures) i na prijelome u oslabljenoj kosti (engl. insufficiency fractures). Prijelomi zamora nastaju u zdravoj kosti zbog dugotrajnog ponavljanja neprimjerenog opterećenja, dok prijelomi u oslabljenoj kosti nastaju spontano, odnosno bez prethodne traume. Prijelomi sakruma u oslabljenoj kosti često su neprepoznat uzrok križobolje i boli u zdjelici, posebice u žena starije dobi s osteoporozom. Osim starije dobi i postmenopauzalne osteoporoze, rizični čimbenici za prijelom u oslabljenoj kosti jesu dugotrajna terapija glukokortikoidima i bisfosfonatima, dugotrajan teži nedostatak vitamina D i osteomalacija, renalna osteodistrofija, primarni hiperparatiroidizam, Pagetova bolest, dugotrajna nepokretnost i radioterapija zbog maligne bolesti. Specifični klinički znakovi stresnog prijeloma sakruma ne postoje. Ovakvi prijelomi često su udruženi s degenerativnim promjenama kralježnice i intervertebralnog diska, a često su prisutni i osteoporotični prijelomi kralježaka. Na standardnim radiogramima kralježnice i zdjelice, koji su prvi korak u slikovnoj dijagnostičkoj obradi, prijelomi sakruma najčešće se ne uočavaju. Zbog često prisutnih radikularnih simptoma sljedeći dijagnostički korak jest magnetska rezonancija lumbosakralne kralježnice na kojoj su prijelomi sakruma najčešće slučajan nalaz. Prikazujemo bolesnicu s multiplim komorbiditetima i višestrukim čimbenicima rizika kod koje je zbog prolongirane križobolje provedena fizikalna terapija s nezadovoljavajućim učinkom. Tijekom obrade učinjena je magnetska rezonancija gdje je kao slučajan nalaz potvrđen prijelom sakruma. Ističemo važnost ranog prepoznavanja rizičnih skupina pacijenata čime se postiže izbjegavanje suvišnih, katkad i invazivnih dijagnostičkih postupaka. Slikovna metoda izbora za dijagnozu stresnog prijeloma sakruma jest magnetska rezonancija.