Abstract
Objective:
Spinopelvic dissociation from U- or H-type pathologic sacral fractures can be debilitating and often results in chronic pain and functional impairment. In the setting of metastatic disease with prior or planned radiotherapy and/or chemotherapy, obtaining a successful fracture union is particularly challenging. We sought to determine the effectiveness of lumbopelvic fixation for the treatment of U- or H-type pathologic sacral fractures.
Methods:
We reviewed data from patients with metastatic disease who presented with U- or H-type pathologic sacral fractures recalcitrant to nonoperative management and were treated with lumbopelvic instrumentation at a single institution between January 2019 and November 2024. Primary outcome measures were pre- and postoperative sacral pain (assessed using a visual analog scale), ambulatory status, and opioid use in morphine milligram equivalents (MMEs).
Results:
Twenty-two patients met the inclusion criteria (mean age, 63.4 ± 12.8 years) and had a mean of 14.5 ± 9.2 months of follow-up. Seventeen patients (77%) received radiotherapy prior to surgery with a mean biologically effective dose of 59.1 ± 14.6 Gy. The mean preoperative sacral pain score was 7.5 ± 2.2, which decreased to 2.2 ± 2.2 at 3 weeks postoperatively (p < 0.001) and 0.4 ± 1.1 at final follow-up (p < 0.001). All 22 patients had radicular symptoms preoperatively, compared to 2 patients (9.1%) at final follow-up (p < 0.001). Improvement in ambulatory status relative to preoperative baseline was evident in 15 patients (68%) at 3 weeks and in 19 patients (86%) at final follow-up. Mean preoperative daily opioid use was 156.1 ± 154.9 MMEs, which decreased to 77.0 ± 92.7 at 6 weeks postoperatively (p=0.048) and 59.1 ± 97.5 at final follow-up (p = 0.018). There was one reoperation at final follow-up (4.5%) for a set-screw disengagement.
Conclusion:
Patients with metastatic disease who present with spinopelvic dissociation from U- or H-type pathological sacral fractures use fewer opioid medications for axial and radicular pain and have better ambulatory function following lumbopelvic fixation. Larger, prospective studies are needed to confirm our findings.
Level of Evidence:
IV
Keywords: Sacral fracture, pathologic fracture, spinopelvic dissociation, lumbopelvic, complications
INTRODUCTION
With advances in multidisciplinary care, including the development of such systemic therapies as targeted molecular agents and immunotherapies, the life expectancy of patients with metastatic cancer has significantly improved over the last several decades.1,2 The rate of cancer-related deaths has declined nearly 33% since 1991, and more patients are living longer with the complications of metastatic disease.1 Since the spine and sacrum are the most common sites for bone metastasis, these regions are focal points in the ongoing evolution of treatment paradigms for skeletal metastases.2,3
The sacrum serves a critical biomechanical role in that it forms the keystone at the spinopelvic junction and acts as a central load-bearing structure that transmits axial loads from the spine to the pelvis and lower extremities.3 The structural integrity of the sacrum is thus pivotal for maintaining mobility and upright posture. When transverse sacral fractures occur in combination with bilateral longitudinal fractures—particularly in high-energy traumatic injuries—spinopelvic dissociation may result.4 These injury patterns, which are classified as U- or H-type sacral fractures, are characterized by the complete destabilization of the spinopelvic continuity, often leading to progressive neurologic deficits, intractable pain, and profound functional impairment and immobility.5
Similar destabilizing fracture patterns can present in the context of metastatic disease in the sacrum, even in the absence of a traumatic event. This is largely due to the inherently destructive nature of the malignant process and the deleterious effects of radiotherapy (RT), which can individually or collectively compromise the integrity of sacrum and result in structural collapse.6
In routine traumatic settings, U- and H-type sacral fractures can be stabilized using a variety of techniques to obtain successful fracture union and restore biomechanical stability.5 However, in patients with metastatic disease, the bone stock of the sacral bodies is often insufficient for screw purchase, and exposure to RT eliminates or significantly reduces biologic healing potential. In these patients, obtaining a successful fracture union is an unrealistic goal and surgical management should focus on mechanical stabilization that will be durable for the remainder of the disease course.6 While standalone iliosacral screw fixation is a potential option in such cases, it has a failure rate of up to 26% even in the setting of normal bone, and the rate would likely be higher for pathologic bone.7 Lumbopelvic fixation is a biomechanically superior alternative, given its greater resistance to both initial and cyclical loads,8 and as such has been our construct of choice for patients with unstable sacral fractures due to pathologic bone.
Recent case series have documented the viability of lumbopelvic fixation (also known as triangular osteosynthesis) as a potential treatment in this high-risk population.6,9 However, these studies are largely limited by small sample sizes, heterogenous patient populations, and short-term follow-up. Given these limitations, the objective of this study was to investigate the effectiveness and complication profile of lumbopelvic fixation for the treatment of U- or H-type pathologic sacral fractures in patients with metastatic cancer.
METHODS
Study Population
We conducted a retrospective analysis of patients treated at a single tertiary cancer center from January 2019 to November 2024. Patients were included if they had an unstable H- or U-type pathologic sacral fracture secondary to metastasis, had pain in the axial and/or radicular lower extremity that was recalcitrant to nonoperative management, underwent lumbopelvic fixation, and had follow-up data for a minimum of six months or until death (Figure 1). Patients were excluded if they had nonpathologic fractures, stable fractures, or a history of partial sacrectomy.
Figure 1.
X-rays from a 64-year-old woman with metastatic rectal carcinoma who sustained a pathologic H-type sacral fracture (A, B) treated with L4-pelvis fixation with cement augmentation (C, D).
Data Collection
Demographic, surgical, and other data were retrospectively retrieved from patients’ electronic medical records. We extracted information on patients’ age, gender, primary cancer diagnosis, and RT exposure. Perioperative variables included number of levels instrumented, surgical approach (open vs. percutaneous), additional decompression(s), supplementary use of iliosacral or transiliac-transsacral screws, and estimated blood loss. We also collected data on pre- and postoperative outcomes, including sacral pain (measured using a visual analog scale [VAS]); presence of radiculopathy, neurologic dysfunction, and bowel/bladder dysfunction; ambulatory status (0 = nonambulatory, 1 = ambulatory with assistive device, 2 = ambulatory); daily use of opioid pain medication, measured using morphine milligram equivalents (MMEs); occurrence of perioperative complications and hardware complications; 30-day reoperation rates; and postoperative length of stay.
Surgical Technique
Surgery was performed with patients in the prone position on a padded operative table with an open frame. Intraoperative computed tomography–based navigation was used for instrumentation. Fenestrated lumbar pedicle screws and nonfenestrated iliac screws were placed percutaneously when procedures involved stabilization alone, or via an open midline approach when decompression and tumor excision were performed. An S2 alar iliac trajectory was used for the iliac screws. Lumbar pedicle screws were augmented with cement under fluoroscopic guidance. A single 6.0-mm titanium rod was used on each side. Supplemental transiliac-transsacral screws or cement-augmented iliosacral screws were percutaneously placed under navigation in patients with sufficient bone stock in the S1 or S2 sacral bodies.
Outcome Measures
The primary outcome measures were pre- and postoperative sacral VAS pain score, ambulatory status, and pain medication use in MMEs. Secondary outcome measures were pre- and postoperative radiculopathy, neurologic function, reoperations, and complications. The minimal clinically important difference (MCID) was defined as a 30% or greater reduction in sacral VAS pain score, as recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus.10
Statistical Analysis
Data analysis was performed using R statistical software (version 4.3.1, Indianapolis, IN, USA). Continuous variables were assessed using two-tailed Student’s t-tests, while categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate. For non-normally distributed continuous data, the Mann-Whitney U test was applied. Statistical significance was defined as p < 0.05.
Ethical Approval
The study was conducted in accordance with the Declaration of Helsinki and received approval from our institutional review board (protocol 16-1123). Informed consent was waived due to the retrospective and observational nature of the study.
RESULTS
Study Population
A total of 22 patients (mean age, 63.4 ± 12.8 years) were included in the study (Table 1). Fifteen (68%) were female. The mean follow-up was 14.5 ± 9.2 months. Seven patients (32%) died from progression of disease (mean follow-up, 11.9 ± 9.2 months), whereas 15 patients (68%) were alive and continuing routine follow-up. Primary pathologies were multiple myeloma (n=4; 18%), breast carcinoma (n=3; 14%), thyroid carcinoma (n=2; 9%), rectal carcinoma (n=2; 9%), non-small cell lung carcinoma (n=2; 9%), cervical adenocarcinoma (n=1; 4%), endometrial carcinoma (n=1; 4%), prostate carcinoma (n=1; 4%), renal cell carcinoma (n=1; 4%), urothelial carcinoma (n=1; 4%), Hürthle cell carcinoma (n=1; 4%) pleomorphic sarcoma (n=1; 4%), leiomyosarcoma (n=1; 4%), and chordoma (n=1; 4%).
Table 1.
Demographic and surgical characteristics of study population (N=22)
| Characteristic | Value |
|---|---|
| Age (years) | 63.4 ± 12.8 |
| Female | 15 (68.2) |
| Follow-up (months) | 14.5 ± 9.2 |
| Upper instrumented vertebra | |
| L3 | 2 (9.1) |
| L4 | 18 (81.8) |
| L5 | 2 (9.1) |
| Percutaneous instrumentation | 18 (81.8) |
| Decompression/tumor excision | 6 (27.3) |
| Transiliac-transsacral screw fixation | 8 (36.4) |
| Bilateral iliosacral screw fixation | 1 (4.5) |
| Unilateral iliosacral screw fixation | 1 (4.5) |
| Radiotherapy | 18 (81.8) |
| Preoperative only | 14 (63.6) |
| Postoperative only | 1 (4.5) |
| Pre- and postoperative | 3 (13.6) |
| BED of preoperative radiotherapy (n=17) | 59.1 ± 14.6 |
Values presented as n (%) or mean ± standard deviation.
BED = biologically effective dose.
Percutaneous instrumentation was utilized in 18 patients (82%). Two of these patients underwent simultaneous neurologic decompression, one through a separate limited midline approach and one using a tubular approach. Four patients underwent open decompression and/or tumor excision with simultaneous open instrumentation. One or more supplemental iliosacral screws or transiliac-transsacral screws were placed percutaneously in 10 patients (45%). Seventeen patients (77%) had prior RT to the surgical field, with a mean biologically effective dose (BED) of 59.1 ± 14.6 Gy. Two of the 4 patients undergoing open instrumentation had had prior RT; their mean BED was 65.8 ± 8.8 Gy.
Perioperative Outcomes
Patients’ mean preoperative sacral VAS pain score was 7.5 ± 2.2, which decreased to 2.2 ± 2.2 at the 3-week postoperative follow-up (p < 0.001) and to 0.4 ± 1.1 at final follow-up (p < 0.001) (Figure 2). A total of 21 patients (95%) met the MCID for sacral VAS at the 3-week postoperative follow-up, and all 22 patients (100%) did so at final follow-up. Improvement in ambulatory status from baseline was evident in 15 patients (68%) at three weeks post-surgery and 19 patients (86%) at final follow-up. The overall ambulatory status was significantly different at all postoperative time points compared to the preoperative ambulatory status (Figure 3). Mean preoperative opioid use was 156.1 ± 154.9 MMEs per day, which decreased to 77.0 ± 92.7 at the six-week follow-up (p = 0.048) and 59.1 ± 97.5 at final follow-up (p = 0.018) (Figure 4). Radicular symptoms were present in all 22 patients preoperatively but in only two patients (9.1%) at final follow-up (p < 0.001) (Table 2). Mean estimated blood loss was 338 ± 537 mL in the full sample and was lower when surgery was performed using percutaneous instrumentation (135 ± 124 mL) rather than an open approach (1,250 ± 759 mL) (p < 0.001). There were two deaths (9.1%) prior to the six-month follow-up due to progression of disease.
Figure 2.
Pre- and postoperative sacral pain scores, assessed by a visual analog scale (VAS). ****p < 0.0001.
Figure 3.
Pre- and postoperative ambulatory status. **p < 0.01; ***p < 0.001; ****p < 0.0001.
Figure 4.
Pre- and postoperative daily opioid use in morphine milligram equivalents. **p < 0.01; ***p < 0.001; ****p < 0.0001.
Table 2.
Perioperative outcomes
| Characteristic | Value | P Value |
|---|---|---|
| Length of stay (days) | 7.2 ± 3.9 | |
| Radiculopathy | ||
| Preoperative | 22 (100.0) | <0.001 |
| Final follow-up | 2 (9.1) | |
| Weakness | ||
| Preoperative | 15 (68.2) | 0.006 |
| Final follow-up | 6 (27.3) | |
| Bowel/bladder dysfunction | ||
| Preoperative | 4 (18.2) | 0.376 |
| Final follow-up | 2 (9.1) | |
| Estimated blood loss (ml) | 338 ± 537 | |
| Percutaneous (n=18) | 135 ± 124 | <0.001† |
| Open (n=4) | 1,250 ± 759 |
Values presented as n (%) or mean ± standard deviation.
For comparison between percutaneous and open subgroups.
Complications
In the 30 days following surgery, seven patients (32%) had a total of eight complications (Table 3), including three venous thromboembolisms and one case each of urinary tract infection, delirium, superficial hematoma, pneumonia, and urinary retention, all of which resolved by final follow-up. Three patients (14%) had asymptomatic hardware complications: one set-screw disengagement and two screw head fractures, all of which were found on routine postoperative imaging at 12-month follow-up. One patient (4.5%) underwent reoperation at final follow-up for a set-screw disengagement, which was revised at the time of an unrelated surgical procedure.
Table 3.
Types and number of complications
| Characteristic | N (%) |
|---|---|
| 30-Day | |
| Deep vein thrombosis | 2 (9.1) |
| Pulmonary embolism | 1 (4.5) |
| Urinary tract infection | 1 (4.5) |
| Delirium | 1 (4.5) |
| Superficial hematoma | 1 (4.5) |
| Pneumonia | 1 (4.5) |
| Prolonged urinary retention | 1 (4.5) |
| Pneumonia | 1 (4.5) |
| Hardware complications | |
| Screw fracture | 2 (9.1) |
| Set-screw disengagement | 1 (4.5) |
| Reoperation | 1 (4.5) |
DISCUSSION
In this study, we explored lumbopelvic fixation’s potential as a viable treatment option for patients with metastatic disease presenting with spinopelvic dissociation from U- or H-type pathologic sacral fracture. Our analysis found that in these patients, lumbopelvic fixation is associated with statistically significant improvement in pain-related and functional outcomes.
A major finding in this study was that the procedure resulted in statistically significant and sustained reductions in sacral pain and opioid use among patients with U- or H-type pathologic sacral fractures. The average sacral VAS pain score decreased from 7.5 preoperatively to 2.2 at 3 weeks postoperatively and further improved to 0.4 at a mean final follow-up of 14.5 months. In addition, patient’s opioid use (in MMEs) decreased by more than 60% between the preoperative and final assessments, and their ambulatory function improved markedly. These findings are similar to those presented in the trauma literature. Brodell Jr et al. reported a retrospective case series of patients who underwent percutaneous lumbopelvic fixation for the management of traumatic U- or H-type sacral fractures and experienced substantial improvement in pain and function scores at both the 6-week follow-up and the final (mean, 18.7 months) follow-up.11 Similarly, Liu et al. reported substantial improvement in functional status at a mean follow-up of 17.1 months in a cohort of 32 patients undergoing lumbopelvic fixation for traumatic spinopelvic dissociation.12 Our results indicate oncologic patients may also experience the rapid and durable improvements in pain and function achieved through this procedure, reinforcing the effectiveness of mechanical stabilization. These improvements are particularly important for high-risk patients with metastatic disease, for whom immobility and pain can result in diminished quality of life, increased caregiver burden, and higher risks of adverse events, such as venous thromboembolism, pressure ulcers, and respiratory decline.13,14 Restoration of ambulation may enable patients to better tolerate systemic oncologic therapies and maintain independence during palliative care.15 Finally, achieving pain control without a heavy reliance on opioids is especially relevant to the oncologic population, given the risks of sedation, constipation, and cognitive impairment that are associated with complications and limit eligibility for other therapies.16 Thus, the primary benefit of lumbopelvic fixation in this patient population is the ability to provide immediate weight-bearing and mobilization after the intervention while achieving substantial pain relief and decreased opioid usage.
However, unlike their counterparts with traumatic spinopelvic dissociation, oncologic patients with pathologic sacral fractures exhibit markedly reduced or absent healing potential due to the combination of a malignant marrow-replacement process and exposure to RT and/or chemotherapy. Although lumbopelvic fixations performed for traumatic indications have had rates of successful fracture union approaching 100% in large multicenter series, this would be an unrealistic goal for patients with metastatic disease.17 Instead, the surgical management emphasizes durable mechanical stabilization and symptomatic relief for the remainder of the disease course. To achieve this goal, we routinely utilized fenestrated lumbar pedicle screws for cement augmentation to optimize pull-out strength. We used 6.0-mm caliber rods made of titanium, which proved sufficient despite ongoing micromotion at the sites of chronic fracture nonunion. However, hardware failure did occur at a rate of 14% in the form of one set-screw disengagement and two screw fractures at the junction of the tulip and shank. All three of these patients, including two who did not undergo revision, were asymptomatic at final follow-up. Our hardware failure rate was higher than the 0% rate reported in a multicenter study of 260 patients with traumatic spinopelvic dissociation who were treated with lumbopelvic fixation; the fracture union rate in that study was 100%.17
Another important finding from our investigation was the ability of lumbopelvic fixation to treat radiculopathy and neurologic deficits in this patient population. All patients presented with radiculopathy preoperatively, but the prevalence declined to 9.1% at final follow-up. In addition, 68% of patients presented with preoperative weakness, whereas only 27% had weakness at final follow-up. This was true despite only five patients (23%) receiving direct decompression. These results demonstrate that by eliminating dynamic nerve root compression associated with the unstable fracture pattern, stabilization alone may have a role as a reliable method of indirect decompression in this patient population. These results are slightly different from those reported for traumatic fracture patients. In a study by Morris et al., 27% of the 137 patients with traumatic spinopelvic dissociation who had undergone lumbopelvic fixation exhibited neurologic symptoms at presentation.18 All patients who presented with radiculopathy or weakness and neurologic compression underwent direct decompression; however, radiculopathy was the most common long-term sequelae, persisting in 32% of patients who initially presented with neurologic deficits. These differences in response to treatment between the oncologic and trauma populations may reflect that neurologic injury resulting from the dynamic neural compression associated with unstable pathologic fractures is more reversable than the injury from high-energy trauma.
Finally, in our study, lumbopelvic fixation was associated with a 30-day complication rate of 32%, which included venous thromboembolism, urinary tract infection, delirium, superficial hematoma, pneumonia, and urinary retention with no 30-day reoperation. All complications resolved by or were addressed at final follow-up; this included one patient who underwent reoperation at final follow-up for an asymptomatic set-screw disengagement that was subsequently revised opportunistically at the time of an unrelated surgical procedure. These findings demonstrate the overall safety and feasibility of lumbopelvic fixation in this patient population, as prolonged immobility from nonoperative management is associated with worse functional outcomes and high rates of fatal complications.15,19
This study has several limitations. First, the retrospective nature of the design presents inherent risk of selection bias and limits the ability to establish causation. Furthermore, although this series represents the largest cohort to date focused specifically on the rare phenomenon of pathologic U- or H-type sacral fractures, the sample size was nonetheless modest and was underpowered for additional subgroup analyses (e.g., open versus percutaneous techniques). In addition, the mean duration of follow-up, while longer than that in previous reports, was less than 15 months. Thus, although the three hardware complications were asymptomatic at final follow-up, longer term follow-up is needed to elucidate the possible long-term symptoms. However, in patients with advanced metastatic disease and relatively brief anticipated survival, understanding the outcomes and complication profiles in a short-term follow-up period is crucial for making clinical decisions aimed at maximizing quality of life while minimizing complications during the remainder of the disease process. Finally, the study did not include a nonoperative control group, which prevents a direct comparison to conservative management approaches.
CONCLUSION
Despite these limitations, to our knowledge this study represents the most comprehensive investigation of the effectiveness and complication profile of lumbopelvic fixation for the treatment of U- or H-type pathologic sacral fractures. Our findings suggest that lumbopelvic fixation is a valuable surgical strategy in this patient population. The procedure can often be performed completely percutaneously and appears to offer rapid and sustained relief from debilitating symptoms while restoring functional mobility and reducing dependence on opioid analgesia. In a population with limited options and significant morbidity, this approach may provide a meaningful improvement in quality of life. Future prospective studies with larger sample sizes and longer follow-up are warranted to further validate these results and refine surgical indications.
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