Diagnosis, Risk Factors, and Management of Sacral and Pelvic Fractures After Instrumented Lumbar Fusions: A Systematic Review

Study Design: Systematic literature review. Objectives: To evaluate risk factors, diagnosis, and management of sacral and pelvic fractures (SPFs) after instrumented fusions. Methods: A systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed using the PubMed database. Articles with patients with an SPF after a lumbar instrumented fusion were included. The articles addressing specifically proximal junctional kyphosis were excluded. Eleven small cases series (level of evidence IV) were reviewed. Results: The incidence of SPF was 1.86% in one study. The risk factors reported were elderly patients, multilevel surgery, long fusions stopping at L5 or S1 instead of the ilium, osteoporosis, obesity, and sagittal imbalance. Computed tomography scan was the preferential image modality for diagnosing. Nonsurgical treatment may be used in patients with tolerable pain and nondisplaced fracture. Persistent pain was an indication for surgery, as well as fracture displacement. The most common surgical treatment reported was an extension of the fusion to the iliac using iliac screws. Conclusion: SPFs after lumbar instrumented fusion are rare but clinically meaningful complications. The risk factors, diagnosis, and management of SPFs are described in our review.