Case report 247. Post-radiation osteitis of the sacrum.
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We have presented a case of a patient with sacral giant-cell tumor and reviewed the literature. This is a rare disease originating from the mesenchyme of bone marrow which grows out through the cortex. It is essentially benign but behaves like a malignant tumor in view of frequent recurrences and a high incidence of malignant transformation. Cure can be achieved only by complete extirpation of tumor along with surrounding soft tissue.
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Sacral insufficiency fractures are an easily overlooked injury of the elderly, leading to severe and debilitating lower back pain. Percutaneous vertebroplasty with polymethylmethacrylate (PMMA) has become the treatment of choice for painful osteoporotic vertebral compression fractures. This is mainly due to the excellent results in pain relief, combined with the low morbidity of the procedure and the possibility of performing it in an outpatient setting. This well known technique can be transferred to the treatment of sacral insufficiency fractures for which no active therapy is currently available. This so-called sacroplasty was first reported in 2002 in a single case report. Six other patients with this indication have been reported in the Anglo-American literature to date. This article is the first description of this technique in the German literature. It compromises the description of two typical cases highlighting the difficulties in diagnosis, surgical technique and possible complications. Both patients were treated successfully and showed dramatic pain relief within several hours.
There are relatively few reports of sacral stress fractures in children. In adolescents, sacral stress fractures have been reported in patients involved in vigorous athletic activity. Recognition of these fractures is important to avoid unnecessary biopsy if the findings are confused with tumor or infection. We report a sacral fatigue fracture in a 15-year-old without a history of athletic participation or trauma.
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Excessive bleeding is a significant problem during total sacrectomy. Ligation of the internal iliac veins to control bleeding from the pelvic venous plexus has been reported to be mandatory. However, despite ligation of the internal iliac veins, excessive hemorrhage from the pelvic and epidural venous plexuses is often encountered. We postulated that ligation of the internal iliac veins increases blood loss during total sacrectomy and we investigated the influence of ligation of the internal iliac veins on the pelvic and epidural venous plexuses in white rabbits. We also investigated the influence of the animal's operative position on the epidural venous pressure. Venography was performed to study the differences in blood flow patterns before and after ligation of the internal iliac veins. Without ligation, contrast medium passed into the inferior vena cava, but not into the epidural venous plexus. The epidural venous plexus was contrast-filled when the internal iliac veins were ligated. The pressure in the internal iliac veins was increased with their ligation, and decreased with ligation of the abdominal aorta. The pressure was also decreased with intentional bleeding from the epidural venous plexus, and with changing the animal's position to headdown. Ligation of the internal iliac veins leads to congestion of the pelvic venous and epidural venous plexuses. Ligation of the internal iliac arteries and positioning the animal headdown were effective ways to resolve the congestion in these venous plexuses.
Involuted intraosseous lipoma with extensive fat necrosis resulting in cyst formation (Milgram stage III) is distinguishable from lesions without necrosis (stage I) or lesions with focal fat necrosis (stage II), based on differences in signal intensity on magnetic resonance imaging (MRI). Fat tissue has a high signal intensity on both T1- and T2-weighted MR images, whereas the extensive fat necrosis that results in cyst formation shows high signal intensity on T2-weighted images and low intensity on T1-weighted images. We report a patient in whom an intraosseous lipoma with high signal intensity on both T1- and T2-weighted MRI was found to be extensively involuted on histopathologic examination. Intraosseous lipoma appears to undergo spontaneous involution. In some patients, therefore, surgical excision may not be necessary. A correct preoperative diagnosis should reduce the necessity for a biopsy or surgery. Although lesions classified as stage I or II are easily identified by MRI, those of stage III are difficult to diagnose preoperatively by this method.