Rheumatology 2001; 40: 1065-1066
© 2001 British Society for Rheumatology
Letters to the Editor |
Sacral insufficiency fracture—a case of post-coital back pain
Department of Rheumatology, Queen Elizabeth Hospital, Woodville Road, Woodville, South Australia, Australia
SIR, A 64-yr-old Italian women presented to our department with a 3-week history of sudden, severe lower back pain. There was no history of trauma or obvious precipitating event prior to presentation. Oral and topical non-steroidal anti-inflammatory drug (NSAID) preparations were unhelpful. She had long-standing seropositive, deforming rheumatoid arthritis (RA) and osteoporosis. Her RA was currently in clinical remission with leflunomide 20 mg daily and prednisolone 10 mg daily and osteoporosis treatment consisted of calcitriol and cyclical etidronate. In 1999, bone mineral density confirmed osteoporosis with T-scores of -3.81 and -2.24 at the lumbar and femoral regions, respectively.
Clinically there was tenderness over the left sacroiliac region. A pelvic X-ray revealed no fracture or bony lesion of the pelvis or hips. A bone scan revealed a pelvic insufficiency fracture involving the sacrum with disruption of both sacroiliac joints (Fig. 1
). There was a characteristic ‘H’ sign consistent with a sacral fracture.
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We were enlightened as to the aetiology of the fracture by a nuclear medicine technician who spoke Italian, to whom the patient had explained the nature of her complaint. The severe pain commenced after a rather physical sexual encounter with her husband.
Management consisted of admission to hospital for relative bed rest, adequate pain control and osteoporosis education regarding risk factors to prevent further fractures.
Osteoporosis is a condition of low bone mass and subsequent increased bone fragility. It is a major factor in fractures in the elderly and leads to considerable morbidity and mortality [1]. Significant risk factors for osteoporosis in our case include the patient's sex, age, RA and corticosteroid use. A recent meta-analysis of 508 cases of sacral insufficiency fractures by Finiels et al. [2] revealed that most fractures occurred in women over 60 yr of age. Trauma was identified in one-third, osteoporosis and pelvic radiotherapy were risk factors and the ‘H’ sign was present on scintigraphy in 43%. Dasgupta et al. [3] described 10 cases of sacral insufficiency fractures, nine of whom had spontaneous fractures. Weber et al. [4] reported 20 cases, 11 of whom had had a fall, most falling from a standing or sitting position to the ground, prior to presentation. To our knowledge, this is the first report of sacral insufficiency fracture precipitated by a vigorous sexual encounter.
We conclude that sacral insufficiency fracture should be considered in the differential diagnosis of patients presenting with acute lower back pain, especially in the setting of established osteoporosis. A sexual history should be considered when no obvious precipitating event is present.
Notes
References
- O'Neill S, Eisman J, Glaszion P et al. The prevention and management of osteoporosis—consensus statement. Med J Aust1997;167(Suppl.).
- Finiels H, Finiels PJ, Jacquot JM, Strubel D. Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases. Presse Med1997;33:1568–73.
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Dasgupta B, Shah N, Brown H, Gordon T, Tanqueray A, Mellor J. Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol1998;37:789–93.
[Abstract/Free Full Text] - Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum—twenty cases and review of the literature. Spine1993; 16:2507–12.
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