Journal of Orthopaedic Surgery 2012;20(2):250-3

Cauda equina syndrome following sacral

fractures: a report of three cases
Nick Aresti,1,2 Govin Murugachandran,1,2 Rohit Shetty1,3

Department of Trauma and Orthopaedics, The Whittington Hospital, Archway, London, United Kingdom
Core Surgical Trainee, London Deanery, United Kingdom
3
The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
1
2

ABSTRACT
We report 3 patients with cauda equina syndrome
(CES) secondary to a sacral fracture. The difficulty
in early diagnosis of CES and the lack of evidence
and guidance on treatment are highlighted. When
there is a sacral fracture, CES should be suspected.
Thorough clinical examination including digital rectal
examinations and bladder function quantification
is advised. The threshold for performing computed
tomography and/or magnetic resonance imaging of
the pelvis should be low. Patients should be treated
by a multi-disciplinary team with both orthopaedic
and neurosurgical input. Further studies are needed
to identify the timing and to which patients surgical
decompression should be performed.
Key words: cauda equina; fractures, stress; sacrum

INTRODUCTION
Cauda equina syndrome (CES) is a rare complication

of sacral fractures. We report 3 such cases and review

the literature.
CASE REPORTS
Patient 1
In July 2010, a 35-year-old woman presented to an
accident and emergency department with low back
pain after falling from a cliff. She was discharged
with analgesia. 10 days later after returning from
her trip, she presented to our hospital with left S1
radicular symptoms but with normal bladder and
bowel function and no sensory deficit. Computed
tomography (CT) showed a sacral fracture (zone
3, type 1), and magnetic resonance imaging (MRI)
showed no evidence of cauda equina compression (Fig.
1). She was managed conservatively with analgesia,
physiotherapy, and instructions not to weight bear.
Six weeks later, she presented with urinary hesitancy
and persistent left S1 radicular symptoms. She
had saddle anaesthesia, normal motor power, and
an absent left ankle reflex. Repeat MRI showed a
progression of the fracture and compression of the

Address correspondence and reprint requests to: Mr Nick Aresti, Department of Trauma and Orthopaedics, The Whittington
Hospital NHS Trust, Magdala Avenue, London, N19 5NF, United Kingdom. E-mail: n.aresti@doctors.org.uk

Vol. 20 No. 2, August 2012

Cauda equina syndrome following sacral fractures 251

Figure 1 Patient 1: cauda equina syndrome secondary to a traumatic sacral fracture in a young woman.

Figure 2 Patient 2: cauda equina syndrome secondary to a sacral insufficiency fracture in an elderly woman with severe
osteoporosis.

cauda equina. Given the acute presentation of CES,

she underwent emergency sacral decompression.
Postoperatively, her radicular symptoms resolved
quickly, and her bladder function took 6 months to
return to normal. Her saddle anaesthesia has yet to
resolve (after 18 months).
Patient 2
In September 2010, a 62-year-old diabetic woman
presented with a 2-week history of difficulty
in walking, back and leg pain, and urinary and
faecal incontinence. She had no history of a fall
or trauma. She had saddle anaesthesia with intact
motor power and reflexes. CT and MRI revealed a
sacral insufficiency fracture (zone 3, type 2) with
cauda equina compression (Fig. 2). A bone scan
demonstrated further insufficiency fractures at the
T5 vertebral body, left pubic ramus, and thoracic
cage (Fig. 2). A bone density scan showed a T-score
of -5.5 at L1 to L4, with a bone mineral density of
0.443 g/cm2. She was treated conservatively with bed
rest and analgesia, because of her poor bone stock,
late presentation (delayed diagnosis), and urinary
and faecal incontinence. Although the symptoms

improved slightly, she never fully regained bladder

and bowel control.
Patient 3
In February 2011, a 63-year-old woman presented
with worsening back pain, reduced mobility, and
urinary and faecal incontinence. She had no history
of a trauma. Her co-morbidities included chronic
obstructive pulmonary disease for which she had
been taking prednisolone. Her urinary and bowel
symptoms were assumed to be a result of poor pain
management and her frail condition, so she was
admitted under the care of the medical team. Three
weeks later her back pain had not resolved. An MRI
showed a sacral insufficiency fracture (zone 3, type
2). She was treated with analgesia and bed-to-chair
mobilisation because of her medical co-morbidities
and late presentation. She died a few weeks later; the
fracture did not contribute to her death directly.
DISCUSSION
Denis et al.1 classified traumatic sacral fractures

Journal of Orthopaedic Surgery

252 N Aresti et al.

anatomically into 3 zones based around the neural

foramina. Fractures lateral to the neural foramina
involving the sacral ala are classified as zone 1. Those
involving the neural foramina, but not the spinal
canal are zone-2 fractures. Those extending into the
spinal cord with primary or associated fracture lines
are zone-3 fractures. This classification also indicates
the risk of a neurological deficit. Zone-1 fractures
involve deficits of the L4/L5 nerve root and sciatic
nerve in 6% of cases. Zone-2 fractures involve deficits
of the L5, S1 and S2 nerve roots in 28% of cases. Zone3 fractures contribute to 60% of neurological deficits
and commonly give rise to bladder, bowel and sexual
dysfunction.1 In addition, zone-3 fractures have
been modified2 and sub-classified,3 based on flexion,
translation, and comminution (Fig. 3).
Traumatic sacral fractures are a cause of acute
abnormal neurology and CES.1 Although patients
with obvious abnormal neurology are easily detected,
some signs are subtle or masked by severe injuries,4
in particular urinary retention.5 Delays in diagnosis
of CES and in the onset of symptoms by several days
have been reported. A study reported a patient with
bilateral calcaneal fractures who was discharged after
5 days but re-presented 2 days later with bladder and
bowel dysfunction, at which point a sacral fracture
causing CES was diagnosed.6 It is unclear whether
symptoms of incomplete CES were missed in this
patient who later returned with complete CES, or
if the cauda equina was compressed at a later date
following worsening of the injury, as was the case in
patient 1.
Sacral insufficiency fractures were first described
as spontaneous osteoperotic fractures of the
sacrum and associated with old age and osteopenia.7
In fact over 90% occur in elderly women.810 Other
risk factors include rheumatoid arthritis,11 radiation
therapy,9 and steroid use.11 They are under-diagnosed
and difficult to detect, owing to a low index of clinical
suspicion and poor imaging techniques.12,13 In a
prospective study over a 2-year period, the incidence
of sacral insufficiency fracture was 1.8% in women
over 55 years admitted with back pain.14
There is no formal classification for sacral
insufficiency fractures, and therefore descriptions
are based on the Denis classification of traumatic
sacral fractures. Neurological complications differ
in patients with sacral insufficiency fractures
and traumatic sacral fractures. A review study
identified 14 of 493 reported sacral insufficiency
fractures to have abnormal neurology, suggesting a
neurological involvement rate of 2.8%.15 The most
common neurological abnormalities were sphincter
dysfunction (n=11), distal paraesthesia (n=7) and

Type 1

Type 2

Type 3

Type 4

Figure 3 Sub-classification of Denis zone-III fractures of the

sacrum2,3: type 1 is simple flexion deformity of the sacrum;
type 2 is partial translation and hyperkyphotic; type 3 is
complete translation with no fracture overlap; and type 4 is
segmental comminution of the S1 vertebral body caused by
axial loading of the lumbar spine into the cephalad part of the
sacrum.

weakness (n=5).15 All the patients presented with

low back/perineal/referred pain, but without
neurological symptoms. Manifestation of neurological
symptoms was delayed in only 5 of those cases.15
Sacral insufficiency fractures presenting with
CES are uncommon. A prospective study identified 4
such cases over a 2-year period in patients who were
referred with acute (n=3) and chronic (n=1) back
and leg pain, with neurological symptoms; all had
fractures in zone 1.16 Patients with zone-3 fractures
presenting with CES are rare.
Delays in identifying abnormal neurology in
sacral insufficiency fractures is in part due to the delay
in recognising CES. In patients with multiple comorbidities, CES symptoms such as incontinence and
urinary retention are subtle and often misdiagnosed
as geriatric issues.
Sacral insufficiency fractures are generally treated
conservatively with bed rest, analgesia, and gentle
mobilisation. Instrumentation is difficult because of
technical difficulties and poor bone quality. Internal
fixation is therefore not commonly practised.
Sacroplastyinjection of polymethylmethacrylate
cement along the fracture planesis increasingly
popular. It provides immediate pain relief, reduces
the use of analgesia and improves activities of
daily living by reducing mobility at the fracture
site.17,18
Poor evidence exists on the optimal timing,
technique and indications for surgery of sacral
insufficiency fractures. Although early intervention is
beneficial for lumbar cauda equina decompression,
the optimum timing of sacral nerve root

Vol. 20 No. 2, August 2012

decompression is not as clear, as is postoperative

instability following decompression. Removing
posterior tension bands by decompressing the sacrum
may require pelvic stabilisation in order to prevent
further kyphotic injuries of the sacrum.
When there is a sacral fracture, clinicians should
raise the level of suspicion of abnormal neurology.
Likewise, abnormal neurology in the elderly should be
properly investigated. Thorough clinical examination

Cauda equina syndrome following sacral fractures 253

including digital rectal examinations and bladder

function quantification is advised. The threshold for
performing computed tomography and/or magnetic
resonance imaging of the pelvis should be low.
Patients should be treated by a multi-disciplinary
team with both orthopaedic and neurosurgical input.
Further studies are needed to identify which patients
would benefit from surgical decompression and the
safest time frame for surgery.

REFERENCES
1. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat
Res 1988;227:6781.
2. Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum. J Orthop Trauma 1991;5:2003.
3. Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumpers fracture. Spine
(Phila Pa 1976) 1985;10:83845.
4. Blanco JF, De Pedro JA, Hernandez P, Santamarta D, Pastor A. Zone III sacral fracturestwo case reports. Injury
2004;35:13113.
5. Phelan ST, Jones DA, Bishay M. Conservative management of transverse fractures of the sacrum with neurological features.
A report of four cases. J Bone Joint Surg Br 1991;73:96971.
6. Hussin P, Chan CY, Saw LB, Kwan MK. U-shaped sacral fracture: an easily missed fracture with high morbidity. A report of
two cases. Emerg Med J 2009;26:6778.
7. Lourie H. Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA 1982;248:715
7.
8. Newhouse KE, el-Khoury GY, Buckwalter JA. Occult sacral fractures in osteopenic patients. J Bone Joint Surg Am
1992;74:14727.
9. Grasland A, Pouchot J, Mathieu A, Paycha F, Vinceneux P. Sacral insufficiency fractures: an easily overlooked cause of back
pain in elderly women. Arch Intern Med 1996;156:66874.
10. Aretxabala I, Fraiz E, Perez-Ruiz F, Rios G, Calabozo M, Alonso-Ruiz A. Sacral insufficiency fractures. High association with
pubic rami fractures. Clin Rheumatol 2000;19:399401.
11. Dasgupta B, Shah N, Brown H, Gordon TE, Tanqueray AB, Mellor JA. Sacral insufficiency fractures: an unsuspected cause
of low back pain. Br J Rheumatol 1998;37:78993.
12. Peh WC, Khong PL, Ho WY, Yeung HW, Luk KD. Sacral insufficiency fractures. Spectrum of radiological features. Clin
Imaging 1995;19:92101.
13. Cooper KL, Beabout JW, Swee RG. Insufficiency fractures of the sacrum. Radiology 1985;156:1520.
14. Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine (Phila
Pa 1976) 1993;18:250712.
15. Finiels PJ, Finiels H, Strubel D, Jacquot JM. Spontaneous osteoporotic fractures of the sacrum causing neurological damage.
Report of three cases. J Neurosurg 2002;97(3 Suppl):3805.
16. Muthukumar T, Butt SH, Cassar-Pullicino VN, McCall IW. Cauda equina syndrome presentation of sacral insufficiency
fractures. Skeletal Radiol 2007;36:30913.
17. Pommersheim W, Huang-Hellinger F, Baker M, Morris P. Sacroplasty: a treatment for sacral insufficiency fractures. AJNR
Am J Neuroradiol 2003;24:10037.
18. Bayley E, Srinivas S, Boszczyk BM. Clinical outcomes of sacroplasty in sacral insufficiency fractures: a review of the
literature. Eur Spine J 2009;18:126671.