Hindawi
Case Reports in Orthopedics
Volume 2017, Article ID 7396564, 6 pages
https://doi.org/10.1155/2017/7396564

Case Report
Usefulness of Sacral Sublaminar Wire for Low Transverse Sacral
Fractures: Two Cases’ Report
Tatsuro Sasaji, Hideki Imaizumi, and Taishi Murakami
Department of Orthopedic Surgery, Osaki Citizen Hospital, No. 3-8-1, Furukawa Honami, Osaki-shi, Miyagi 989-6183, Japan
Correspondence should be addressed to Tatsuro Sasaji; taturosasaji@gmail.com
Received 12 March 2017; Revised 20 August 2017; Accepted 5 September 2017; Published 4 October 2017
Academic Editor: Koichi Sairyo
Copyright © 2017 Tatsuro Sasaji et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Low transverse sacral fractures are rare, with only two published reports regarding their surgery. The complication associatedwith surgery for sacral fractures is the prominence of implants. In addition, screw fixation below S3 is impractical. We performed
posterior sacral fixation using S2 alar iliac (S2AI) screws and sacral sublaminar wires for low transverse sacral fractures. Case 1
was 65-year-old male with an S2-3 transverse sacral fracture. We performed laminectomy (S2-3) and passed ultrahigh molecularweight polyethylene (UHMWPE) cables from laminectomy area to the third posterior sacral foramina. We inserted S2AI screws andconnected rods. We also tightened the UHMWPE cables. The implants did not protrude into skin. One year after surgery, the sacral
fracture healed without any displacement. Case 2 was a 42-year-old female with an S2 transverse sacral fracture. We performed
laminectomy (S1–3) and passed UHMWPE cables from laminectomy area to the third and fourth posterior sacral foramina. We
inserted S1 pedicular screws and S2AI screws and connected rods. We also tightened UHMWPE cables. The implants did not
protrude into skin. One year after surgery, the sacral fracture healed without any displacement. We consider sacral sublaminarwires to be useful bone anchors in lower sacrum.

1. Introduction
Transverse sacral fractures account for only 3%–5% of all
sacral fractures, with the rest being longitudinal sacral fractures [1, 2]. High transverse sacral fractures occur more
frequently than low transverse sacral fractures [2]. Low
transverse sacral fractures are reportedly considered to berelatively rare.
Selecting a treatment for sacral fractures is primarily
based on the fracture pattern and neurological status of
the patient [3]. For high transverse sacral fractures, various
techniques such as Harrington rod [4–7], Luque method [8],lumbopelvic fixation [9], and locking plate [10] have beendeveloped. The lower part of the sacrum is not involved in
the transmission of weight from the lower extremities tothe spine, and low transverse sacral fractures are consideredstable [2]. For low transverse sacral fracture, there have been
only two reports regarding surgical repair, locking plate [10],pedicular screws [7], and hook systems [7]. In the report ofthe locking plate technique, screws are inserted into the sacral
midline [10]. Midline sacral screws have a risk for impinging

on sacral nerves. Pedicular screw and hook placement have arisk for protrusion into the sacral skin. Therefore, we selected
an alternative surgical method for incapacitated patients.
The reported complication regarding surgery for sacral
fractures is that prominent hardware may be a source of
discomfort or a nidus for skin breakdown postoperatively[11, 12]. In addition, because screw fixation below S3 is
impractical [11], surgical methods for low transverse sacral
fractures have not yet been established. Here, we performedinternal fixation using an S2 alar iliac (S2AI) screw and sacralsublaminar wire (Schwend’s technique) [13] and reported
regarding the treatment course. On the basis of our surgicalresults, we described the usefulness of sacral sublaminarwires for repairing low sacral fractures. To the best of ourknowledge, this is the first study to describe the usefulnessof sacral sublaminar wires as low sacral bone anchor.

2. Case Presentation
2.1. Case 1. A 65-year-old male with schizophrenia had
urinary retention and gait disturbance owing to sacral pain.

2

Case Reports in Orthopedics

S1

S1

R
(a)

R
(b)

(c)

(d)

Figure 1: Reconstructed computed tomography (CT) and magnetic resonance images of sacrum at first hospital presentation. (a) Sagittal
reconstructed CT image. (b) Axial CT image at S2-3 level. (c) Sagittal plane on a T2-weighted image. (d) Axial plane on a T2-weighted
image. Fractures in the sacral vertebral body (white arrow) and lamina (white arrowhead) can be observed (a). Radiological findings wereconsistent with a Roy-Camille classification type I fracture [5]. Sacral canal was narrowed by the protruding sacral vertebral body (blackarrow) (b). This radiological finding was diagnosed as a Denis Zone III sacral fracture [15]. Sagittal and axial plane on T2-weighted images
showed that sacral nerves were compressed by the vertebral body (white arrow) (c, d).

His height was 173.7 cm, weight was 49.7 kg, and body massindex was 16.5 kg/m2 (weight loss) [14]. He complained ofsacral pain and urinary retention 2 weeks after slipping andfalling to the floor. Performing neurological examination
was impossible because of schizophrenia. The urinary tract
was not damaged. Thus, a diagnosis of neurogenic bladderdysfunction was made.
Sagittal reconstructed computed tomography (CT)revealed that both sacral lamina and vertebral body werefractured and displaced into the sacral canal at the S2-3
level (Figure 1(a)). The sacral kyphotic angle was 110 degrees(Figure 2). Axial reconstructed CT revealed that sacral
canal was narrowed by the protruding sacral vertebral body
(Figure 1(b)). Sagittal and axial plane magnetic resonanceimaging (MRI) revealed that sacral nerves were compressedby the angulated sacral vertebral body and lamina on
T2-weighted images (Figures 1(c) and 1(d)). We determinedthat this fracture was unstable and would subsequently
become a sacral kyphotic deformity. Our treatment plan wasa decompression surgery with stabilization.
The second and third sacral laminae were exploredthrough a straight posterior midline approach. Laminectomyof the second and third laminae was performed using aburr. No hematoma was observed. The sacral nerve roots
were not disrupted. We passed ultrahigh molecular weight
polyethylene (UHMWPE) cables (the NESPLON Cable
System, Alfresa Pharma Corporation, Osaka, Japan) fromthe central laminectomy area to the third posterior sacralforamina using a sublaminar wire technique. We inserted
bilateral S2AI screws and connected the rods. Finally, wetightened the UHMWPE cables to the rods (Figures 3(a) and3(b)).
One year after the surgery, the patient returned tonormal daily life without a cane, although urinary retention
persisted. One- and 3-month postoperative follow-up sagittal
reconstructed CT revealed high-density areas in the second
and third sacral vertebral bodies (Figures 4(a) and 4(b)).
One-year postoperative follow-up sagittal reconstructed CT

Promontorium

S1

Sacral kyphotic
angle

S4

CoccyxFigure 2: Schemata of sacral kyphotic angle. We defined the sacralkyphotic angle as the angle between the line from the sacral promontorium to the anterior edge of the proximal fracture fragment andthe line from the anterior edge of the distal fracture fragment tothe caudal edge of the fourth sacral body in a midline sagittal
reconstructed computed tomography image.

revealed that the sacral vertebral bodies had united without
any displacement (Figure 4(c)). The sacral kyphotic angle
was 108 degrees and the sacral kyphotic deformity did not
deteriorate (Figure 2).
2.2. Case 2. A 42-year-old female with anxiety neurosispresented with urinary retention, perineal numbness, andgait disturbance owing to sacral pain. Her height was 160 cm,
weight was 37.65 kg, and body mass index was 14.7 kg/m2(weight loss) [14]. She complained of urinary retention 10
days after slipping and falling to the floor. Neurologicalexamination revealed normal muscle power in her lower

Case Reports in Orthopedics

3

S2

R

R

(a)

(b)

Figure 3: Postoperative three-dimensional computed tomography (CT) and schemata. (a) Three-dimensional CT. (b) Operation schema. Threedimensional CT showing S2-3 laminectomy and S2AI screws and rods (red color) (a). Surgical method (b): we performed S2-3 laminectomy
and then passed ultrahigh molecular weight polyethylene (UHMWPE) cables from the central laminectomy area to the third posterior sacralforamina. We inserted S2AI screws and connected the rods, after which the UHMWPE cables were tightened to the rods.

S1

S1

(a)

S1

(b)

(c)

Figure 4: Follow-up sagittal reconstructed computed tomography (CT) images of the sacrum. (a) One-month sagittal reconstructed CT image.
(b) Three-month sagittal reconstructed CT image. (c) One-year sagittal reconstructed CT image. The second-third sacral vertebral body
exhibited a high-density area (a). The high-density area in the second-third sacral vertebral body increased (b). The second-third sacralvertebral body had united without any displacement (c).

extremities, with decreased ankle jerk. Sensory disturbancewas detected in the perineal region. Urinary retention was
severe, with loss of bladder urgency. On the basis of the abovefindings, we diagnosed neurogenic bladder dysfunction.
Sagittal reconstructed CT revealed that the second sacralvertebral body was fractured and displaced into the sacral
canal (Figure 5(a)). The sacral kyphotic angle was 107 degrees(Figure 2). Axial reconstructed CT confirmed that sacral
canal was narrowed by the protruding sacral vertebral body
(Figure 5(b)). Sagittal and axial plane MRI revealed that sacral
nerves were compressed by the angulated sacral vertebral
body and lamina on T2-weighted images (Figures 5(c) and5(d)). We determined that the fracture was unstable andwould subsequently become a sacral kyphotic deformity.
Thus, we planned to perform decompression surgery withstabilization.
The first, second, and third sacral laminae were exploredthrough a straight posterior midline approach. Laminectomyof the first, second, and third sacral laminae was performed
using a burr. No hematoma was observed. The sacral nerveroots were not disrupted. We passed UHMWPE cables fromthe central laminectomy area to the third and fourth posterior
sacral foramina using a sublaminar wire technique. We
inserted bilateral S1 pedicular and S2AI screws and connected
the rods. Finally, we tightened the UHMWPE cables to therods (Figures 6(a) and 6(b)).
The patient’s perineal numbness improved immediately
after surgery. One month after surgery, she was able tourinate, and, 3 months after surgery, her bladder function hadcompletely recovered. Three months after surgery, implant
infection occurred. We considered that the fracture became
stabilized at that time. Thus, we removed all implants.
Following the surgery, the infection was healed. One year
after the surgery, she returned to normal daily life without acane. One- and three-month postoperative follow-up sagittal
reconstructed CT revealed a high-density area in the second

4Case Reports in Orthopedics

S1

S1

R
(a)

(b)

(c)

R
(d)

Figure 5: Reconstructed computed tomography (CT) and magnetic resonance image of sacrum at first hospital presentation. (a) Sagittal
reconstructed CT image. (b) Axial CT image at S2 level. (c) Sagittal plane on a T2-weighted image. (d) Axial plane on a T2-weighted image.
Displaced fractures in the second sacral vertebral body (white arrow) can be observed (a). This radiological finding was consistent with a
Roy-Camille classification type II fracture [5]. Sacral canal was narrowed by the protruding sacral vertebral body (black arrow) (b). This
radiological finding was diagnosed as a Denis Zone III sacral fracture [15]. Sagittal and axial planes on T2-weighted images showed thatsacral nerves were compressed by the vertebral body (white arrow) (c, d).

S2

R
(a)

R
(b)

Figure 6: Postoperative three-dimensional computed tomography (CT) and schema. (a) Three-dimensional CT. (b) Operation schema. Threedimensional CT showing S1–3 laminectomy, S1 pedicular screws, S2AI screws, and rods (red color) (a). Operation method (b): we performed
S1–3 laminectomy. We then passed ultrahigh molecular weight polyethylene (UHMWPE) cables from the central laminectomy area to thethird and fourth posterior sacral foramina. We inserted S1 pedicular screws and S2AI screws and connected the rods, following which the
UHMWPE cables were tightened to the rods.

Case Reports in Orthopedics

5

S1

S1

S1

(a)

(b)

(c)

Figure 7: Follow-up sagittal reconstructed computed tomography (CT) images of the sacrum. (a) One-month sagittal reconstructed CT image.
(b) Three-month sagittal reconstructed CT image. (c) One-year sagittal reconstructed CT image. The second sacral vertebral body was not
displaced (a). The second sacral vertebral body contained a high-density area (b). The second sacral vertebral body had united without any
displacement (c).

sacral vertebral body (Figures 7(a) and 7(b)). One-year
postoperative follow-up sagittal reconstructed CT revealed
that the second sacral vertebral body had united without any
displacement (Figure 7(c)). The sacral kyphotic angle was 105
degrees and the sacral kyphotic deformity did not deteriorate(Figure 2).

3. Discussion
We believed that lumbopelvic fixation was not indicatedin low sacral fractures because such a fixation would not
be effective in these cases. Moreover, there was no verticalinstability in these cases. We decided to perform internal
fixation across the fracture line. These patients were severely
incapacitated: therefore, a low-profile sacral bone anchor wasessential. We selected S2AI screws as the cranial bone anchor
and sacral sublaminar wire as the caudal bone anchor.
The S2AI screw is a sacropelvic instrument that provides
a secure distal foundation [16]. The S2AI screw is a lowprofile implant that minimizes implant prominence andtissue dissection [17–19]. Previous reports have determinedthat the S2AI screw was a strong and low-profile sacral boneanchor. Before operation, we were afraid that our patientswould not follow our postoperative program and we neededa strong bone anchor to withstand their free behaviors. Thus,
we selected the S2AI screw as a cranial bone anchor, resulting
in good surgical outcomes.
The high-risk sacral midline locking screw [10] andprotruded pedicular screw and hook system [7] were rejected
as low sacral bone anchors. We also required another low
sacral bone anchor. Schwend et al. reported the use of asacral sublaminar wire for lumbar spondylolisthesis surgery[13]. On the basis of previous successful surgical outcomes,
we selected a sacral sublaminar wire as caudal sacral boneanchor. In these incapacitated cases, the sacral sublaminar
wire did not protrude into the skin and maintained a sacralkyphotic angle. Based on the successful results, we consider
that a sacral sublaminar wire will overcome any reported
postoperative problems to act as a useful bone anchor of low
sacrum.

4. Conclusion
For low transverse sacral fractures, sacral sublaminar wire
was low profile and could maintain the sacral alignment.
Sacral sublaminar wire can be a useful low sacral bone anchor.

Ethical Approval
The protocol for case report was approved by the Ethics
Committee at Osaki Citizen Hospital (Osaki, Japan) (H28Rinri-25).

Consent
Written informed consent was obtained from the family ofPatient 1 and from Patient 2 for publication of these casereports and any accompanying images.

Conflicts of Interest
The authors declare that they have no conflicts of interest.

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