Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures
Authors: Aprato Alessandro , Branca Vergano Luigi , Casiraghi Alessandro , Liuzza Francesco , Mezzadri Umberto , Balagna Alberto , Prandoni Lorenzo , Rohayem Mohamed , Sacchi Lorenzo , Smakaj Amarildo , Arduini Mario , Are Alessandro , Battiato Concetto , Berlusconi Marco , Bove Federico , Cattaneo Stefano , Cavanna Matteo , Chiodini Federico , Commessatti Matteo , Addevico Francesco , Erasmo Rocco , Ferreli Alberto , Galante Claudio , Giorgi Pietro Domenico , Lamponi Federico , Moghnie Alessandro , Oransky Michel , Panella Antonio , Pascarella Raffaele , Santolini Federico , Schiro Giuseppe Rosario , Stella Marco , Zoccola Kristijan , Massé Alessandro 
Published: September 2023

Abstract
Background
There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.

Materials and methods
The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.

Results
Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is “as early as possible”. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.

Conclusions
This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients.
Level of Evidence: IV.
Trial registration: not applicable (consensus paper).