Spine iSAWE 19

Question

A 78 year old woman on long term corticosteroids has severe low back and buttock pain with no history of trauma. Plain radiographs are normal.

Spine iSAWE 19, coronal inversion recovery MRI of the pelvis
Coronal inversion recovery MRI of the pelvis. Image by Mohamed Jarraya, Daichi Hayashi, Frank W. Roemer, Michel D. Crema, Luis Diaz, Jane Conlin, Monica D. Marra, Nabil Jomaah and Ali Guermazi, Wikimedia Commons, CC BY 3.0.
  1. What does the MRI show?
  2. What imaging signs are described?
  3. Outline management.

Answer

MRI

  • Bone marrow oedema in the right sacral ala
  • Sacral insufficiency fracture
  • Risk factors include osteoporosis, corticosteroids, pelvic radiotherapy, rheumatoid arthritis and prior lumbar fusion

Imaging signs

  • Radiographs often normal
  • Honda sign (H pattern) on bone scan when bilateral with a horizontal limb
  • CT shows sclerosis and fracture lines
  • MRI is most sensitive
  • Look for pubic rami fractures, which coexist in many

Management

  • Analgesia and mobilisation as tolerated
  • Investigate and treat osteoporosis, vitamin D and calcium
  • Consider teriparatide, which may speed healing
  • Sacroplasty for refractory pain
  • Percutaneous iliosacral or transsacral screw fixation for displaced or non healing fractures
  • Thromboprophylaxis while mobility is limited

Related pages

Author Contributions

Orthofracs team

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.