Introduction
Sacral insufficiency fractures (SIF) have been described as a common, but often underdiagnosed cause of lower back pain and mobility, especially in elderly patients with osteoporosis [1–3]. Patients with osteoporosis have low bone mineral density, poor bone quality, and are susceptible to falling due to muscle weakness [4].
Patients with SIF present with vague symptoms, including lower back pain and buttock pain [5], while some may present with neurological deficits [1]. Additionally, SIF are difficult to diagnose using x-ray scans alone. These factors make a definitive diagnosis of SIF difficult to achieve [6,7].
Past medical history
Conservative treatment options should be offered first to patients with SIF [6]. Contrary to previous studies, recent research suggests that early mobilization improves outcomes and reduces complications [8]. Several studies have reported the effectiveness of conservative treatment for fractures, including Korean medicine treatment such as acupuncture, moxibustion, herbal medication, bee venom, and pharmacopuncture [9]. In Korea, there have been reports of pelvic fractures caused by apparent trauma or traffic accidents [9–12]. This case report describes the effectiveness of Korean medicine treatment for SIF in an elderly patient with osteoporosis.
Case Report
Patient
○○○ (F/75)
Chief complaint
Pain in both hips and inner thighs.
Past medical history
Hospitalization on July 24th, 2019, due to systemic arthralgia, for 1 month, during which she was diagnosed with rheumatoid arthritis and osteoporosis, and steroid medication was prescribed.
Present illness
Early in November 2019 the patient started to experience spontaneous pain in her right hip whilst squatting. On November 15th, 2019 she had a magnetic resonance imaging (MRI) scan of the lumbar spine which showed spinal stenosis affecting L2–5. A nerve block injection was administered twice. She was then hospitalized in a Western hospital from November 25th until December 3rd, 2019, during which time, a bone scan, X-rays of the lumbar spine, pelvis, and hips, in addition to an MRI scan of the lumbar spine and sacrum were performed. She was diagnosed with SIF and spinal stenosis. After discharge, she visited the Korean Medicine hospital for treatment.
Clinical chemistry
Laboratory investigations, including total blood count, routine biochemical tests, erythrocyte sedimentation rate, and C-reactive protein levels fell within normal limits. Urinalysis demonstrated the presence of 5–7 red blood cells per high power field, 7–10 white blood cells, 10–15 epithelial cells, and a few bacteria. With respect to the urinalysis, the patient was asymptomatic.
Treatment
Acupuncture
The acupuncture needles used were 0.25×30 mm and 30×40 mm stainless steel standardized, and disposable (Eastern acupuncture equipment manufacturer, Boryung, Korea). Acupuncture was administered at BL27, BL28, BL29, BL30, BL31, BL32, BL33, BL34, BL35, BL36, BL37, BL53, BL54, GB29, GB30, LR9, and the tender points on tissues, including the gluteus muscle, piriformis, iliopsoas, adductor, and hamstrings, for 15 minutes twice daily.
Pharmacopuncture
Pharmacopuncture was performed, once daily, on each day of hospitalization. Acupoints BL27, BL28, BL29, BL30, BL53, BL54, or trigger points around the hip were used. Aconitum ciliare decaisne pharmacopuncture (ADP) (Korean Pharmacopuncture Institute, Seoul, Korea) was administered just before acupuncture therapy. Doses of 0.05 to 0.1 mL were injected at each acupoint at a depth of between 1 cm to 1.2 cm. The maximum, total dose per treatment was 1.0 mL This was administered using a 1.0 mL disposable syringe with needle (Jungrim Medical, Seoul, Korea, 30 G ×1.27cm, 12.7 mm needle).
Bee venom (BV)
Due to the potential risks associated with the use of bee venom (delayed hypersensitivity reaction or anaphylaxis), informed consent was obtained from the patient prior to treatment. A hypersensitivity skin test to BV (1:20,000, 0.1 mL; Korean Pharmacopuncture Institute, Seoul, Korea) was performed, and was negative. The concentration of BV administered was serially increased in the order of 1:20,000, 1:10,000, 1:5,000, 1:2,000, and sweet bee venom (SBV) 25% and SBV 50% were also used for intramuscular (IM) injections. The method of injection, either subcutaneous (SC) or IM injection, was chosen according to the site of the lesion. The volume injected also increased with each treatment if no hypersensitivity reaction occurred (Table 1). BV was substituted with SBV, if the patient felt pain from the IM injection of BV in the gluteus area. BV was injected using 30 G, 1 mL syringes.
Herbal medicine
The patient took herbal medication 3 times daily. Whallak-tang, Tongeodalchetang-gamibang (TDT-gamibang) and Ganghwalsokdantang-gamibang (GST-gamibang) were prescribed (Table 2).
Evaluation
Numerical rating scale
The patient’s pain was assessed daily using the NRS. A score of 0 indicated no pain and 10 the most severe pain.
Progress of the patient under treatment
Numeric rating scale
On admission, the patient complained of pain and rated her pain score as a NRS 7 in both her hips and inner hamstrings. Her pain was most severe in the supine position, causing sleep disturbances at night. From the 3rd day of treatment and onwards, the patient’s hip pain started to decline (Fig. 5).
Walking and sitting positions
At admission, the patient was only able to use a wheelchair or walk 1 or 2 steps with assistance. Due to the intensity of pain, she could not remain in a seated position. On Day 3 after admission, she could walk 3 m using a walker, and on Day 9, she could remain seated for more than 10 minutes. On Day 25, she could walk unassisted for 3 m, and for 150 m using a walker. On Day 27, she walked 30 m, unassisted. On Day 30, she could sit for 20 minutes, but she suffered left posterior thigh pain. On Day 41, because her hip pain was greatly reduced, she could remain seated for 30 minutes. On Day 42, she tried to walk unassisted for 300 m, resting after every 100 m. On Day 48, she remained seated for 1 hour. At discharge, she could walk unassisted for more than 200 m. On the 2nd April, the patient visited the outpatient clinic complaining of lumbago and numbness in both legs, which she had in her past medical history. She was able to walk for an hour restlessly and after walking she had hip pain on both sides which she rated as NRS 3.
Radiology findings
X-rays of the pelvis taken at admission and after treatment showed ossification of the fracture was progressing (Fig. 6).
Discussion
SIF commonly occurs in the elderly population and is often associated with conditions, such as rheumatoid arthritis, steroid-induced osteopenia, and osteoporosis. Due to nonspecific clinical symptoms, SIF can be misdiagnosed and improperly managed [1]. Most pelvic fractures are stable, non-displaced, low-energy fractures that can be treated conservatively with bed rest [12,13].
In this case report, a patient presenting with pain in both hips due to SIF, was successfully and conservatively treated using traditional Korean medicine. This patient had osteoporosis and rheumatoid arthritis, and was taking oral steroids, which were thought to have increased the risk of fracture. Although the patient’s fracture involved more than 1 part of the pelvis, because the fracture state was stable, conservative medical management with Korean medicine was a safe option. Rehabilitation was also performed early in the course of treatment.
Under management, the patient’s NRS score decreased from 7 to 2, and the duration for which she was able to remain seated increased from 0 to more than 1 hour by Day 48. At her outpatient appointment on the 2nd April, around 5 months later she could remain seated for as long as she desired. At admission, the patient was only capable of assisted walking and took absolute bed rest. After Day 27 of hospitalization, she had gradually increased her unassisted walking time. At discharge, she was able to walk unassisted for more than 200 m.
Bee venom was injected both SC and IM and the effects of both injection methods did not significantly differ according to a study of knee osteoarthritis patients [14]. In the treatment of this case, however, the method was chosen according to treatment site. The patient’s main complaint was pain in both hips, but because she had a history of lumbar spinal stenosis, lumbar pain was also a target of treatment. Pharmacopuncture treatment incorporated the use of ADP. ADP has both anti-inflammatory and analgesic properties [15], and is used in treatment of arthralgia [16].
At admission, Whallak-tang was prescribed for alleviating severe pain and blood-activating. TDT-gamibang, used to cure pain from contusion, was then prescribed for 12 days to reduce the pain associated with the fracture [17]. As the NRS scores decreased with reduced pain, GST-gamibang was prescribed for the remainder of her stay in hospital. This herbal medication is known to strengthen the bones and muscle, and it effects osteoclast inhibition and activation and is used in the treatment and prevention of osteoporosis [18].
As SIF are a common, but often underdiagnosed condition in elderly patients, clinical practitioners should put SIF in the differential diagnosis of acute hip pain. Symptoms of SIF are nonspecific, such as diffuse pain, inguinal pain from anterior pelvic rim fracture, sacroiliac joint pain, or lower back pain from posterior pelvic rim fracture [19]. SIF are best diagnosed using a bone scan, while an MRI scan can aid in detection of peripheral tissue damage. As was observed in the present study, changes on anteroposterior x-ray scans are only seen after fracture union with callus formation [20].
This study is the first to report the management of a patient with SIF using traditional Korean medicine. Cases of pelvic fracture are rarely treated with traditional Korean medicine, and reports on conservative treatments are rare. This patient had suffered from SIF which occurred in early November, 2019. She was first treated with Western medicine for about a week and on December 3rd, 2019, she was treated by conservative Korean medicine treatment. She made an improvement in her condition and the level of pain she experienced reduced from an NRS score of 7 to 2. However, this report does have several limitations, in that it was limited to only 1 case, and complex treatments were performed simultaneously, making it difficult to determine the efficacy of each treatment method. Further studies are needed to substantiate the findings reported here.
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