Radiculopathy due to cement extravasation after sacroplasty: A case report

Sacral insufficiency fractures are an underrecognized source of atraumatic lumbopelvic pain in elderly osteoporotic patients and may evade diagnosis when initial radiographs are inconclusive. We describe an elderly osteoporotic woman who presented to an outpatient spine clinic with atraumatic low back and hip girdle/groin pain, without radicular symptoms or neurologic deficit. After failure of four weeks of conservative treatment, MRI confirmed bilateral sacral insufficiency fractures, and CT-guided bilateral sacroplasty was performed for persistent axial pain. The procedure was complicated by immediate severe right L5-S1 radicular pain, with MRI and CT demonstrating cement extravasation into the right S1 neural foramen, posterior epidural space, cephalad to the L5 vertebral body, and caudally within the sacral canal. Conservative management with pharmacologic therapy, rehabilitation, and a single right L5 and S1 transforaminal epidural steroid injection resulted in gradual symptom resolution. Spine surgery was consulted, but operative intervention was deferred because symptoms improved and no neurologic deficit developed. This case highlights both the diagnostic complexity of sacral insufficiency fractures and the importance of prompt recognition of cement migration after sacroplasty, while supporting nonoperative management in selected patients without neurologic deficit.