Comparatively, an injury to the posterior rami of the sacral nerve roots is less debilitating, as the primary function of the posterior rami is to provide sensation to the buttocks via the cluneal nerves. ![]() 4 Importantly, an injury to the anterior rami of S2 to S5 nerve roots can lead to significant morbidity, as these nerves are critical in bowel and bladder control (parasympathetic innervation) as well as sexual function. For this reason, the S1 and S2 nerve roots are at higher risk of injury after a sacral fracture compared with the S3 and S4 roots. The sacral foramina are also relatively large in comparison with the sacral nerve roots the S1 and S2 nerve roots occupy approximately one-third to one-fourth of their corresponding foramina, and the S3 and S4 nerve roots occupy approximately one-sixth of their respective foramina. The sacral spinal canal is large, providing sufficient space for the cauda equina. ![]() Additionally, while the L5 nerve root exits the spinal canal cephalad to the sacrum, it travels along the anterior surface of the S1 vertebral body and sacral ala, so it is also commonly injured during injuries to the sacrum. The neural structures at risk after a sacral fracture are the cauda equina, filum terminale, the sacral plexus, and the sciatic nerve. The soft tissue envelope around the sacrum is relatively thin, consisting of the multifidus muscle and the lumbosacral fascia, making this region particularly susceptible to infection, skin breakdown, and hardware-related complications. Sacral stability is highly dependent on the strong ligamentous structures of the pelvic ring. This angulation contributes to the inclination of the superior endplate of the sacrum and to the pelvic incidence, which then influence the lordosis of the lumbar spine. It is a kyphotic structure formed by the fusion of 5 sacral vertebrae, with an angulation that varies from 10° to 90°. ![]() The sacrum transmits axial loads from the trunk to the lower limbs and protects the lumbosacral (L4-S1) and sacral (S2-S4) plexi and iliac vessels. The origin of its name has been suggested to derive from ancient cultures where the sacrum, being the seat of the organs of procreation, was the part of the animal offered for sacrifice, although it has also been suggested that this interpretation is erroneous, with the name deriving from a mistranslation of the Greek hieron osteon (“strong bone”). The sacrum is the mechanical nucleus of the axial skeleton, located at the base of the lumbar spine and acts as the keystone at the center of the pelvic ring. The purpose of this article is to review the evaluation of sacral fractures briefly and to identify the most common injuries that are associated with sacral fractures. 2 Because of this, it is essential that any treatment algorithm for sacral fractures account for these injuries. 1 Furthermore, the associated injuries are often one of the critical factors that determine the outcome of patients with sacral fractures. ![]() Only 5% of sacral fractures occur as isolated injuries, and up to 45% occur with a concomitant pelvic ring injury. One of the critical differences between sacral fractures and other fractures of the spinal column is that sacral fractures rarely occur in isolation. For this reason, treatment is often determined on a case-by-case basis, and this may be influenced significantly by the attending surgeons training (ie, spine surgeon vs orthopedic trauma surgeon). Adding to the complexity of these fractures there is little supporting literature on diagnosis and management, with no level 1 or 2 studies published to date and a myriad of classification systems available. Because of their relative rarity and heterogeneous nature, they are frequently misdiagnosed and not properly treated. Sacral fractures are complex in nature and pose diagnostic challenges and technical difficulties for treatment.
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