Disclosures: YIDING LI, MBBS, MRCP: No financial relationships or conflicts of interest

Case Description: We report a case of a 72 years old lady with sacral ala fracture (Denis zone I) presenting with radicular pain that was not identified on X-rays and only later diagnosed on MRI pelvis. This patient presented to the Emergency Department for acute low back pain after she slipped and fell on the gluteal region. This is associated with radiating pain to the back of the left thigh and leg and difficulty bearing weight. Examination was limited by pain but did not reveal any neurological deficits. Lumbosacral, pelvic and hip X-rays did not show any fractures. She was initially diagnosed as having lumber spondylosis with “myofascial referred pain” and started on paracetamol and tramadol which helped with the pain marginally. She continued to have difficulty ambulating due to pain 5 days later and was referred for inpatient rehabilitation. MRI pelvis including the sciatic nerve was ordered to rule out other injuries. Linear undisplaced fractures were noted in the left sacral ala at the S1 and S2 level with reactive bone marrow oedema, suggestive of acute insufficiency fractures of the sacrum. Sciatic nerve was normal but significant oedema noted around the left S1 and S2 nerve roots.

Setting: Rehabilitation unit within a regional general hospital

Patient: 72 years old lady with sacral ala fracture Assessment/

Results: She was started on pregabalin and managed conservatively with non-weight bearing for 6 weeks and was eventually discharged home successfully 7 weeks later.

Discussion: Sacral fractures can be associated with nerve root involvement and radicular symptoms. Normal X-ray cannot be used to exclude this condition absolutely, and other imaging modalities should be considered.

Conclusion: In patients with persistent low back pain and initial normal imaging. It is important to consider the differential diagnosis of sacral insufficiency fractures.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/persistent-severe-radicular-low-back-pain-more-to-this-than-meets-the-eye/