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Abstract
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Background and Aims Background: Severe pain from sacral fractures can be difficult to treat especially in the parturient where systemic analgesia options are limited by its maternal and fetal side effects. Regional anaesthesia can be especially useful in providing analgesia due to its minimal side effects. Aims: We postulated that a sacral plexus catheter can help achieve our goals of 1) long-lasting pain control without need for repeated procedures, 2) minimal maternal and fetal side effects, 3) facilitating physiotherapy and rehabilitation, and 4) early home discharge.
Methods We detail the case of a 30-year-old 16-week parturient with traumatic sacral fractures. Despite optimal multimodal analgesia, our patient experienced debilitating pain affecting her breathing, sleep, and rehabilitation. As analgesia options were limited, regional anaesthesia techniques including a sacral plexus catheter, caudal and lumbar epidural block were offered. A right sacral plexus catheter was eventually inserted for pain relief, using the parasacral parallel shift approach under ultrasound guidance. An initial local anaesthetic bolus of 15mL Lignocaine 1.5% with adrenaline 1:200,000 was injected, followed by a continuous infusion of Ropivacaine 0.2% at 5ml/h. She was followed up daily by the Acute Pain Service team.
Results With the sacral plexus catheter, our patient experienced significant pain relief and rehabilitated well. She reported improvement in pain with from a Numeric Rating Scale of 10 to 2 post-procedure and recovered sufficient function for home within 1 week.
Plain radiograph of the pelvis showing mildly displaced fracture of the right inferior pubic ramus. Site of fracture indicated by yellow arrow
Computed tomography of the abdomen and pelvis showing undisplaced fracture of the right sacral ala with possible extension to the right sacroiliac joint. Site of fracture indicated by yellow arrow
(A) Diagram of an ultrasound image showing the relevant sonoanatomy for performing the sacral plexus block with relevant structures identified. The needle path via a lateral-to-medial approach is also highlighted with the tip of the needle targeting the sacral plexus as depicted in yellow dashed lines. (B) 3D reconstruction of the pelvis from computed tomography (CT) scan showing the right closed sacral ala fracture (white arrow) and right inferior pubic rami fracture (yellow arrow). (C) Schematic image showing the appropriate placement of the curvilinear ultrasound probe at a position translated inferomedially with a parasacral parallel shift, from a point between posterior sacral iliac spine (PSIS) and the midpoint of a line connecting the PSIS and greater trochanter
Conclusions We conclude that a sacral plexus catheter is a good viable option in providing analgesia and facilitating rehabilitation in the parturient with traumatic sacral fractures.
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