1
|
Silverstein JW, D'Amico RS, Mehta SH, Gluski J, Ber R, Sciubba DM, Lo SFL. The diagnostic accuracy of neuromonitoring for detecting postoperative bowel and bladder dysfunction in spinal oncology surgery: a case series. J Neurooncol 2024:10.1007/s11060-024-04742-y. [PMID: 38884662 DOI: 10.1007/s11060-024-04742-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE Postoperative bowel and bladder dysfunction (BBD) poses a significant risk following surgery of the sacral spinal segments and sacral nerve roots, particularly in neuro-oncology cases. The need for more reliable neuromonitoring techniques to enhance the safety of spine surgery is evident. METHODS We conducted a case series comprising 60 procedures involving 56 patients, spanning from September 2022 to January 2024. We assessed the diagnostic accuracy of sacral reflexes (bulbocavernosus and external urethral sphincter reflexes) and compared them with transcranial motor evoked potentials (TCMEP) incorporating anal sphincter (AS) and external urethral sphincter (EUS) recordings, as well as spontaneous electromyography (s-EMG) with AS and EUS recordings. RESULTS Sacral reflexes demonstrated a specificity of 100% in predicting postoperative BBD, with a sensitivity of 73.33%. While sensitivity slightly decreased to 64.71% at the 1-month follow-up, it remained consistently high overall. TCMEP with AS/EUS recordings did not identify any instances of postoperative BBD, whereas s-EMG with AS/EUS recordings showed a sensitivity of 14.29% and a specificity of 97.14%. CONCLUSION Sacral reflex monitoring emerges as a robust adjunct to routine neuromonitoring, offering surgeons valuable predictive insights to potentially mitigate the occurrence of postoperative BBD.
Collapse
Affiliation(s)
- Justin W Silverstein
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
- Department of Clinical Neurophysiology, Neuro Protective Solutions, New York, NY, USA.
| | - Randy S D'Amico
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Shyle H Mehta
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Jacob Gluski
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Roee Ber
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Daniel M Sciubba
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Sheng-Fu Larry Lo
- Department of Neurological Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| |
Collapse
|
2
|
Dietz S, Fritzmann J, Weidlich A, Schaser KD, Weitz J, Kirchberg J. [Treatment strategies for recurrent rectal cancer]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:495-509. [PMID: 38739162 DOI: 10.1007/s00104-024-02087-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/14/2024]
Abstract
Multimodal treatment approaches with neoadjuvant radiotherapy and chemotherapy followed by oncological and total mesorectal excision (TME) have significantly reduced the recurrence rate even in locally advanced rectal cancer. Nevertheless, up to 10% of patients develop a local relapse. Surgical R0 resection is the only chance of a cure in the treatment of locally recurrent rectal cancer (LRRC). Due to the altered anatomy and physiology of the true pelvis as a result of the pretreatment and operations as well as the localization and extent of the recurrence, the treatment decision is individualized and remains a challenge for the interdisciplinary team. Even locally advanced tumors with involvement of adjacent structures can be treated in designated centers using multimodal treatment concepts with potentially curative intent.
Collapse
Affiliation(s)
- Sophia Dietz
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
- Nationales Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Johannes Fritzmann
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
- Nationales Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Anne Weidlich
- Nationales Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland
- UniversitätsCentrum für Orthopädie, Unfall- & Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Klaus-Dieter Schaser
- Nationales Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland
- UniversitätsCentrum für Orthopädie, Unfall- & Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Jürgen Weitz
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
- Nationales Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Johanna Kirchberg
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
- Nationales Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland.
| |
Collapse
|
3
|
FERRONATO DANILODESOUZA, TAVARES JUNIOR MAUROCOSTAMORAIS, NARAZAKI DOUGLASKENJI, GHILARDI CESARSALGE, TEIXEIRA WILLIAMGEMIOJACOBSEN, CRISTANTE ALEXANDREFOGAÇA, BARROS FILHO TARCISIOELOYPESSOADE. COMPLICATIONS AFTER PARTIAL, TOTAL OR EXTENDED SACRECTOMY: A CASE SERIES. COLUNA/COLUMNA 2021. [DOI: 10.1590/s1808-185120212003235738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective The aim of this study was to conduct a survey of the different complications of partial, total or extended sacrectomy for the treatment of spinal tumors. Method This study is a descriptive analysis of medical records from a series of 18 patients who underwent sacrectomy between 2010 and 2019 at a tertiary center specializing in spinal tumor surgeries. The variables analyzed were sex, age, hospitalization time, oncologic diagnosis, posterior fixation pattern, rate of complications, and Frankel, ASA and ECOG scales. Results Of the 18 patients, 10 (55.5%) were male and 8 (44.5%) were female, and the mean age was 48 years. The mean hospitalization time was 23 days. Of the 18 patients, 8 (44.5%) contracted postoperative infections requiring surgery. Perioperative complications included liquoric fistula (22.25%), hemodynamic instability requiring vasoactive drugs in the immediate postoperative period (22.25%), wound dehiscence (11.1%), acute obstructive abdomen (11.1%), occlusion of the left external iliac artery (11.1%), immediate postoperative death due to acute myocardial infarction (11.1%), and intraoperative death due to hemodynamic instability (11.1%). Conclusions Partial, total or extended sacrectomy is a complex procedure with high morbidity and mortality, even in centers specializing in the treatment of spinal tumors. Level of evidence IV; case series study.
Collapse
|
4
|
Asaad M, Mericli AF, Hanasono MM, Roubaud MS, Bird JE, Rhines LD. Free Vascularized Fibula Flap Reconstruction of Total and Near-total Destabilizing Resections of the Sacrum. Ann Plast Surg 2021; 86:661-667. [PMID: 33009144 DOI: 10.1097/sap.0000000000002562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascularized bone grafts (VBGs) are associated with improved union and fewer instrumentation complications in the mobile spine. It is not known if VBGs are similarly efficacious after sacrectomy. METHODS We conducted a retrospective chart review of all patients who underwent total sacrectomy and immediate reconstruction with VBG between 2005 and 2019. Patient and surgical characteristics in addition to union and functional outcomes were analyzed. RESULTS We identified 10 patients (6 women and 4 men) with a mean age of 42 years (range, 12-71 years). All patients received iliolumbar instrumentation as well as a free fibula flap as a VBG. There were no complications at the fibula flap donor site or specifically related to the VBG. Bony union was achieved in 7 (88%) of 8 patients with an average union time of 6.3 months (range, 2-10 months). Surgical complications occurred in 5 patients, 4 patients required reoperation for wound dehiscence, and 1 patient required conversion to a 4-rod construct and bone grafting for instrumentation loosening and partial nonunion. Instrumentation failure developed in 1 patient, but no surgical intervention was required. One patient was able to walk independently without any limitation, 5 patients required a walker, 2 were wheelchair-bound except for short (<15 ft) distances, and 2 were lost to follow-up. CONCLUSIONS The free vascularized fibula flap is a safe and effective option for supplementing spinal reconstruction after destabilizing sacrectomy.
Collapse
Affiliation(s)
| | | | | | | | | | - Laurence D Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
5
|
Sambri A, Medellin MR, Errani C, Campanacci L, Fujiwara T, Donati D, Parry M, Grimer R. Denosumab in giant cell tumour of bone in the pelvis and sacrum: Long-term therapy or bone resection? J Orthop Sci 2020; 25:513-519. [PMID: 31155442 DOI: 10.1016/j.jos.2019.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/08/2019] [Accepted: 05/06/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Surgery of GCTB in sacrum and pelvis is challenging, with high rates of complications and local recurrence. Denosumab can consolidate the peripheral rim of the tumour, thus reducing the rate of morbidities of surgery. The aim of this paper is to evaluate the use of denosumab in pelvic/sacrum giant cell tumours of bone (GCTB). PATIENTS AND METHODS We retrospectively reviewed a cohort of 26 patients with aggressive GCTB in sacrum or pelvis treated with denosumab at two referral centres. Clinical response and local recurrence were recorded and the radiologic responses were evaluated with the MDA criteria. RESULTS 69% of the pelvic GCTB treated with denosumab presented partial or good radiologic responses (type 2A or 2B) after 49 weeks of treatment. Denosumab was administered as adjuvant therapy prior and after surgery in 11 patients (group A), and as the only treatment in 15 patients (group B). In group A, 62% of local recurrence was observed in patients treated with intralesional curettage. No recurrences were identified after en bloc resection. In group B, 9 patients were on continuous bimonthly long term denosumab administration with type 2A and 2B responses. Six patients stopped denosumab and 66% remained stable after 10 months of follow-up. CONCLUSIONS Long-term denosumab therapy can be considered with curative intent for pelvic and sacrum GCTB. If surgical intervention is required wide resection may be advisable to reduce the risk of recurrence.
Collapse
|
6
|
Asaad M, Rajesh A, Wahood W, Vyas KS, Houdek MT, Rose PS, Moran SL. Flap reconstruction for sacrectomy defects: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2020; 73:255-268. [DOI: 10.1016/j.bjps.2019.09.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/12/2019] [Accepted: 09/09/2019] [Indexed: 01/16/2023]
|
7
|
Abstract
RATIONALE Chordoma is a relatively rare tumor that accounts for 1% to 4% of all malignant bone tumors, with an annual incidence of <0.1 per 100,000 people. Although chordoma is aligned with the axis of the spine and most commonly develops in the sacrum, to the best of our knowledge, giant sacrococcygeal chordoma is extremely rare. PATIENT CONCERNS A 61-year-old Chinese man presented with a massive dorsal sacral mass. The patient's primary complaint was that, during the last two months, the mass had been increasing in size and his right lower extremity was uncomfortable while he was sitting, although the discomfort was relieved when he was standing. DIAGNOSES Based on the imaging findings, we suspected that the sacrococcygeal mass was a chordoma, and a postoperative pathological examination confirmed the diagnosis of a sacral chordoma. INTERVENTION The patient underwent extensive open surgery to achieve complete resection of the sacrococcygeal mass. An occlusion balloon catheter was used in the abdominal aorta to minimize intraoperative bleeding and maintain a clear surgical field. OUTCOMES The patient was discharged without complications at 27 days after surgery. The 3-month follow-up revealed that the patient had recovered well, the discomfort in his right lower extremity while standing had completely resolved and that there was no evidence of recurrence. LESSONS The development of chordoma is not associated with clear symptoms, although early diagnosis and treatment are needed to prevent invasion of the nearby tissues and organs. Therefore, we believe that surgical treatment of sacral chordoma is effective, although care must be taken to completely remove all residual tumor tissue and reduce the risk of recurrence. Besides, This report adds to our limited understanding of the rare giant sacrococcygeal chordoma.
Collapse
Affiliation(s)
- Qiang Xu
- Department of Orthopedics, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, The First Affiliated Hospital of Nanchang University, Nanchang
| | - Houyun Gu
- Department of Spine Surgery, The Affiliated Ganzhou Hospital of Nanchang University (Ganzhou People's Hospital), Ganzhou, Jiangxi, China
| | - Xuqiang Liu
- Department of Orthopedics, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, The First Affiliated Hospital of Nanchang University, Nanchang
| | - Hucheng Liu
- Department of Orthopedics, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, The First Affiliated Hospital of Nanchang University, Nanchang
| | - Yibiao Zhou
- Department of Orthopedics, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, The First Affiliated Hospital of Nanchang University, Nanchang
| | - Guiping Chen
- Department of Orthopedics, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, The First Affiliated Hospital of Nanchang University, Nanchang
| | - Min Dai
- Department of Orthopedics, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, The First Affiliated Hospital of Nanchang University, Nanchang
| | - Bin Zhang
- Department of Orthopedics, Artificial Joints Engineering and Technology Research Center of Jiangxi Province, The First Affiliated Hospital of Nanchang University, Nanchang
| |
Collapse
|
8
|
Araújo TPF, Narazaki DK, Teixeira WGJ, Busnardo F, Cristante AF, Barros Filho TEPD. SACRECTOMY ASSOCIATED WITH VERTEBRECTOMY: A NEW TECHNIQUE USING DOWEL GRAFTS FROM CADAVERS. ACTA ORTOPEDICA BRASILEIRA 2018; 26:260-264. [PMID: 30210257 PMCID: PMC6131279 DOI: 10.1590/1413-785220182604183451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver. Study design: Report of a case series with description of a new surgical technique. Methods: The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used. Results: In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively). Conclusion: The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.
Collapse
|
9
|
Neurosurgical Management of Sacral Tumors: Review of the Literature and Operative Nuances. World Neurosurg 2018; 116:362-369. [DOI: 10.1016/j.wneu.2018.05.212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/25/2018] [Accepted: 05/26/2018] [Indexed: 11/21/2022]
|
10
|
He SH, Xu W, Sun ZW, Liu WB, Liu YJ, Wei HF, Xiao JR. Selective Arterial Embolization for the Treatment of Sacral and Pelvic Giant Cell Tumor: A Systematic Review. Orthop Surg 2018. [PMID: 28644557 DOI: 10.1111/os.12336] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Giant cell tumor of the bone (GCTB) is a locally aggressive tumor with a certain distant metastatic rate. For sacral GCT (SGCT) and pelvic GCT (PGCT), surgery has its limitations, especially for unresectable or recurrent tumors. Selective arterial embolization (SAE) is reported to be an option for treatment in several cases, but there are few systematic reviews on the effects of SAE on SGCT and/or PGCT. Medline and Embase databases were searched for eligible English articles. Inclusion and exclusion criteria were conducted before searching. All the clinical factors were measured by SPSS software, with P-values ≤0.05 considered statistically significant. A total of 9 articles were retrieved, including 44 patients receiving SAE ranging from 1 to 10 times. During the mean follow-up period of 85.8 months, the radiographic response rate was 81.8%, with a local control and overall survival rate of 75% and 81.8%, respectively. No bowel, bladder, or sexual dysfunction was observed. Three patients developed distant metastases and finally died. Patients with primary tumors tended to have better prognosis than those with recurrence (P = 0.039). The favorable outcomes of SAE suggest that it may be an alternative treatment for SGCT and PGCT patients for whom surgery is not appropriate.
Collapse
Affiliation(s)
- Shao-Hui He
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei Xu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zheng-Wang Sun
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wei-Bo Liu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Spine Surgery, Central Hospital of Qingdao, Qingdao, China
| | - Yu-Jie Liu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Hai-Feng Wei
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jian-Ru Xiao
- Department of Orthopaedic Oncology, Spinal Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| |
Collapse
|
11
|
Xu W, Wang Y, Wang J, Yang X, Liu W, Zhou W, Liu T, Xiao J. Long-term administration of bisphosphonate to reduce local recurrence of sacral giant cell tumor after nerve-sparing surgery. J Neurosurg Spine 2017; 26:716-721. [PMID: 28338455 DOI: 10.3171/2016.10.spine151197] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the effect of long-term bisphosphonate treatment on reducing local recurrence of sacral giant cell tumors (GCTs) after nerve-sparing surgery. METHODS Thirty-five consecutive patients with sacral GCTs who received treatment in Shanghai Changzheng Hospital between January 2000 and December 2010 were included in this study. Between January 2007 and December 2010, 19 patients received bisphosphonates following nerve-sparing surgery. Before January 2007, 16 patients received nerve-sparing surgery alone, and these cases were included as the control group. The difference in clinical data between the groups was compared by Student's t-test and 2-tailed chi-square or Fisher's exact test. The postoperative recurrence-free survival (RFS) and overall survival (OS) rates were estimated by the Kaplan-Meier method and compared between the groups by log-rank test. A p value < 0.05 was considered statistically significant. RESULTS All of the patients had relatively good nerve function. The clinical data were homogeneous between the groups. The local recurrence rate was 10.53% (2 of 19) in the bisphosphonate treatment group and 43.75% (7 of 16) in the control group. The log-rank test showed that the 3-year RFS and 3-year OS in the bisphosphonate treatment group were significantly higher than those in the control group (RFS 89.5% vs 56.3%, p = 0.04; OS 100% vs 81.3%, p = 0.05). CONCLUSIONS The long-term use of bisphosphonates after nerve-sparing surgery is a viable option for the treatment of sacral GCTs. This approach could reduce local recurrences while preserving nerve function.
Collapse
Affiliation(s)
- Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Yu Wang
- Department of Spine Surgery, First Affiliated Hospital of Wenzhou Medical University, Zhejiang; and
| | - Jing Wang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Xinghai Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Weibo Liu
- Department of Spine Surgery, Qingdao Central Hospital, Qingdao, Shandong, China
| | - Wang Zhou
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Tielong Liu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| | - Jianru Xiao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai
| |
Collapse
|
12
|
How Does the Level of Nerve Root Resection in En Bloc Sacrectomy Influence Patient-Reported Outcomes? Clin Orthop Relat Res 2017; 475:607-616. [PMID: 26992721 PMCID: PMC5289168 DOI: 10.1007/s11999-016-4794-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND For patients with sacral tumors, who are well enough for surgery, en bloc resection is the preferred treatment. Survival, postoperative complications, and recurrent rates have been described, but patient-reported outcomes often are not included in these studies. QUESTIONS/PURPOSES The purposes of this study were (1) to compare patient-reported outcomes after en bloc sacrectomy, based on the level of sacral nerve root resection, in terms of mental health, physical health, bowel function, and sexual function; and (2) to assess differences in terms of mental health, physical health, and pain between patients with and without a colostomy. METHODS A total of 74 patients, of whom 58 (78%) were diagnosed with chordoma, were surveyed between February 2012 and October 2014. This represented 48% of patients with sacral chordoma who were alive and who had been treated with a transverse sacral resection between June 2000 and August 2013 at three institutions with a minimum followup of 6 months (mean, 59 months; range, 6-255 months). We chose 6 months because we believe that neurologic deficits generally are stable by this point and that patients generally have recovered from the operation by this time. Patients were divided into five groups based on the most caudal nerve root spared: L5 (N = 10), S1 (N = 22), S2 (N = 17), S3 (N = 18), and S4 (N = 7). Only postoperative outcomes were collected using the National institute of Health's Patient Reported Measurement Information System (PROMIS) Global Health survey, PROMIS Pain Interference survey, PROMIS Pain Intensity survey, PROMIS Sexual Function survey, and the Modified Obstruction and Defecation Score survey. RESULTS Differences between two adjacent levels were found in terms of mental health, physical health, and sexual function. Patients in whom the S2 nerve roots were spared had a lower mental health score (median = 44, interquartile range [IQR] = 41-51) than patients in whom the S3 nerve roots were spared (median = 53, IQR = 48-56, q = 0.049). Patients in whom the S2 nerve roots were spared had a slightly lower physical health score (median = 42, IQR = 40-51) than patients in whom the S3 nerve roots were spared (median = 47, IQR = 45-54, q = 0.043). Patients in whom the S1 roots were spared (median = 1.0, range = 1.0-1.0) had a lower orgasm score than patients in whom the S2 nerve roots were spared (median = 3, range = 2-5, q = 0.027). No differences in terms of mental health, physical health, or pain were found between the colostomy group and the no colostomy group. CONCLUSIONS The combination of our findings can be used to further educate patients and discuss expectations. In an operative setting, these data can be considered when deciding to place a colostomy. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
|
13
|
Tsarkov PV, Efetov SK, Sidorova LV, Tulina IA. [Sacral resection in surgical treatment of locally advanced primary and recurrent rectal and anal cancer: short-term outcomes]. Khirurgiia (Mosk) 2017:4-13. [PMID: 28745699 DOI: 10.17116/hirurgia201774-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIM To assess safety of rectum removal with distal sacral resection. MATERIAL AND METHODS The short-term results of surgical treatment of primary and recurrent locally advanced rectal and anal cancer with sacral fixation have been analyzed. 32 patients underwent combined operations with sacral resection at the level of S2-S5. In 12 patients only one point of tumor fixation (F1) was revealed, 10 patients had two points of fixation (F2), three patients had three fixation points (F3) and in 7 cases the tumor was fixed to four points (F4) of fixation to different pelvic structures. RESULTS AND DISCUSSION Mean intraoperative blood loss and surgery time was 551±81 ml and 320±20 min in cases of sacral fixation only that was significantly lower compared with F2 cases - 1278±551 ml and 433±45 min, F3 cases - 2200±600 ml and 620±88 min, F4 cases - 2157±512.5 ml and 519±52,3 min, respectively (р<0.05). Complications requiring surgical intervention occurred in 9% patients (n=3). Among 23 patients with intact bladder and ureters urinary disorders occurred in 42% (n=10). Resection margin was negative along posterior surface of the specimen in all cases. CONCLUSION Advanced surgery with distal sacral resection is advisable for radical removal of locally advanced and recurrent rectal and anal canal cancer fixed to the sacrum with negative resection margin. These operations are feasible in specialized centers and should be performed by specially trained oncological or colorectal surgeon.
Collapse
Affiliation(s)
- P V Tsarkov
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
| | - S K Efetov
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
| | - L V Sidorova
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
| | - I A Tulina
- Sechenov First Moscow State Medical University, Department of colorectal and endoscopic surgery, Moscow, Russia
| |
Collapse
|
14
|
Proposed Scoring System for Evaluating Neurologic Deficit after Sacral Resection: Functional Outcomes of 170 Consecutive Patients. Spine (Phila Pa 1976) 2016; 41:628-37. [PMID: 27018902 DOI: 10.1097/brs.0000000000001274] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-section analysis. OBJECTIVE A quality-of-life oriented scoring system for evaluation of lower limbs, bladder, and bowel functions of patients after sacral tumor resection has been proposed and was adopted in a clinical research. SUMMARY OF BACKGROUND DATA Surgical resections of sacral tumors usually cause postoperative neurologic deficits. A widely agreed scoring system for detailed evaluation of functional outcomes is not yet established. METHODS The scoring system has three domains with three items in each domain, being allocated 0 to 3 points of each item according to the degree of functional impairment. Overall function scale is presented in percentage form. In the current single-center cross-section study, it was adopted to evaluate and quantify the postoperative functional outcomes of 170 consecutive patients who underwent sacrectomy. RESULTS Significant observer agreement (P < 0.01) was found in all nine items of the proposed system. Detailed functional outcome and difference between each group can be well described by the scoring results. Preservation of bilateral S1 nerve roots preserved majority of motor and sensory function in lower limbs. The probability and degree of urine incontinence (P = 0.003) and abnormal bladder sensation (P = 0.039) was significantly lower in patients with bilateral S3 nerve preserved than those whose unilateral S3 was severed. Patients with unilateral S3 preserved had a lower incidence and degree of dysuria (P = 0.056), constipation (P = 0.059), bowel incontinence (P = 0.007), and abnormal rectal sensation (P = 0.002) than those whose bilateral S3 were sacrificed. Functional outcomes for patients with retained coccyx were better than those with coccyx transected. Functional outcome of different level sacral nerve preservation was semi-quantified and profiled. CONCLUSION Detailed and intuitive description of neurologic deficits after sacral tumor resection is the major purpose of current scoring system. The ease of use and reproducibility makes it a practical tool to evaluate function status after sacrectomy under oncologic condition. LEVEL OF EVIDENCE 4.
Collapse
|
15
|
Phukan R, Herzog T, Boland PJ, Healey J, Rose P, Sim FH, Yazsemski M, Hess K, Osler P, DeLaney TF, Chen YL, Hornicek F, Schwab J. How Does the Level of Sacral Resection for Primary Malignant Bone Tumors Affect Physical and Mental Health, Pain, Mobility, Incontinence, and Sexual Function? Clin Orthop Relat Res 2016; 474:687-96. [PMID: 26013155 PMCID: PMC4746195 DOI: 10.1007/s11999-015-4361-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND En bloc resection for treatment of sacral tumors is the approach of choice for patients with resectable tumors who are well enough to undergo surgery, and studies describe patient survival, postoperative complications, and recurrence rates associated with this treatment. However, most of these studies do not provide patient-reported functional outcomes other than binary metrics for bowel and bladder function postresection. QUESTIONS/PURPOSES The purpose of this study was to use validated patient-reported outcomes tools to compare quality of life based on level of sacral resection in terms of (1) physical and mental health; (2) pain; (3) mobility; and (4) incontinence and sexual function. METHODS Our analysis included 33 patients (19 men, 14 women) who had a mean age of 53 years (range, 22-72 years) with a quality-of-life survey administered at a mean postoperative followup of 41 months (range, 6-123 months). The majority of patient-reported quality-of-life outcome surveys for this study were taken from the National Institute of Health's Patient Reported Outcome Measurement Information System (PROMIS) system. To assess physical and mental health, the PROMIS Global Items Survey with physical and mental subscores, Anxiety, and Depression scores were used. Pain outcomes were assessed using PROMIS Pain Intensity and Pain Interference surveys. Patient-reported lower extremity function was assessed using the PROMIS Mobility Survey. Patient-reported quality of life for sexual function was assessed using the PROMIS Sex Interest and Orgasm survey, whereas incontinence was measured using the International Continence Society Voiding and Incontinence scores and the Modified Obstruction and Defecation Score. Surveys were collected prospectively during clinic visits in the postoperative period. Patients were grouped by the level of osteotomy as determined by review of postoperative MRI or CT and half levels were grouped with the more cephalad level. This resulted in the inclusion of total sacrectomy (N = 6), S1 (N = 8), S2 (N = 10), S3 (N = 5), and S4 (N = 4). One-way analysis of variance tests on means or ranks were used to conduct statistical analysis between levels. RESULTS Patients with more caudal resections had higher physical health (95% confidence interval [CI] total sacrectomy 36-42 versus S4 50-64, p < 0.001), less intense pain (95% CI total sacrectomy 47-60 versus S4 28-37, p < 0.001), less interference resulting from pain (95% CI total sacrectomy 58-69 versus S4 36-51, p = 0.004), higher mobility (95% CI total sacrectomy 24-46 versus S4 59-59, p = 0.002), and were more functionally able to achieve orgasm (95% CI S1 1-1 versus S4 2.2-5.3, p = 0.043). No difference was found for PROMIS Global Item Mental Health Subscore, Sex Interest, Sex Satisfaction, modified obstruction and defecation score, and International Continence Society Voiding and Incontinence although this could be the result of an inadequate sample size. CONCLUSIONS Our analysis on patient-reported quality of life based on the level of bony resection in patients who underwent resection for primary sacral tumor indicates that patients with higher resections have more pain and loss of physical function in comparison to patients with lower resections. Additionally, use of the PROMIS outcomes allows for comparisons to normative data. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Rishabh Phukan
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit Street, Boston, MA 02114 USA
| | - Tyler Herzog
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit Street, Boston, MA 02114 USA
| | - Patrick J. Boland
- />Department of Orthopaedic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - John Healey
- />Department of Orthopaedic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Peter Rose
- />Department of Gynecological Oncology, Cleveland Clinic, Cleveland, OH USA
| | - Franklin H. Sim
- />Department of Orthopaedic Oncology, Mayo Clinic, Rochester, MN USA
| | - Michael Yazsemski
- />Department of Orthopaedic Oncology, Mayo Clinic, Rochester, MN USA
| | - Kathryn Hess
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit Street, Boston, MA 02114 USA
| | - Polina Osler
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit Street, Boston, MA 02114 USA
| | - Thomas F. DeLaney
- />Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA USA
| | - Yen-Lin Chen
- />Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA USA
| | - Francis Hornicek
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit Street, Boston, MA 02114 USA
| | - Joseph Schwab
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit Street, Boston, MA 02114 USA
| |
Collapse
|
16
|
Zoccali C, Skoch J, Patel AS, Walter CM, Maykowski P, Baaj AA. Residual neurological function after sacral root resection during en-bloc sacrectomy: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3925-3931. [PMID: 26914097 DOI: 10.1007/s00586-016-4450-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE Sacrectomy is a highly demanding surgery representing the main treatment for primary tumors arising in the sacrum and pelvis. Unfortunately, it is correlated with loss of important function depending on the resection level and nerve roots sacrificed. The current literature regarding residual function after sacral resection comes from several small case series. The goal of this review is to appraise residual motor function and gait, sensitivity, bladder, bowel, and sexual function after sacrectomies, with consideration to the specific roots sacrificed. METHODS An exhaustive literature search was conducted. All manuscripts published before May 2015 regarding residual function after sacrectomy were considered; if a clear correlation between root level and functioning was not present, the paper was excluded. The review identified 15 retrospective case series, totaling 244 patients; 42 patients underwent sacrectomies sparing L4/L4, L4/L5 and L5/L5; 45 sparing both L5 and one or both S1 roots; 8 sparing both S1 and one S2; 48 sparing both S2; 11 sparing both S2 and one S3, 54 sparing both S3, 9 sparing both S3 and one or both S4, and 27 underwent unilateral variable resection. RESULTS Patients who underwent a sacrectomy maintained functionally normal ambulation in 56.2 % of cases when both S2 roots were spared, 94.1 % when both S3 were spared, and in 100 % of more distal resections. Normal bladder and bowel function were not present when both S2 were cut. When one S2 root was spared, normal bladder function was present in 25 % of cases; when both S2 were spared, 39.9 %; when one S3 was spared, 72.7 %; and when both S3 were spared, 83.3 %. Abnormal bowel function was present in 12.5 % of cases when both S1 and one S2 were spared; in 50.0 % of cases when both S2 were spared; and in 70 % of cases when one S3 was spared; if both S3 were spared, bowel function was normal in 94 % of cases. When even one S4 root was spared, normal bladder and bowel function were present in 100 % of cases. Unilateral sacral nerve root resection preserved normal bladder function in 75 % of cases and normal bowel function in 82.6 % of cases. Motor function depended on S1 root involvement. CONCLUSION Total sacrectomy is associated with compromising important motor, bladder, bowel, sensitivity, and sexual function. Residual motor function is dependent on sparing L5 and S1 nerve roots. Bladder and bowel function is consistently compromised in higher sacrectomies; nevertheless, the probability of maintaining sufficient function increases progressively with the roots spared, especially when S3 nerve roots are spared. Unilateral resection is usually associated with more normal function. To the best of our knowledge, this is the first comprehensive literature review to analyze published reports of residual sacral nerve root function after sacrectomy.
Collapse
Affiliation(s)
- Carmine Zoccali
- Oncological Orthopaedics Department, Muscular-skeletal Tissue Bank, IFO - Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Jesse Skoch
- Division of Neurosurgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA
| | - Apar S Patel
- Division of Neurosurgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA
| | - Christina M Walter
- Division of Neurosurgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA
| | - Philip Maykowski
- Division of Neurosurgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA
| | - Ali A Baaj
- Division of Neurosurgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA
| |
Collapse
|
17
|
|
18
|
Maintenance of bowel, bladder, and motor functions after sacrectomy. Spine J 2015; 15:222-9. [PMID: 25195977 DOI: 10.1016/j.spinee.2014.08.445] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 06/29/2014] [Accepted: 08/18/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Repeated cohort studies have consistently demonstrated a survival advantage after en bloc resection for locally aggressive primary tumors in the sacrum. A sacrectomy is often required to remove the tumor en bloc, which may necessitate the sacrifice of sacral nerves. This can potentially result in functional complications, including the impairment of gait, bowel function, or bladder function. PURPOSE To assess the bladder, bowel, and motor functions of patients after resection of a primary sacral tumor. STUDY DESIGN This was a retrospective cohort study at a single academic institution. PATIENT SAMPLE Consecutive patients who underwent an en bloc sacral tumor resection at a single institution between December 2002 and June 2012 were included. The study population comprised 73 patients. OUTCOME MEASURES Patients were classified as having had a low, middle, high, or total sacrectomy based on the level of sacral nerves sacrificed, if applicable. METHODS Patient data were collected from clinic notes and hospital records that included operative notes, lab studies, and rehabilitation notes. RESULTS Across all patients, there was no change in bowel function after sacrectomy, whereas bladder and motor functions returned to preoperative (pre-op) levels at 3 and 6 months, respectively. Higher level sacrectomies were associated with worse bowel (p<.001), bladder (p<.001), and motor (p=.027) functions 12 months postoperatively (post-op). At 1 year, none of the six patients with a high or total sacrectomy had intact bladder function and 14.3% (N=7) had intact bowel function. Of patients with a middle sacrectomy, 62.5% (N=8) had intact bladder function and 71.4% (N=7) had intact bowel function at 1 year. Of patients with a low sacrectomy, 91.7% (N=12) had intact bladder function and 91.7% (N=12) had intact bowel function. CONCLUSIONS Preoperative bladder, bowel, and motor functions, level of sacral tumor involvement, and corresponding level of sacrectomy were the greatest predictors of long-term bladder, bowel, and motor functions. There were no statistically significant changes in bladder, bowel, or motor functions from pre-op to 6 months post-op, and therefore, pre-op functional status was predictive of long-term function.
Collapse
|
19
|
Modified kraske procedure with mid-sacrectomy and coccygectomy for en bloc excision of sacral giant cell tumors. Case Rep Surg 2014; 2014:834537. [PMID: 25386379 PMCID: PMC4216674 DOI: 10.1155/2014/834537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 10/05/2014] [Indexed: 12/13/2022] Open
Abstract
Sacral giant cell tumors are rare neoplasms, histologically benign but potentially very aggressive due to the difficulty in achieving a complete resection, their high recurrence rate, and metastization capability. Although many treatment options have been proposed, en bloc excision with tumor-free margins seems to be the most effective, being associated with long term tumor control, improved outcome, and potential cure. An exemplifying case of a 29-year-old female with progressive complaints of pain and paresthesias in the sacral and perianal regions, constipation, and weight loss for 6 months is presented. The surgical technique for en bloc excision of a large sacral giant cell tumor through a modified Kraske procedure with mid-sacrectomy and coccygectomy is described. Complete resection with wide tumor-free margins was achieved. At 5 years of follow-up the patient is neurologically intact, without evidence of local recurrence on imaging studies. A multidisciplinary surgical procedure is mandatory to completely remove sacral tumors. In the particular case of giant cell tumors, it allows minimizing local recurrence preserving neurovascular function, through a single dorsal and definitive approach.
Collapse
|
20
|
A case study using total en bloc sacrectomy and neuroanastomosis for sacral tumor. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1963-7. [DOI: 10.1007/s00586-014-3351-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 04/26/2014] [Accepted: 04/26/2014] [Indexed: 10/25/2022]
|
21
|
Houdek MT, Wagner ER, Wyles CC, Moran SL. Anatomical feasibility of the anterior obturator nerve transfer to restore bowel and bladder function. Microsurgery 2014; 34:459-63. [PMID: 24710737 DOI: 10.1002/micr.22256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/17/2014] [Accepted: 03/24/2014] [Indexed: 11/10/2022]
Abstract
Total sacrectomies are radical procedures required to treat tumorigenic processes involving the sacrum. The purpose of our anatomical study was to assess the feasibility of a novel nerve transfer involving the anterior obturator nerve to the pudendal and pelvic nerves to the rectum and bladder. Anterior dissection of the obturator nerve was performed in eight hemipelvis cadaver specimens. The common obturator nerve branched into the anterior and posterior at the level of the obturator foramen. The anterior branch then divided into two separate branches (adductor longus and gracilis). The branch to the gracilis was on average longer and also larger than the branch to the adductor longus (8.7 ± 2.1 cm vs. 6.7 ± 2.6 cm in length and 2.6 ± 0.2 mm vs 1.8 ± 0.4 mm in diameter). Each branch of the anterior obturator was long enough to reach the pelvic nerves. The novel transfer of the anterior branch of the obturator nerve to reinnervate the bladder and bowel is anatomically feasible. This represents a promising option with minimal donor site deficit.
Collapse
|
22
|
Muro K, Das S, Raizer JJ. Chordomas of the craniospinal axis: multimodality surgical, radiation and medical management strategies. Expert Rev Neurother 2014; 7:1295-312. [DOI: 10.1586/14737175.7.10.1295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
23
|
Osaka S, Osaka E, Kojima T, Yoshida Y, Tokuhashi Y. Long-term outcome following surgical treatment of sacral chordoma. J Surg Oncol 2013; 109:184-8. [PMID: 24249252 DOI: 10.1002/jso.23490] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 10/17/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Sixteen sacral chordoma surgeries performed at a single institution during the 1983-2008 period were retrospectively studied. Our aim is to assess surgical treatment and long-term outcomes. METHODS Fifteen patients underwent primary wide excision, and one intralesional excision using ethanol for local control and radiation therapy (RT). A combined anteroposterior approach for large tumors above S2, and wide excision was performed with the modified threadwire-saw (MT-saw) after 1997. RESULTS Fourteen of the 15 patients had wide margins, one a wide margin with contamination. The MT-saw was facilitated sacral excision with wide margins. Eleven patients are alive for 5-28 years. Five patients died before 10 years, two patients experienced sepsis, and one of another disease. Two patients died of local recurrence (LR) and another of multiple metastases after intralesional excision and wide excision with contamination, respectively. LR and complications occurred 4 each of 11 patients with tumors ≥ 10 cm, neither with tumors < 10 cm. The overall 5- and 10-year survival rate with wide surgical margins was 13/16 (81.3%) and 8/13 (61.5%). CONCLUSIONS A combined anteroposterior approach for large tumors, and the MT-saw facilitates sacral excision with wide margins. Wide excision is recommended for younger patients.
Collapse
Affiliation(s)
- Shunzo Osaka
- Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | | | | | | | | |
Collapse
|
24
|
Abstract
Chordoma is a relatively rare, locally aggressive tumor which is known to arise from embryonic remnants of the notochord and to occur exclusively along the spinal axis, with a predilection for the sacrum. Although chordoma typically presents as a single lesion, a few cases of metastasis have been reported and the prognosis of such patients may be poor. Chordomas are slowly growing tumors with insidious onset of symptoms, making early diagnosis difficult. Recent improvements in imaging have provided valuable information for early diagnosis. The optimal treatment for sacral chordoma is en bloc sacral resection with wide surgical margins. Improvement in surgical techniques has widened the opportunities to provide effective treatment. However, the effects of adjuvant treatment options are still both unclear and controversial. Substantial progress has been made in the study of molecular-targeted therapy. The authors review the current surgical and adjuvant treatment modalities, including molecular-targeted therapy, available for management of sacral chordoma.
Collapse
Affiliation(s)
- Kang-wu Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | | | | | | | | |
Collapse
|
25
|
Mavrogenis AF, Soultanis K, Patapis P, Guerra G, Fabbri N, Ruggieri P, Papagelopoulos PJ. Pelvic resections. Orthopedics 2012; 35:e232-43. [PMID: 22310412 DOI: 10.3928/01477447-20120123-40] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The complexity of pelvic anatomy and the extent of tumor growth makes treatment of patients with primary bone sarcomas in the pelvis difficult in terms of local control. Before the 1970s, most tumors in the bony pelvis were surgically treated with hindquarter amputation. Currently, improved techniques for clinical staging, adjuvant treatments, evolutions in metallurgy, and development of new surgical techniques make limb-salvage surgery and reconstruction possible alternatives to hemipelvectomy and resection-arthrodesis. The advantages of amputation over resections at the pelvis are a lower incidence of complications, a limited area at risk for recurrence, and a faster recovery time compared with all but the most limited pelvic resections. The disadvantages, especially after periacetabular resections, are leg-length discrepancy and impaired hip and gait function. The indication for limb salvage is the ability to obtain wide margins without compromising survival and function. Although having to resect the sciatic nerve to obtain adequate margins does not always mean that an amputation should be performed, the combination of a major pelvic resection and the functional consequences of sciatic nerve resection results in an extremity usually not worth saving; loss of femoral nerve function does not result in a significant gait disturbance, especially if the hemipelvis is stable. Reconstruction options after major pelvic resections have also evolved, but they remain difficult, especially when the acetabulum is involved.
Collapse
Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, ATTIKON University Hospital, Athens University Medical School, Athens, Greece
| | | | | | | | | | | | | |
Collapse
|
26
|
Kido A, Koyama F, Akahane M, Koizumi M, Honoki K, Nakajima Y, Tanaka Y. Extent and contraindications for sacral amputation in patients with recurrent rectal cancer: a systematic literature review. J Orthop Sci 2011; 16:286-90. [PMID: 21451973 DOI: 10.1007/s00776-011-0050-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Abdominosacral amputation is a potentially curative surgical approach for patients with recurrent rectal cancer. Previous reports have described differing extents of sacral resection. Most of these reports stated that high sacral involvement of the tumor is a contraindication for surgery; however, the basis for this is unclear. METHODS In this study, we reviewed the highest level of sacral amputation and the "contraindications" for this technique. Using a systematic literature survey, we analyzed the theoretical basis and the changes in surgical indications for recurrent rectal cancer. RESULTS We retrieved 33 articles from Medline and one study from the Cochrane Center Register of Controlled Trials. The highest level of resection was at the level of L5/S and S1 in one article, S1/2 and S2 in nine articles and S2/3 and S3 in 11 articles. Fifteen articles stated contraindications regarding sacral level, including tumor involvement of S1, the S1/2 junction, or the level above the S2/3 junction. Reasons stated for these contraindications included the risks associated with surgery, namely bladder dysfunction, anorectal dysfunction, genital dysfunction, walking disorder, and spinal fluid leak. In terms of the rationale for the contraindications, three articles referred to four previously published reviews or case series. None of these supporting publications were randomized controlled trials and they did not include any statistical evaluation. CONCLUSION The consensus for contraindications for sacral amputation was formed empirically, without strong supporting evidence. The balance between curability and dysfunction should be further evaluated scientifically.
Collapse
Affiliation(s)
- Akira Kido
- Department of Orthopedic Surgery, School of Medicine, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.
| | | | | | | | | | | | | |
Collapse
|
27
|
Scott SM, van den Berg MM, Benninga MA. Rectal sensorimotor dysfunction in constipation. Best Pract Res Clin Gastroenterol 2011; 25:103-18. [PMID: 21382582 DOI: 10.1016/j.bpg.2011.01.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 01/03/2011] [Indexed: 01/31/2023]
Abstract
The pathophysiological mechanisms underlying chronic constipation in both adults and children remain to be unravelled. This is a not inconsiderable challenge, but is fundamental to improving management of such patients. Rectal sensorimotor function, which encompasses both sensation and motility, as well as biomechanical components (compliance, capacity), is now strongly implicated in the pathogenesis of constipation. Rectal hyposensitivity, rectal hypercompliance, increased rectal capacity, rectal motor dysfunction (phasic contractility and tone), and altered rectoanal reflex activity are all found in constipated patients, particularly in association with 'functional' disorders of defaecation (i.e. pelvic floor dyssynergia). This review covers contemporary understanding of how components of rectal sensorimotor function may contribute to symptom development in both adult and paediatric populations. The complex interaction between sensory/motor/biomechanical domains, and how best to measure these functions are addressed, and where data exist, the impact of sensorimotor dysfunction on therapeutic outcomes is highlighted.
Collapse
Affiliation(s)
- S M Scott
- Academic Surgical Unit & Neurogastroenterology Group, Barts and The London School of Medicine and Dentistry, Queen Mary University London, United Kingdom.
| | | | | |
Collapse
|
28
|
Yang HL, Chen KW, Wang GL, Lu J, Ji YM, Liu JY, Wu GZ, Gu Y, Sun ZY. Pre-operative transarterial embolization for treatment of primary sacral tumors. J Clin Neurosci 2010; 17:1280-5. [PMID: 20627583 DOI: 10.1016/j.jocn.2009.12.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 12/23/2009] [Accepted: 12/29/2009] [Indexed: 10/19/2022]
Abstract
Pre-operative embolization of hypervascular spinal tumors can be helpful in tumour resection; however, few studies have been reported on its effectiveness in sacral tumors. We aimed to investigate the value of surgical excision with pre-operative transarterial embolization for primary sacral tumors and evaluate the long-term follow-up outcomes. Data were obtained from a consecutive series of 60 patients (33 female, 27 male) who had sacral tumors and who, between 1992 and 2007, underwent surgical excision in conjunction with arterial embolization. The evaluation parameters included intraoperative blood loss, transfusion, treatment, local recurrence and complications associated with surgery. All tumor masses were resected without intraoperative shock or death. The mean intraoperative blood loss was 1168.3mL (range: 200-5700mL) and the mean transfusion amount was 5.2 units (range: 0-35 units). Radical wide excision was performed on eight patients, marginal excision was conducted for 34 patients and intralesional excision was undertaken for the remaining 18 patients. The mean follow-up period was 75.2months (range: 15-180months). Nineteen (31.7%) patients developed local recurrences. Of the patients who had at least the second sacral roots and the unilateral S3 preserved, 33 (84.6%) had normal bladder function and 34 (87.2%) had normal bowel control. Pre-operative arterial embolization may significantly reduce the likelihood of intraoperative hemorrhage, and has the potential to assist surgeons in completing tumor resection and improving the outcomes for these patients.
Collapse
Affiliation(s)
- Hui-Lin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 188 ShiZi Street, Suzhou 215006, Jiang Su, China
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Ruggieri P, Mavrogenis AF, Ussia G, Angelini A, Papagelopoulos PJ, Mercuri M. Recurrence after and complications associated with adjuvant treatments for sacral giant cell tumor. Clin Orthop Relat Res 2010; 468:2954-61. [PMID: 20623262 PMCID: PMC2947682 DOI: 10.1007/s11999-010-1448-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The best treatment of giant cell tumor of the sacrum is controversial. It is unclear whether adjuvant treatment with intralesional surgery reduces recurrences or increases morbidity. QUESTIONS/PURPOSES We therefore asked whether adjuvants altered recurrence rates and complications after intralesional surgery for sacral giant cell tumors. METHODS We retrospectively studied 31 patients with sacral giant cell tumors treated with intralesional surgery with and without adjuvants. Survival to local recurrence was evaluated using Kaplan-Meier analysis. The differences in survival to local recurrence with and without adjuvants were evaluated using multivariate Cox regression analysis. Complications were recorded from clinical records and images. The minimum followup was 36 months (median, 108 months; range, 36-276 months). RESULTS Overall survival to local recurrence was 90% at 60 and 120 months. Survival to local recurrence with and without radiation was 91% and 89%, with and without embolization was 91% and 86%, and with and without local adjuvants was 88% and 92%, respectively. Adjuvants had no influence on local recurrence. Mortality was 6%: one patient died at 14 days postoperatively from a massive pulmonary embolism and another patient had radiation and died of a high-grade sarcoma. Fifteen of the 31 patients (48%) had one or more complications: eight patients (26%) had wound complications and seven patients (23%) had massive bleeding during curettage with hemodynamic instability. L5-S2 neurologic deficits decreased from 23% preoperatively to 13% postoperatively; S3-S4 deficits increased from 16% to 33%. CONCLUSIONS Adjuvants did not change the likelihood of local recurrence when combined with intralesional surgery but the complication rate was high.
Collapse
Affiliation(s)
- Pietro Ruggieri
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | | | - Giuseppe Ussia
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | - Andrea Angelini
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| | | | - Mario Mercuri
- Department of Orthopaedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, BO Italy
| |
Collapse
|
30
|
Kazim SF, Enam SA, Hashmi I, Lakdawala RH. Polyaxial screws for lumbo-iliac fixation after sacral tumor resection: experience with a new technique for an old surgical problem. Int J Surg 2009; 7:529-33. [PMID: 19735745 DOI: 10.1016/j.ijsu.2009.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 07/18/2009] [Accepted: 08/22/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although numerous reports have been published about various methods for reconstruction after sacrectomies, there are still biomechanical and technical dilemmas that are unaddressed. This report describes the experience at authors' institution of five cases in which polyaxial pedicle screws construct has been successfully used for lumbo-iliac fixation after sacral tumor resection. METHODS Five cases of sacral tumors, two of Ewing's sarcoma and three of giant cell tumor (GCT) underwent surgical resection and then reconstruction was done with hardware using vertical rods placed alongside the spine bilaterally, transfixing monoaxial and polyaxial pedicle screws in lower lumbar levels and polyaxial screws into the ilium bilaterally. Cross links were also used to connect the two vertical members, thus enhancing biomechanical stability of the construct. Use of autologous bone grafts was relied upon to fill the gap created by sacral resection. RESULTS No instrumentation failure was noted and the continuity of the spine and pelvis was well established with the instrumentation and auto grafts. In follow up of these patients (1-3 years), no complications were seen. CONCLUSION Polyaxial pedicle screws fixation is an effective technique to transmit axial load from spine to the appendicular bone and can be used safely in patients in whom sacral integrity is compromised after surgical resection. However, the long term benefits of this technique need to be evaluated.
Collapse
Affiliation(s)
- Syed Faraz Kazim
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | | | | |
Collapse
|
31
|
|
32
|
Sabourin M, Biau D, Babinet A, Dumaine V, Tomeno B, Anract P. Surgical management of pelvic primary bone tumors involving the sacroiliac joint. Orthop Traumatol Surg Res 2009; 95:284-92. [PMID: 19482533 DOI: 10.1016/j.otsr.2009.04.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 01/09/2009] [Accepted: 04/28/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Pelvic primary malignant bone tumours, especially when involving the sacroiliac joint are difficult to treat. Abdominoperineal amputations are today used, only in life-threatening situations. HYPOTHESIS A precisely planed surgical technique can save the affected extremity without compromising the resection quality and subsequent patient survival. OBJECTIVE To assess the procedures used for resection and reconstruction of bone tumours invading the sacroiliac joint as well as their effects on cancer outcome and functional results. MATERIALS AND METHODS This is a continuous and retrospective analysis of 24 patients treated between 1986 and 2003. Six tumours affected the sacral body and 18 tumours involved the wing of the ilium. The joint articular surface was invaded in only six cases. Seventeen patients received neoadjuvant chemotherapy. The procedure was performed through an enlarged iliac crest incision, giving access to two sections of the pelvic ring. Six cases required neurological sacrifice. Initial tumour grading was based on the Enneking classification, and the functional results, on the Musculoskeletal Tumour Society (MSTS) scoring system. RESULTS The average operation lasted 5.27 hours. Reconstruction was performed with bone autograft and instrumentation. Resection was large with adequate margins 11 times, marginal 12 times, and contaminated once. Average follow-up was 4.77 years. The 5-year survival rate was 50%. Twelve patients either died from their disease or were in the metastatic stage at final follow-up. Survival was linked to the quality of resection and initial tumour staging. Hemisacrectomy did not affect patient survival. Local recurrences had a poor prognosis with eight cases of secondary metastases out of 11. Bone healing occurred in 13 patients, 10 of whom survived. Of the 12 patients who survived and were in complete remission at final follow-up, the average MSTS score was 61%. The score was at 38.6% in cases involving neurological sacrifice, and at 77.1% for the rest of the group. It was at 64% in healed cases and 13% in nonunion cases. DISCUSSION The survival of patients presenting with a sacroiliac joint tumour is substantially related to both tumour histology and resection quality. Local recurrences carry a poor prognosis with a high rate of secondary metastatic dissemination. In situations where disease control can be achieved, the proposed method of reconstruction allows, satisfactory bone healing and fair functional recovery, provided no major neurological sacrifice has taken place. LEVEL OF EVIDENCE level IV: Retrospective Therapeutic Study.
Collapse
Affiliation(s)
- M Sabourin
- Surgical Orthopaedics Department B, Cochin Hospital, Paris, France.
| | | | | | | | | | | |
Collapse
|
33
|
Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopedics, ATTIKON General University Hospital, Athens University Medical School, Athens, Greece
| | | | | | | |
Collapse
|
34
|
Gladman MA, Aziz Q, Scott SM, Williams NS, Lunniss PJ. Rectal hyposensitivity: pathophysiological mechanisms. Neurogastroenterol Motil 2009; 21:508-16, e4-5. [PMID: 19077147 DOI: 10.1111/j.1365-2982.2008.01216.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension. It may occur due to afferent nerve dysfunction and/or secondary to abnormal structural or biomechanical properties of the rectum. The aim of this study was to determine the contribution of these underlying pathophysiological mechanisms by systematically evaluating rectal diameter, compliance and afferent nerve sensitivity in patients with RH, using methodology employed in clinical practice. The study population comprised 45 (33 women; median age 48, range 25-72 years) constipated patients (Rome II criteria) with RH and 20 with normal rectal sensitivity on balloon distension and 20 healthy volunteers. Rectal diameter was measured at minimum distending pressure during isobaric distension under fluoroscopic screening. Rectal compliance was assessed during phasic isobaric distension by measuring the slope of the pressure-volume curve. Electrical stimulation of the rectal mucosa was employed to determine afferent nerve function. Values were compared to normal ranges established in healthy volunteers. The upper limits of normal for rectal diameter, compliance and electrosensitivity were 6.3 cm, 17.9 mL mmHg(-1) and 21.3 mA respectively. Among patients with RH, rectal diameter, but not compliance, was increased above the normal range (megarectum) in seven patients (16%), two of whom had elevated electrosensitivity thresholds. Rectal diameter and compliance were elevated in 23 patients (51%), nine of whom had elevated electrosensitivity thresholds. The remaining 15 patients (33%) with RH had normal rectal compliance and diameter, all of whom had elevated electrosensitivity thresholds. Two-third of the patients with RH on simple balloon distension have elevated rectal compliance and/or diameter, suggesting that impaired perception of rectal distension is due to inadequate stimulation of the rectal afferent pathway. However, a proportion of such patients also appear to have impaired nerve function. In the remaining one-third of the patients, rectal diameter and compliance are normal, while electrosensitivity thresholds are elevated, suggestive of true impaired afferent nerve function. Identification of these subgroups of patients with RH may have implications regarding their management.
Collapse
Affiliation(s)
- M A Gladman
- Institute of Cell & Molecular Science, Barts and The London School of Medicine & Dentistry, Whitechapel, London, UK.
| | | | | | | | | |
Collapse
|
35
|
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE To estimate the clinical outcome of conservative surgery (intralesional curettage or partial excision) aided by effective intraoperative hemorrhage control in patients with giant cell tumors of the sacrum. SUMMARY OF BACKGROUND DATA Giant cell tumors of the sacrum present a challenging therapeutic problem. Wide resection is associated with higher morbidity and spinal instability. Whether conservative surgery aided by effective intraoperative hemorrhage control can achieve low recurrence rates remains uncertain. METHODS The clinical records of 24 patients with an average age of 35 years who had undergone conservative surgery for sacral giant cell tumor between 1996 and 2005 were evaluated retrospectively. The disease onset, tumor size, operation records, complications, follow-up status, and functional outcome were analyzed. RESULTS The mean duration of follow-up was 58 months (median, 50 months; range: 25-132 months). All the patients had a conservative procedure aided by intraoperative occlusion of the abdominal aorta. The mean estimated blood loss was 3217 mL. The mean length of the operation was 190 minutes. Seven (29.2%) patients developed recurrences. The mean time from the index surgical procedure to the first recurrence was 13 months (range: 8-31 months). The 5-year local recurrence-free survival rate was 69.6%. Seventeen (70.8%) patients retained normal urinary function and 16 (66.7%) patients preserved normal bowel function. No patients had urinary or bowel dysfunction when both S3 nerves were preserved. Ten (41.7%) patients had complications perioperatively or during the follow-up. Seven (29.2%) patients had wound complications. CONCLUSION Considering the acceptable local recurrence rate, conservative surgery aided by effective control of intraoperative hemorrhage should be considered as an alternative procedure for patients with giant cell tumors of the sacrum. The advantages include lower morbidity, reduced neurologic deficits, speed and ease of the surgical procedure, reduced blood loss, preservation of spinal and pelvic continuity, and a low recurrence rate.
Collapse
|
36
|
Hosalkar HS, Jones KJ, King JJ, Lackman RD. Serial arterial embolization for large sacral giant-cell tumors: mid- to long-term results. Spine (Phila Pa 1976) 2007; 32:1107-15. [PMID: 17471094 DOI: 10.1097/01.brs.0000261558.94247.8d] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Level III retrospective case series with historical controls. OBJECTIVE To evaluate the mid- to long-term outcomes of serial arterial embolization as a primary treatment modality for large sacral giant-cell tumors (SGCT). SUMMARY OF BACKGROUND DATA Giant-cell tumors are potentially aggressive benign tumors that can cause significant morbidity and may occasionally prove lethal. Large GCTs in the sacrum present a significant challenge, and treatment methods, including surgical resection and radiation, are associated with morbid complications and high recurrence rates. This report presents the mid- to long-term follow-up results of our cases of SGCT treated with serial arterial embolization. METHODS Nine consecutive patients with biopsy-proven SGCTs received initial primary treatment with serial arterial embolization between 1984 and 2006. All patients underwent angiography and selective arterial embolization at the time of diagnosis, followed by repeat embolization every 6 weeks until no new vessels were noted, and then at 6 and 18 months following stabilization of the lesion. Patients were closely monitored with MRI and/or CT every 6 months for 5 years and annually thereafter. Functional outcomes were measured using the 1993 Musculoskeletal Tumor Society Rating Scale (MSTS93). RESULTS The mean duration of follow-up in this series was 8.96 years (median, 7.8 years; range, 3.8-21.2 years). No progression was noted in 7 of the 9 cases. Two cases experienced tumor progression of less than 1 cm early in the treatment course and continued to remain asymptomatic. Adjuvant radiation therapy provided local control in 1 of these cases, while radiation and chemotherapy failed in the other case with ultimate mortality. All patients demonstrated substantial pain relief. Cross-sectional MSTS93 scores were obtained in the 8 surviving patients at their most recent follow-up visit with a mean score of 29/30. CONCLUSIONS Serial arterial embolization is a useful primary treatment modality for large SGCTs given the favorable long-term results and potential morbidity of alternative treatments.
Collapse
Affiliation(s)
- Harish S Hosalkar
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19106, USA
| | | | | | | |
Collapse
|
37
|
Court C, Bosca L, Le Cesne A, Nordin JY, Missenard G. Surgical excision of bone sarcomas involving the sacroiliac joint. Clin Orthop Relat Res 2006; 451:189-94. [PMID: 16770289 DOI: 10.1097/01.blo.0000229279.58947.91] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Adequate (wide or marginal and uncontaminated) margins and reconstruction are difficult to achieve when performing an internal hemipelvectomy for bone sarcomas involving the sacroiliac joint. We evaluated whether adequate surgical margins could be achieved and if functional outcomes could be predicted based on the type of resection and reconstruction. Forty patients had resections of the sacroiliac joint. Vertical sacral osteotomies were through the sacral wing (n = 2), ipsilateral sacral foramina (n = 27), sacral midline (n = 9), or contralateral foramina (n = 2). Iliac resections were Type I, Type I-II with partial or total acetabular re-section, or Type I-II-III. Surgical margins were adequate in 28 of 38 patients (74%), two (7%) of whom experienced local recurrence, compared with seven of 10 (70%) patients with inadequate margins. Reconstruction consisted of restoring continuity between the spine and pelvis. Resection of the entire acetabulum and removal of the lumbosacral trunk were the two main determinants of function, as assessed using the Musculoskeletal Tumor Society score. There were no life-threatening or function-threatening complications. Internal hemipelvectomy with a limb salvage procedure can be achieved with adequate surgical margins in selected patients. Functional outcomes can be predicted based on the type of resection and reconstruction, which helps the surgeon plan the procedure and inform the patient.
Collapse
Affiliation(s)
- C Court
- Department of Orthopaedic Surgery, Bicêtre Hospital, Paris XI University, Kremlin-Bicêtre, France.
| | | | | | | | | |
Collapse
|
38
|
Tötterman A, Glott T, Madsen JE, Røise O. Unstable sacral fractures: associated injuries and morbidity at 1 year. Spine (Phila Pa 1976) 2006; 31:E628-35. [PMID: 16915078 DOI: 10.1097/01.brs.0000231961.03527.00] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, longitudinal single-cohort study of 32 patients treated with internal fixation for unstable sacral fractures. OBJECTIVES To describe the prevalence of associated injuries in blunt pelvic trauma with unstable sacral fractures, and to characterize late impairments. SUMMARY OF BACKGROUND DATA In high-energy pelvic ring injury, the close association of the spine, the intrapelvic organs and the bony pelvic ring result in high risk for additional injuries. These injuries may result in long-term sequels pertaining to mobility, voiding, bowel function, and sexual function. However, little is known about the components of long-term morbidity after unstable sacral fractures. METHODS The minimum 1-year follow-up included 32 patients surgically treated for unstable sacral fractures. Patients were analyzed for associated injuries, fracture classification, severity of trauma, and long-term measures of neurologic recovery, mobility, and functions pertaining to voiding, defecation, and sexual function. RESULTS Additional injuries occurred in 84%. Injury Severity Score was 27 (range, 9-57). At follow-up, sensory impairments were observed in 91%; impaired gait in 63%, and bladder, bowel, or sexual impairments in 59%. Sacral radiculopathies explained only 60% to 69% of these impairments. The presence of late impairments correlated to the severity of injury and to the presence of associated injuries, but not to fracture characteristics. CONCLUSIONS Unstable fractures of the sacrum are frequently associated with additional injuries. These injuries have a significant effect on morbidity still 1 year after injury. The multifactor etiology of impairments after sacral fractures should be acknowledged in the assessment of these patients.
Collapse
Affiliation(s)
- Anna Tötterman
- Ulleval University Hospital, Orthopaedic Centre, Oslo, Norway.
| | | | | | | |
Collapse
|
39
|
Abstract
Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only "apparent" identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although "sensory-retraining biofeedback" appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.
Collapse
Affiliation(s)
- Marc A Gladman
- Gastrointestinal Physiology Unit, Barts and The London, Queen Mary's School of Medicine and Dentistry, Whitechapel, London, United Kingdom
| | | | | | | |
Collapse
|
40
|
Fourney DR, Rhines LD, Hentschel SJ, Skibber JM, Wolinsky JP, Weber KL, Suki D, Gallia GL, Garonzik I, Gokaslan ZL. En bloc resection of primary sacral tumors: classification of surgical approaches and outcome. J Neurosurg Spine 2006; 3:111-22. [PMID: 16370300 DOI: 10.3171/spi.2005.3.2.0111] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECT En bloc resection with adequate margins is associated with the highest probability of long-term tumor control or cure in most cases of primary sacral malignancies. The authors present their experience with a systematic approach to these lesions. They provide a novel classification of surgical techniques based on the level of nerve root sacrifice and evaluate the functional and oncological outcomes. METHODS Seventy-eight consecutive patients underwent 94 resections of sacral neoplasms at The University of Texas M. D. Anderson Cancer Center in Houston between August 1993 and June 2002. The records of 29 consecutive patients who underwent en bloc resection of primary sacral tumors were retrospectively reviewed. The median follow-up period was 55 months (range 1-103 months). Chordoma was the most frequent tumor type (16 cases). Midline sacral amputation was performed in 25 patients (eight low, four middle, seven high, and five total sacrectomies; one hemicorporectomy). Lateral sacrectomy was undertaken in four patients (two unilateral excisions of the sacroiliac joint and two hemisacrectomies). The surgical margins were wide in 19 cases, marginal in nine, and contaminated in one. The type of sacrectomy correlated with characteristic outcomes with respect to bladder, bowel, and ambulatory functions. Duration of hospital stay was related to the extent of sacrectomy (p = 0.003, Wilcoxon signed-rank test). The median Kaplan-Meier disease-free survival for patients with chordoma was 68 months (95% confidence interval 46-90 months). CONCLUSIONS Classification of en bloc sacral resection techniques by the level of nerve root transection is useful in predicting postoperative function and the potential for morbidity. Adequate surgical margins should not be compromised to preserve function when they are necessary to affect tumor control.
Collapse
Affiliation(s)
- Daryl R Fourney
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Devin C, Chong PY, Holt GE, Feurer I, Gonzalez A, Merchant N, Schwartz HS. Level-adjusted perioperative risk of sacral amputations. J Surg Oncol 2006; 94:203-11. [PMID: 16900511 DOI: 10.1002/jso.20477] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Sacral amputations above the S2 body often involve increased surgical complexity leading to long-term morbidity. The purpose of this study was to determine whether proximal sacral amputations have substantially higher perioperative morbidity compared with more distal sacral amputations. METHODS We evaluated the effect of sacral amputation level on perioperative outcomes within 90 days of surgery. Outcome measures included blood loss, intensive care unit (ICU) and hospital stay, hospital cost, and incidence of a major and minor morbidity. Survival analyses were adjusted for the level of resection and histological appearance. RESULTS Thirteen proximal and 14 distal resections were performed. In comparing proximal versus distal resections, median estimated blood loss was 4 L versus 1 L (P < 0.001), ICU stay was 4 days versus 0 days (P = 0.012), hospital stay was 19 days versus 8 days (P = 0.001), hospital cost was 28,800 dollars versus 7,500 dollars (P = 0.003), with one or more major complications in 85% versus 29% (P = 0.011). Survival analysis demonstrated that the sacral resection level did not influence survival (P = 0.936), whereas the type of tumor did influence survival (P = 0.012). CONCLUSION Tumor resections above S2 demonstrate increased perioperative morbidity, suggesting that proximal osteotomies be reserved for patients with a realistic cure potential.
Collapse
Affiliation(s)
- Clinton Devin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-8774, USA
| | | | | | | | | | | | | |
Collapse
|
42
|
Abstract
Retrorectal tumors (RRT) constitute an anatomical grouping of various tumors of different nature, both benign and malignant. The diversity of their presentation, surgical management, and prognosis are illustrated by five clinical cases. A simple categorization would distinguish vestigial tumors (whether cystic or solid), congenital nonvestigial tumors such as chordoma, and tumors of neural or bony origin. Imaging by CT scan and by MRI will usually determine the nature of the tumor and its relationship to the surrounding anatomical structures. The principle of treatment is complete removal with free margins. The surgical approach may be posterior, anterior or combined depending on the nature and the size of the lesion and on how high it is situated relative to the second sacral vertebra. Complete resection may be both difficult and bloody. Sacral segments may need to be resected either for reasons of surgical approach or to obtain clear margins. Rectal resection is rarely necessary. The prognosis of these lesions depends on the nature of the tumor and particularly on the quality and completeness of the resection.
Collapse
Affiliation(s)
- L S Kołodziejski
- Service de Chirurgie Oncologique, Centre d'Oncologie Maria Skłodowska-Curie - Cracovie, Pologne
| | | | | |
Collapse
|
43
|
Bakx R, van Lanschot JJB, Zoetmulder FAN. Sacral resection in cancer surgery: surgical technique and experience in 26 procedures1 1No competing interests declared.Dutch Digestive Diseases Foundation has provided financial support. J Am Coll Surg 2004; 198:846-51. [PMID: 15110821 DOI: 10.1016/j.jamcollsurg.2003.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2003] [Accepted: 12/03/2003] [Indexed: 10/26/2022]
Affiliation(s)
- Roel Bakx
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | | | | |
Collapse
|
44
|
Doita M, Harada T, Iguchi T, Sumi M, Sha H, Yoshiya S, Kurosaka M. Total sacrectomy and reconstruction for sacral tumors. Spine (Phila Pa 1976) 2003; 28:E296-301. [PMID: 12897508 DOI: 10.1097/01.brs.0000083230.12704.e3] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Report of three patients in whom the lumbosacral junctions were successfully restored by spinal instrumentations after total sacrectomies. OBJECTIVES To describe the surgical technique of the reconstruction of the continuity between the pelvic ring and spinal column by using a transpedicular and iliac screw system. SUMMARY OF BACKGROUND DATA Although there have been case reports about reconstruction methods after total sacrectomy, biomechanical, and technical problems still remain unresolved. METHODS Total sacrectomy was carried out in three cases: two with chordomas and one with a recurrent giant cell tumor. In the first case, reconstruction was achieved with Zielke transpedicular screw and rod system and a sacral rod. The other two patients were reconstructed using a transpedicular and iliac screw system and a sacral rod for bilateral fixation of the iliac wings. In the third patient, the vertical rods were connected to transverse rod with rod connectors. RESULTS No instrumentation failure was observed, and the continuity between the pelvic wing and spinal column was established with the instrumentation and bone grafting. Although one patient died of metastatic chordoma, the lumbosacral junction was successfully reconstructed with the instrumentation. The other two patients could stand with double crutches 13 and 2 years after surgery, respectively. CONCLUSIONS Total sacrectomy is a feasible operation for primary malignant tumors involving the entire sacrum. Reconstruction of the union between the lumbar spine and the ilia with spinal instrumentation achieves stabilization suitable for ambulation.
Collapse
Affiliation(s)
- Minoru Doita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan.
| | | | | | | | | | | | | |
Collapse
|
45
|
Abstract
Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Although metastasis is infrequent at presentation, the prognosis for patients with chordoma of the sacrum is reported to be poor and attributable in most cases to intralesional resection. The value of adjuvant treatment is uncertain, and resection remains the primary mode of treatment. Chordomas are difficult to excise completely, but recent improvements in imaging and surgical techniques have allowed surgeons to perform more frequently en bloc sacral resections with wide surgical margins. The technical challenges of such operations, and the functional costs for the patient (with respect to anorectal and urogenital dysfunction) are significantly increased when the tumor involves high sacral levels. The authors review the clinical presentation and natural history of sacral chordoma and discuss the current treatment techniques and outcomes.
Collapse
Affiliation(s)
- Daryl R Fourney
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | |
Collapse
|
46
|
Abstract
Major sacral resection generally is reserved for patients with malignant lesions. Because of the uncommon nature of these diseases, little is known about outcomes of surgical treatment. The current authors describe the retrospective analysis of bowel and bladder function in patients having major sacral resection at their institution during a 10-year period. Fifty-three patients were identified. In patients who had unilateral sacrectomy, in whom the contralateral sacral nerves were preserved, normal bowel and bladder function was retained in 87% and 89%, respectively. In patients who had bilateral S2-S5 nerve roots sacrificed, all had abnormal bowel and bladder function. In patients who had bilateral S3-S5 resection, normal bowel and bladder function was retained in 40% and 25%, respectively. In patients who had bilateral S4-S5 resection, with preservation of the S3 nerves bilaterally, normal bowel and bladder function was retained in 100% and 69%, respectively. In patients who had asymmetric sacral resections, with preservation of at least one S3 nerve root, normal bowel and bladder function was retained in 67% and 60%, respectively. These results show that unilateral resection of sacral roots or preservation of at least one S3 root in bilateral resection preserves bowel and bladder function in the majority of patients.
Collapse
Affiliation(s)
- Larry T Todd
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | | | | |
Collapse
|
47
|
Nakai S. 3. From the oncology department...A sacral tumor of extraordinary size, where bowel and bladder dysfunction were not presenting symptoms. Spine J 2001; 1:156. [PMID: 14588401 DOI: 10.1016/s1529-9430(01)00059-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S Nakai
- Ortho Surgery, Toyoake City, Aichi Prefecture, Japan
| |
Collapse
|