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Elias A, Benady A, Golden E, Segal O, Dadia S. In situ cryoablation of sacral Giant Cell Tumor using three-dimensional (3D) model: A case report. J Orthop 2022; 30:46-50. [PMID: 35241887 PMCID: PMC8857548 DOI: 10.1016/j.jor.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 10/19/2022] Open
Abstract
Three-dimensional planning of in-situ (trans-sacral) image guided cryoablation provides a method to treat sacral GCTs that accommodates the intricacies of the pelvis offering a safer, more efficacious alternative. Here we report on IM a 23-year-old female with a sacral GCT. She presented to Tel Aviv Medical Center with ongoing pain as well as neurological symptoms. For six years, the patient was in-and-out of the hospital for Denosumab treatment and recurrent infections. Eventually, further treatment became necessary, and she was treated with image guided cryoablation. By six months follow-up, the patient was mobile and pain-free.
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Affiliation(s)
- Avital Elias
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Benady
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Levin Center for 3D Printing and Surgical Innovation, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,Corresponding author. Weitzman 14, Tel Aviv, Israel.
| | - Eran Golden
- Levin Center for 3D Printing and Surgical Innovation, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ortal Segal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,National Unit of Orthopedic Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Solomon Dadia
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Levin Center for 3D Printing and Surgical Innovation, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,National Unit of Orthopedic Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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2
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Kim KR, Kim KH, Park JY, Shin DA, Ha Y, Kim KN, Chin DK, Kim KS, Cho YE, Kuh SU. Surgical Strategy for Sacral Tumor Resection. Yonsei Med J 2021; 62:59-67. [PMID: 33381935 PMCID: PMC7820448 DOI: 10.3349/ymj.2021.62.1.59] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE This study aimed to present our experiences with a precise surgical strategy for sacrectomy. MATERIALS AND METHODS This study comprised a retrospective review of 16 patients (6 males and 10 females) who underwent sacrectomy from 2011 to 2019. The average age was 42.4 years old, and the mean follow-up period was 40.8 months. Clinical data, including age, sex, history, pathology, radiographs, surgical approaches, onset of recurrence, and prognosis, were analyzed. RESULTS The main preoperative symptom was non-specific local pain. Nine patients (56%) complained of bladder and bowel symptoms. All patients required spinopelvic reconstruction after sacrectomy. Three patients, one high, one middle, and one hemi-sacrectomy, underwent spinopelvic reconstruction. The pathology findings of tumors varied (chordoma, n=7; nerve sheath tumor, n=4; giant cell tumor, n=3, etc.). Adjuvant radiotherapy was performed for 5 patients, chemotherapy for three, and combined chemoradiotherapy for another three. Six patients (38%) reported postoperative motor weakness, and newly postoperative bladder and bowel symptoms occurred in 5 patients. Three patients (12%) experienced recurrence and expired. CONCLUSION In surgical resection of sacral tumors, the surgical approach depends on the size, location, extension, and pathology of the tumors. The recommended treatment option for sacral tumors is to remove as much of the tumor as possible. The level of root sacrifice is a predicting factor for postoperative neurologic functional impairment and the potential for morbidity. Pre-operative angiography and embolization are recommended to prevent excessive bleeding during surgery. Spinopelvic reconstruction must be considered following a total or high sacrectomy or sacroiliac joint removal.
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Affiliation(s)
- Kwang Ryeol Kim
- Department of Neurosurgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Kyu Chin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Su Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Uk Kuh
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Denaro L, Berton A, Ciuffreda M, Loppini M, Candela V, Brandi ML, Longo UG. Surgical management of chordoma: A systematic review. J Spinal Cord Med 2020; 43:797-812. [PMID: 30048230 PMCID: PMC7808319 DOI: 10.1080/10790268.2018.1483593] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Context: Chordomas are rare primary tumors of bone characterized by local aggressiveness and poor prognosis. The surgical exeresis plays a critical role for their management. Objective: The aim was to provide an overview of the surgical management of chordomas of the mobile spine and sacrum, describing the most common surgical approaches, the role of surgical margins, the difficulties of en block resection, the outcomes of surgery, the recurrence rate and the use of associated therapies. Methods: We performed a systematic search using the keywords "chordoma" in combination with "surgery", "spine", "sacrum" and "radiotherapy". Results: Fifty-eight studies, describing 1359 patients with diagnosis of chordoma were retrieved. 17 studies were performed on subjects with cervical chordomas and 49 focused on patients with sacrococcygeal chordomas. The remaining studies included patients with chordomas in cranial region and/or mobile spine and/or sacroccygeal region. The recurrence rate ranged from 25% to 60% for cervical chordomas, and from 18% to 89% for sacrococcygeal chordomas. Conclusion: Despite the remarkable advances in the local management of chordoma performed in the last decades, the current results of surgery alone are still unsatisfactory. The radical en bloc excision of tumour is technically demanding, particularly in the cervical spine. Although radical surgery must still be considered the gold standard for the management of chordomas, a multidisciplinary approach is required to improve the local control of the disease in patients who undergo both radical and non-radical surgery. Adjuvant radiation therapy increases the continuous disease-free survival and the local recurrence-free survival. Level of evidence: Systematic review; level III.
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Affiliation(s)
- Luca Denaro
- Department of Neuroscience, University of Padua, Padua, Italy
| | - Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Candela
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | | | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
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Lim CY, Liu X, He F, Liang H, Yang Y, Ji T, Yang R, Guo W. Retrospective cohort study of 68 sacral giant cell tumours treated with nerve-sparing surgery and evaluation on therapeutic benefits of denosumab therapy. Bone Joint J 2020; 102-B:177-185. [PMID: 32009426 DOI: 10.1302/0301-620x.102b2.bjj-2019-0813.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To investigate the benefits of denosumab in combination with nerve-sparing surgery for treatment of sacral giant cell tumours (GCTs). METHODS This is a retrospective cohort study of patients with GCT who presented between January 2011 and July 2017. Intralesional curettage was performed and patients treated from 2015 to 2017 also received denosumab therapy. The patients were divided into three groups: Cohort 1: control group (n = 36); cohort 2: adjuvant denosumab group (n = 9); and cohort 3: neo- and adjuvant-denosumab group (n = 17). RESULTS There were 68 patients within the study period. Six patients were lost to follow-up. The mean follow-up was 47.7 months (SD 23.2). Preoperative denosumab was found to reduce intraoperative haemorrhage and was associated with shorter operating time for tumour volume > 200 cm3. A total of 17 patients (27.4%) developed local recurrence. The locoregional control rate was 77.8% (7/9) and 87.5% (14/16) respectively for cohorts 2 and 3, in comparison to 66.7% (24/36) of the control group. The recurrence-free survival (RFS) rate was significantly higher for adjuvant denosumab group versus those without adjuvant denosumab during the first two years: 100% vs 83.8% at one year and 95.0% vs 70.3% at two years. No significant difference was found for the three-year RFS rate. CONCLUSION Preoperative denosumab therapy was found to reduce intraoperative haemorrhage and was associated with shorter operating times. Adjuvant denosumab was useful to prevent early recurrence during the first two years after surgery. Cite this article: Bone Joint J 2020;102-B(2):177-185.
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Affiliation(s)
- Chiao Yee Lim
- Department of Orthopaedic Surgery, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia.,Orthopaedic oncology fellow, Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Xingyu Liu
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Fangzhou He
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Haijie Liang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Yi Yang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Tao Ji
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
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5
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Biomechanical comparison of a 3D-printed sacrum prosthesis versus rod-screw systems for reconstruction after total sacrectomy: A finite element analysis. Clin Biomech (Bristol, Avon) 2019; 70:203-208. [PMID: 31655451 DOI: 10.1016/j.clinbiomech.2019.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 10/11/2019] [Accepted: 10/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reconstruction after total sacrectomy is a difficult problem in the field of orthopedic oncology. Current reconstruction methods have not completely solved the problems associated with instrumentation failure. The purpose of this study was to evaluate the biomechanical properties of a 3D-printed total sacrum prosthesis and to conduct biomechanical comparisons between the total sacrum prosthesis and rod-screw systems for lumbosacral reconstruction after total sacrectomy. METHODS Three types of reconstruction were explored, and corresponding finite element models were simulated: four-rod reconstruction, four-rod plus anterior column reconstruction, and 3D-printed total sacrum prosthesis reconstruction. A vertical load of 600 N was applied to the L4 vertebra, and the bilateral acetabula were set as the boundary with six degrees of freedom fixed, simulating the bipedal standing position. FINDINGS The order of the reconstructions according to decreasing maximum von Mises stress was as follows: four-rod reconstruction > four-rod plus anterior column reconstruction >3D-printed total sacrum prosthesis reconstruction. The order of reconstructions according to decreasing L5 shift-down displacement was as follows: four-rod reconstruction >3D-printed total sacrum prosthesis reconstruction > four-rod plus anterior column reconstruction. INTERPRETATION Compared with the rod-screw systems, the total sacrum prosthesis reconstruction has the biomechanical advantages of a more uniform stress distribution, a lower peak stress and better stability and can thus serve as an alternative choice for reconstruction after total sacrectomy.
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Wang Y, Liang W, Qu S, Zhang Y, Du Z, Ji T, Qu H, Gorlick R, Guo W. Assessment of patient experiences following total sacrectomy for primary malignant sacral tumors: A qualitative study. J Surg Oncol 2019; 120:1497-1504. [PMID: 31705571 DOI: 10.1002/jso.25756] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/31/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Few reports have investigated patient experiences following total en bloc sacrectomy. The aims of this study were to obtain a deeper understanding of patients' personal experiences, needs, and satisfaction with the treatment to reveal areas in which perioperative and long-term patient care can be improved. METHODS A qualitative design was applied to examine patient experiences and supportive care needs. Patients treated between 2007 and 2017 were identified from our institutional database. RESULTS A total of 28 survivors were interviewed (13 females, age 13-75 years). Eight themes were identified: the effect of surgery on patients' (a) daily lives, (b) social activities, (c) work or school activities, (d) and family lives; (e) acceptance of ostomy surgery; (f) need for guidance regarding long-term rehabilitation; (g) satisfaction with the medical services provided in the hospital; and (h) satisfaction with the treatment outcomes. CONCLUSION Total en bloc sacrectomy can yield satisfactory oncological outcomes; however, the procedure is a life-changing event for patients and their families. Physicians must provide long-term support and guidance after surgery to enable patients to fully understand and cope with the changes in their lives.
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Affiliation(s)
- Yifei Wang
- Department of Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China.,Department of Pediatrics, MD Anderson Cancer Center, Houston, Texas
| | - Weiming Liang
- Department of Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China.,Department of Orthopedics, The First Affiliated Hospital of Guangxi University of Science and Technology, Liuzhou, GuangXi, China
| | - Shan Qu
- Department of Psychology, Peking University People's Hospital, Beijing, China
| | - Yidan Zhang
- Department of Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - Zhiye Du
- Department of Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - Tao Ji
- Department of Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - Huayi Qu
- Department of Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
| | - Richard Gorlick
- Department of Pediatrics, MD Anderson Cancer Center, Houston, Texas
| | - Wei Guo
- Department of Musculoskeletal Tumors, Peking University People's Hospital, Beijing, China
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7
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Liu G, Hasan MY. Minimally Invasive Dual Iliac-Screw and Dual-Rod Construct: A Case Report Describing Optimal Subcrestal Iliac-Screw Entry Points in the Surgical Treatment of Metastatic Lumbosacral Fracture. Oper Neurosurg (Hagerstown) 2019; 17:E219-E223. [PMID: 30726956 DOI: 10.1093/ons/opy410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Dual iliac-screw and dual-rod fixation provides additional stability to lumbopelvic constructs and can be employed in management of neoplastic disease with extensive osseous involvement. Optimal iliac-screw positioning is vital to achieve the desired dual iliac-screw and dual-rod linkage. CLINICAL PRESENTATION In this report, we describe our technique with particular focus on subcrestal iliac-screw entry point position using a 4-quadrant teardrop radiological view concept in a case of minimally invasive L3-iliac spinopelvic fixation using dual iliac-screw and dual-rod for a patient with pathological sacral fracture. At the last follow-up 20 mo postsurgery there was minimal axial and radicular pain and no evidence of screw prominence. Radiographs showed no evidence of construct failure. CONCLUSION The 4-quadrant teardrop concept provides a good visual reference for optimal subcrestal screw placement when employing a dual iliac-screw and dual-construct.
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Affiliation(s)
- Gabriel Liu
- University Orthopaedic, Hand and Reconstructive Surgery Cluster, National University Health System, National University Hospital, Singapore
| | - Muhammed Yaser Hasan
- University Orthopaedic, Hand and Reconstructive Surgery Cluster, National University Health System, National University Hospital, Singapore
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8
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Ankalkoti B, Satheesan B, Dipin J, Nizamudheen P, Sangeetha N. Retrospective Audit of Various Surgical Modalities Adopted for Giant Cell Tumor in a Rural Tertiary Cancer Center. Indian J Surg Oncol 2019; 10:489-493. [PMID: 31496597 DOI: 10.1007/s13193-019-00926-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/18/2019] [Indexed: 11/27/2022] Open
Abstract
Giant cell tumor of bone (GCTB) is a rare tumor with a spectrum of clinical behavior. Standard treatment modalities include surgical curettage to wide resection, and varying oncological and functional results have been reported. The aim of this study was to evaluate the functional outcome and recurrence rates of patients who underwent surgery for giant cell tumor in a rural tertiary cancer center from June 2009 to December 2016. A retrospective review of 12 patients (7 males and 5 females) with GCT of the extremity bones treated in the institution between the period of June 2009 and December 2016 was performed to study the oncological and functional outcomes. All patients were evaluated by clinical examination, plain X-ray of local parts, X-ray of the chest, and MRI of local parts. A biopsy was taken in all cases to confirm the diagnosis. All patients underwent surgical treatment including curettage combined with cryosurgery and bone cement or wide resection and reconstruction. Selection of the surgical technique was based on the site and size of the lesion, soft tissue involvement (intra- or extra-compartmental), and if recurrent or not. The patients were followed up to April 2018. The mean age of the patients was 31.3 years. The tumor sites were distal femur in 3 cases, proximal tibia in 6, ischial bone in 1, distal radius in 1, and 1 in the metacarpal bone. Campanacci radiographic grading was grade1 in 3 cases, grade 2 in 2 cases, and grade 3 in 7 cases. Out of 12 patients, local recurrence was noted in 2 patients (16.7%). Functional evaluation was performed according to the Musculoskeletal Tumor Society Scoring (MSTS) system. Mean MSTS score was 25. To preserve the good function of the extremities and avoid local recurrence, we consider that curettage with adjunctive therapy such as polymethylmethacrylate (PMMA) and liquid nitrogen should be employed for the treatment of benign GCT of bone. Wide excision should be considered for large tumors where achieving oncological results with functional preservation would be difficult with curettage procedure.
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Affiliation(s)
- Basavaraj Ankalkoti
- 1Department of Surgical Oncology, Malabar Cancer Centre, Kodiyeri, Moozhikkara (PO), Thalassery, Kerala 670111 India
| | - B Satheesan
- 1Department of Surgical Oncology, Malabar Cancer Centre, Kodiyeri, Moozhikkara (PO), Thalassery, Kerala 670111 India
| | - J Dipin
- 1Department of Surgical Oncology, Malabar Cancer Centre, Kodiyeri, Moozhikkara (PO), Thalassery, Kerala 670111 India
| | - P Nizamudheen
- 1Department of Surgical Oncology, Malabar Cancer Centre, Kodiyeri, Moozhikkara (PO), Thalassery, Kerala 670111 India
| | - N Sangeetha
- 2Department of Pathology, Malabar Cancer Center, Thalassery, Kerala 670111 India
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Chinder PS, Hindiskere S, Doddarangappa S, Sk R, Mascarenhas A, Pal U. Robotic Surgery Assisted Staged En-Bloc Sacrectomy for Sacral Chordoma: A Case Report. JBJS Case Connect 2019; 9:e0240. [PMID: 31140987 DOI: 10.2106/jbjs.cc.18.00240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CASE Two male patients aged 37 years and 39 years, diagnosed with sacral chordoma, underwent robotic-assisted preparatory adhesiolysis from the anterior aspect of the tumor, followed by posterior en-bloc partial sacrectomy. The average total operative time was 360 minutes (anterior docking + anterior console + posterior excision), and mean blood loss was 930 mL. Both patients were mobilized early, had no postoperative complications, and were free of local recurrence at 18 month of follow-up. CONCLUSIONS Robotic-assisted surgery is a novel, valid, safe, and minimally invasive technique which drastically reduces the associated surgical complications of single-staged posterior sacrectomy, resulting in excellent functional and oncological outcome.
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Affiliation(s)
- Pramod S Chinder
- Department of Musculoskeletal Oncology, HCG Hospital, Bangalore, India
| | - Suraj Hindiskere
- Department of Musculoskeletal Oncology, HCG Hospital, Bangalore, India
| | | | - Raghunath Sk
- Department of Uro Oncology. HCG Hospital, Bangalore, India
| | | | - Utkarsh Pal
- Department of Musculoskeletal Oncology, HCG Hospital, Bangalore, India
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Cannizzaro D, Mancarella C, Tomei M, Ortolina A, Cardia A, Fornari M. Giant intrasacral schwannoma: removal and innovative posterior fixation system. Technical note and literature review. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04792-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kamath N, Agarwal J, Gulia A. Axial giant cell tumor - current standard of practice. J Clin Orthop Trauma 2019; 10:1027-1032. [PMID: 31736609 PMCID: PMC6844211 DOI: 10.1016/j.jcot.2019.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/28/2019] [Accepted: 09/29/2019] [Indexed: 01/21/2023] Open
Abstract
Giant cell tumors of bone are relatively rare in the axial skeleton, accounting for approximately 6.7% of all cases. Due to their anatomical complexity, difficult access and proximity to vital neurovascular structures, management of these tumors poses a huge challenge on the treating surgeon. Several data series reported on axial GCTB involve short series of limited cases with varied methods used in their local control due to which, proper guidelines are unavailable for the management of such difficult cases. Though the present data support the use of denosumab for effective management of these lesions but there is varied consensus on dosage and duration of treatment. This review article summarizes the basic features and treatment modalities related to axial GCTB stressing on multidisciplinary approach to achieve optimum outcomes.
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Affiliation(s)
| | | | - Ashish Gulia
- Corresponding author. Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India.
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12
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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.
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13
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Yin J, Wu H, Tu J, Zou C, Huang G, Xie X, He Y, Shen J. Robot-assisted sacral tumor resection: a preliminary study. BMC Musculoskelet Disord 2018; 19:186. [PMID: 29875022 PMCID: PMC5991456 DOI: 10.1186/s12891-018-2084-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 05/08/2018] [Indexed: 11/12/2022] Open
Abstract
Background Few studies have been done on robot-assisted sacral surgery. This study aims to evaluate the outcomes of seven patients with benign sacral or presacral tumors treated with a robotic surgical system at a single center. Methods All patients with benign sacral or presacral tumors who underwent transperitoneal resection (between June 2015 and June 2016) using the da Vinci Si HD robotic surgical system (Intuitive Surgical Inc.) were included in this retrospective study. Results Seven patients with a mean age of 43.8 years (range: 22- 62 years) were included in this study. The operation time ranged from 60 to 335 min. Five out of these seven patients with presacral tumor underwent complete tumor resection by the da Vinci robotic surgical system, with a median blood loss of 52 ml. The other patients underwent excision of the presacral tumor by the da Vinci robotic surgical system, followed by a posterior approach, with a median blood loss of 675 ml. The histological diagnosis was schwannoma of the sacral nerve in five cases (71.5%). The other two cases were chordoma and solitary fibroma of the sacrum, respectively. No perioperative or postoperative complications were encountered. The average hospitalization stay was 5.7 days. No recurrences were found at follow-up 24 to 31 months later. Conclusion Robot-assisted minimally invasive sacral surgery can provide precise dissection of the tissue under a perfect view. It is a technically feasible procedure that is associated with minimal blood loss, fewer injuries and short hospitalization. It is particularly suitable for presacral benign tumors.
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Affiliation(s)
- Junqiang Yin
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Hui Wu
- Department of gastrointestinal surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Jian Tu
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Changye Zou
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Gang Huang
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Xianbiao Xie
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Yulong He
- Department of gastrointestinal surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China.
| | - Jingnan Shen
- Department of Musculoskeletal Oncology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China.
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14
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Huang S, Ji T, Guo W. [Development and current situation of reconstruction methods following total sacrectomy]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:513-518. [PMID: 29806335 DOI: 10.7507/1002-1892.201712054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the development of the reconstruction methods following total sacrectomy, and to provide reference for finding a better reconstruction method following total sacrectomy. Methods The case reports and biomechanical and finite element studies of reconstruction following total sacrectomy at home and abroad were searched. Development and current situation were summarized. Results After developing for nearly 30 years, great progress has been made in the reconstruction concept and fixation techniques. The fixation methods can be summarized as the following three strategies: spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and anterior spinal column fixation (ASCF). SPF has undergone technical progress from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems. PPRF and ASCF could improve the stability of the reconstruction system. Conclusion Reconstruction following total sacrectomy remains a challenge. Reconstruction combining SPF, PPRF, and ASCF is the developmental direction to achieve mechanical stability. How to gain biological fixation to improve the long-term stability is an urgent problem to be solved.
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Affiliation(s)
- Siyi Huang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, P.R.China
| | - Tao Ji
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044, P.R.China
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, 100044,
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15
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Hasan MY, Liu G. Minimally invasive dual iliac screw, dual rod fixation in a rare case of pathological sacral fracture from a paraganglionoma: a technique description. J Neurosurg Spine 2017; 27:316-320. [PMID: 28686145 DOI: 10.3171/2017.3.spine161293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The management of lumbosacral neoplastic disease can be demanding, often requiring complex reconstruction. In the context of extensive sacral involvement, the risk of iliac screw breakage is greater. Few studies advocate the use of dual iliac screw techniques to reduce implant failure. In this report, the authors have described the first case of percutaneous dual iliac screw, dual rod insertion as part of a minimally invasive spinopelvic stabilization in a patient with a sacral fracture from a paraganglionoma. The patient underwent percutaneous L-2 to ilium fixation. A dual iliac screw, dual rod construct was used for stabilizing the left lumbopelvic junction. At the 1-year follow-up, the patient remained asymptomatic, with radiographs showing no signs of instrumentation failure. Minimally invasive dual iliac screw, dual rod fixation is a viable option in cases in which additional stability is required due to extensive neoplastic disease or active individuals have increased functional demands. Short-term results in this report are encouraging; however, more research is warranted to establish the procedure's long-term safety.
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Affiliation(s)
- Muhammed Yaser Hasan
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, National University Hospital, Singapore
| | - Gabriel Liu
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, National University Hospital, Singapore
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16
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Musaev ER, Polynovsky AV, Rasulov AO, Tsaryuk VF, Kuz'michev DV, Sushentsov EA, Balyasnikova SS, Safronov DI. [The possibilities of treatment of recurrent colorectal cancer with sacral invasion]. Khirurgiia (Mosk) 2017:24-35. [PMID: 28374710 DOI: 10.17116/hirurgia2017324-35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To describe current methods of surgical treatment of rare form of recurrent rectal cancer with sacral invasion. MATERIAL AND METHODS The article presents the methodology for the treatment of patients with recurrent colorectal cancer and sacral invasion using preoperative chemoradiotherapy followed by high-tech surgery of recurrent tumor removal with sacral resection at various levels (including high intersection at S1 level). CONCLUSION It was concluded that chemoradiotherapy is indicated in patients with recurrent colorectal cancer if it was not made at the first stage of treatment. Additional radiotherapy up to optimum overall focal dose prior to surgery is advisable in those patients who previously underwent radiotherapy with partial dose. This type of operations has high risk of complications and requires a personalized approach to the selection of patients. However, R0-resection is associated with favorable long-term prognosis, significantly increased survival and overall quality of life. Combined surgery for recurrent tumors with sacral invasion should be performed by multidisciplinary surgical team in specialized centers using current possibilities of anesthesiology and intensive care.
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Affiliation(s)
- E R Musaev
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - A V Polynovsky
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - A O Rasulov
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - V F Tsaryuk
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - D V Kuz'michev
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - E A Sushentsov
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - S S Balyasnikova
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
| | - D I Safronov
- Blokhin Russian Cancer Research Center, Ministry of Health of the Russian Federation, Moscow
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17
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Kim D, Lim JY, Shim KW, Han JW, Yi S, Yoon DH, Kim KN, Ha Y, Ji GY, Shin DA. Sacral Reconstruction with a 3D-Printed Implant after Hemisacrectomy in a Patient with Sacral Osteosarcoma: 1-Year Follow-Up Result. Yonsei Med J 2017; 58:453-457. [PMID: 28120579 PMCID: PMC5290028 DOI: 10.3349/ymj.2017.58.2.453] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 09/30/2016] [Accepted: 11/03/2016] [Indexed: 11/27/2022] Open
Abstract
Pelvic reconstruction after sacral resection is challenging in terms of anatomical complexity, excessive loadbearing, and wide defects. Nevertheless, the technological development of 3D-printed implants enables us to overcome these difficulties. Here, we present a case of sacral osteosarcoma surgically treated with hemisacrectomy and sacral reconstruction using a 3D-printed implant. The implant was printed as a customized titanium prosthesis from a 3D real-sized reconstruction of a patient's CT images. It consisted mostly of a porous mesh and incorporated a dense strut. After 3-months of neoadjuvant chemotherapy, the patient underwent hemisacretomy with preservation of contralateral sacral nerves. The implant was anatomically installed on the defect and fixed with a screw-rod system up to the level of L3. Postoperative pain was significantly low and the patient recovered sufficiently to walk as early as 2 weeks postoperatively. The patient showed left-side foot drop only, without loss of sphincter function. In 1-year follow-up CT, excellent bony fusion was noticed. To our knowledge, this is the first report of a case of hemisacral reconstruction using a custom-made 3D-printed implant. We believe that this technique can be applied to spinal reconstructions after a partial or complete spondylectomy in a wide variety of spinal diseases.
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Affiliation(s)
- Doyoung Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Young Lim
- Department of Biomedical Engineering, Yonsei University College of Medicine, Seoul, Korea
- Medyssey Co., Ltd., Uijeongbu, Korea
| | - Kyu Won Shim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Woo Han
- Department of Pediatric Hemato-Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Do Heum Yoon
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Gyu Yeul Ji
- Department of Neurosurgery, Guro Cham Teun Teun Hospital, Seoul, Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea.
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18
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Palejwala AH, Fridley JS, Garcia K, Vasudevan SA, Khechoyan D, Rednam S, Koh CJ, Jea A. Hemisacrectomy with preservation of the contralateral sacral nerve roots and sacroiliac joint for pelvic neurofibrosarcoma in a 7-year-old child: case report with 2-year follow-up. J Neurosurg Pediatr 2017; 19:102-107. [PMID: 27689246 DOI: 10.3171/2016.7.peds16203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neurofibrosarcoma is rare in the pediatric age group. A malignant tumor of the sacrum presents significant challenges, especially if the goals are to resect with wide and clean surgical margins and to achieve acceptable functional outcomes. The authors report a case of this rare tumor affecting the sacrum and sacral nerve roots of a 7-year-old girl and review the role of total hemisacrectomy sparing the contralateral sacral nerve roots and lumbopelvic reconstruction in the treatment of this disease. This patient is, to the best of the authors' knowledge, the youngest to be treated in this manner.
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Affiliation(s)
| | | | | | | | - David Khechoyan
- Division of Pediatric Plastic Surgery, Texas Children's Hospital
| | - Surya Rednam
- Division of Pediatric Hematology/Oncology, Texas Children's Cancer Center
| | - Chester J Koh
- Division of Pediatric Urology, Texas Children's Hospital, Houston, Texas; and
| | - Andrew Jea
- Neuro-Spine Program, Division of Pediatric Neurosurgery.,Section of Pediatric Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine Department of Neurosurgery, Indianapolis, Indiana
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19
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Soft Tissue and Bone Defect Management in Total Sacrectomy for Primary Sacral Tumors: A Systematic Review With Expert Recommendations. Spine (Phila Pa 1976) 2016; 41 Suppl 20:S199-S204. [PMID: 27509193 DOI: 10.1097/brs.0000000000001834] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review and expert consensus. OBJECTIVE To address the following two questions: (A) Is there a difference in outcomes after spino-pelvic reconstruction of total sacrectomy defects compared with no reconstruction? (B) What constitutes best surgical technique for soft tissue and bony reconstruction after total sacrectomy? SUMMARY OF BACKGROUND DATA The management of the soft tissue and bony defect after total sacrectomy for primary sacral tumors remains a challenge due to the complex anatomical relationships and biomechanical requirements. The scarcity of evidence-based literature in this specialized field makes it difficult for the treating surgeon to make an informed choice. METHODS A systematic literature review was performed (1950-2015), followed by a meeting of an international expert panel. Medline, Embase, and CINAHL databases and Cochrane Libraries were searched. Using the GRADE guidelines, the panel of experts formulated recommendations based on the available evidence. RESULTS Three hundred fifty-three studies were identified. Of these, 17 studies were included and were case series. Seven were evaluated as high quality of evidence and nine were of low quality. There were a total of 116 participants. Three studies included patients (n = 24) with no spino-pelvic reconstruction. One study included patients (n = 3) with vascularized bone reconstruction. Twelve studies included patients (n = 80) with no soft tissue reconstruction, three studies described patients with a local flap (n = 20), and four studies with patients having regional flap reconstruction (n = 16). Patients with or without spino-pelvic reconstruction had similar outcomes with regards to walking; however, most patients in the nonreconstructed group had some ilio-lumbar ligamentous stability preserved. The wound dehiscence and return to theater rates were higher in patients with no soft tissue reconstruction. CONCLUSION We recommend spino-pelvic reconstruction be undertaken with soft tissue reconstruction after total sacrectomy. LEVEL OF EVIDENCE N/A.
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20
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Pelvic Reconstruction Surgery Using a Dual-Rod Technique with Diverse U-Shaped Rods After Posterior En Bloc Partial Sacrectomy for a Sacral Tumor: 2 Case Reports and a Literature Review. World Neurosurg 2016; 95:619.e11-619.e18. [PMID: 27544341 DOI: 10.1016/j.wneu.2016.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/05/2016] [Accepted: 08/06/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spinopelvic reconstruction after sacrectomy for a sacropelvic tumor can result in various complications and requires a highly complicated surgical technique. We report 2 cases of pelvic reconstruction surgery using diverse U-shaped rods (USRs) after partial sacrectomy. CASE DESCRIPTION A partial sacrectomy was performed for 2 different cases: one case was a metastatic sacral tumor and the other was a chordoma. In the first case, reconstruction was completed with an inner straight rod and an outer USR. The other patient underwent reconstruction using an inner USR and an outer straight rod. In both cases, there was no instrument failure, and the lumbosacral junction was reconstructed in balance. One of the patients died of metastatic lung cancer, and the other patient is alive and has experienced no other complications. CONCLUSIONS A pelvic reconstruction technique using diverse USRs showed good spinopelvic stability without complications. This technique may be a surgical option for reconstructive surgery after partial sacrectomy.
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21
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Gupta A, Kulkarni A. A retrospective analysis of massive blood transfusion and post-operative complications in patients undergoing supra-major orthopaedic oncosurgeries. Indian J Anaesth 2016; 60:270-5. [PMID: 27141111 PMCID: PMC4840808 DOI: 10.4103/0019-5049.179465] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background and Aims: Anaesthetic management of patients undergoing supra-major orthopaedic oncosurgeries is challenging. We wanted to evaluate the effects of pre-operative co-morbid conditions, intraoperative blood loss and transfusion, haemodynamic instability on post-operative complications and hospital outcomes in patients after such surgeries. Methods: We collected data from the patient files, anaesthesia records and the electronic medical records about pre-operative morbidities, intraoperative management, complications, blood loss, fluid therapy and blood products transfused. We also collected data on post-operative complications, intensive care unit (ICU) and hospital length of stay (LOS) and status at discharge. Data were summarised using percentages for categorical data and mean and median for continuous data. Results: The mean blood loss was 4567.44 ml (range 1200–16,000 ml); 95% of all patients received blood transfusion. Twenty patients needed massive blood transfusion. Fresh frozen plasma was needed in 17 patients while 1 patient needed single donor platelets. Haemodynamic instability was present in 38 patients, of which 8 needed continuous vasopressor infusion. Nineteen patients were ventilated post-operatively. Coagulopathy occurred in 22 patients while thrombocytopaenia was seen in 6 patients. The median ICU LOS was 3 (1–6) days, and median hospital stay was 17 (6–53) days. All patients were discharged alive. Conclusion: Supra-major orthopaedic oncosurgeries are associated with massive intraoperative blood loss and transfusion. Common complications include anaemia, coagulopathy and hyperbilirubinaemia and prolonged ICU stay. Meticulous care, anticipating the complications with timely treatment can lead to excellent outcomes.
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Affiliation(s)
- Ankit Gupta
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Atul Kulkarni
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
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22
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Bydon M, De la Garza-Ramos R, Bettegowda C, Suk I, Wolinsky JP, Gokaslan ZL. En Bloc Resection of a Giant Cell Tumor in the Sacrum via a Posterior-Only Approach Without Nerve Root Sacrifice: Technical Case Report. Neurosurgery 2016; 11 Suppl 3:E472-8. [PMID: 26103558 DOI: 10.1227/neu.0000000000000836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Giant cell tumors (GCTs) are rare primary bone neoplasms. The best long-term prognosis is achieved via complete tumor excision, but this feat is challenging in the spine due to proximity of blood vessels and nervous tissue. When occurring in the sacrum, GCTs have been removed in an en bloc fashion via combined anterior/posterior approaches, oftentimes with nerve root sacrifice. The purpose of this article is to present a case of a single-staged, posterior-only approach for en bloc resection of a sacral GCT without nerve root sacrifice. CLINICAL PRESENTATION A 45-year-old female presented with intractable lower back and leg pain, saddle anesthesia, and lower extremity weakness. She underwent imaging studies, which revealed a lesion involving the S1 and S2 vertebral bodies. Computed tomography guided biopsy revealed the lesion to be a GCT. The patient underwent a posterior-only approach without nerve root sacrifice to achieve an en bloc resection, followed by lumbopelvic reconstruction. CONCLUSION Sacrectomy via a single-staged posterior approach with nerve root preservation is a challenging yet feasible procedure for the treatment of giant cell tumors in carefully selected patients.
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Affiliation(s)
- Mohamad Bydon
- ‡The Spinal Column Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland; §Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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23
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Yamagishi T, Kawashima H, Ogose A, Sasaki T, Hotta T, Inagawa S, Umezu H, Endo N. Disappearance of giant cells and presence of newly formed bone in the pulmonary metastasis of a sacral giant-cell tumor following denosumab treatment: A case report. Oncol Lett 2015; 11:243-246. [PMID: 26870196 DOI: 10.3892/ol.2015.3858] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 09/09/2015] [Indexed: 12/18/2022] Open
Abstract
A giant-cell tumor of the bone (GCTB) is a benign but locally aggressive bone tumor. Recently, the receptor activator of nuclear factor κB (RANK) ligand inhibitor, denosumab, has demonstrated activity against giant-cell tumors. The current study reports a case of a sacral GCTB with lung metastasis. A 19-year-old male patient presented with right buttock pain and right lower leg pain, and a sacral GCTB was diagnosed based on the histological analysis of a biopsy specimen. The patient was successfully treated with neoadjuvant denosumab therapy, which allowed curettage. In addition, the pulmonary nodule reduced in size following denosumab administration, and surgical resection was performed. Since the operation, the patient has been managed with the continued use of denosumab with no sign of recurrence. Microscopic findings from the surgical specimen following denosumab treatment revealed that the giant cells had disappeared and woven bone had formed. The specimen from the pulmonary nodule exhibited similar findings to the surgical specimen. It was reported that denosumab treatment was able to reduce the number of giant cells and RANK-positive stromal cells, and cause the formation of new bone in the primary lesion. The present study reports the first case to demonstrate the efficiency of denosumab in treating pulmonary metastasis of GCTB.
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Affiliation(s)
- Tetsuro Yamagishi
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Akira Ogose
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Taro Sasaki
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Tetsuo Hotta
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Shoichi Inagawa
- Division of Radiology, Niigata University Medical and Dental Hospital, Niigata 951-8510, Japan
| | - Hajime Umezu
- Division of Pathology, Niigata University Medical and Dental Hospital, Niigata 951-8510, Japan
| | - Naoto Endo
- Division of Orthopedic Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
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24
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Lim SH, Jo DJ, Kim SM, Lim YJ. Reconstructive surgery using dual U-shaped rod instrumentation after posterior en bloc sacral hemiresection for metastatic tumor: case report. J Neurosurg Spine 2015; 23:630-634. [PMID: 26230420 DOI: 10.3171/2015.2.spine14702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite various complications associated with sacrectomy to remove sacral tumors, total or en bloc sacrectomy has been suggested as the most appropriate surgical treatment in such cases. The authors present the case of a 62-year-old male patient with intractable back pain and voiding difficulty whom they treated with posterior en bloc sacral hemiresection followed by reconstruction using dual U-shaped rods. They report that good spinopelvic stability was achieved without complications. The authors conclude that this technique is relatively simple compared with other sacral reconstructive techniques and can prevent complications, including herniation.
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Affiliation(s)
- Seung-Hoon Lim
- Department of Neurosurgery, Kyung Hee University School of Medicine; and
| | - Dae-Jean Jo
- Department of Neurosurgery, Spine Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sung-Min Kim
- Department of Neurosurgery, Spine Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Young-Jin Lim
- Department of Neurosurgery, Kyung Hee University School of Medicine; and
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25
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Zang J, Guo W, Yang R, Tang X, Li D. Is total en bloc sacrectomy using a posterior-only approach feasible and safe for patients with malignant sacral tumors? J Neurosurg Spine 2015; 22:563-70. [PMID: 25815809 DOI: 10.3171/2015.1.spine14237] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this study the authors' aim was to describe their experience with total en bloc sacrectomy using a posterioronly approach and to assess the outcome of patients with malignant sacral tumors who underwent this procedure at their center. METHODS The authors identified and retrospectively reviewed the records of 10 patients with malignant sacral tumors who underwent a total en bloc sacrectomy via a single posterior approach at their center. The pathological diagnosis was chordoma in 4 patients, chondrosarcoma in 1, osteosarcoma in 1, malignant schwannoma in 1, malignant giant cell tumor in 1, and Ewing's sarcoma in 2. Radiological examination revealed that the tumor involved S1-5 in 7 patients, S1-4 in 1, S1-3 in 1, and S1-2 in 1. RESULTS All 10 patients were stable during the perioperative period. The mean surgery duration was 282 minutes (range 250-310 minutes). The median estimated blood loss was 2595 ml (range 1500-3200 ml). All patients were followed up for 13-29 months (mean 22 months). Two patients had a local recurrence. Two patients died of disease, 1 patient was alive with disease, and 7 patients were alive without evidence of disease. Among the 8 surviving patients, 6 were able to walk without assistive devices, and 2 were able to walk with crutches. The total complication rate was 40% (4 of 10). Wound complications (deep infection and wound healing problems) occurred in 3 patients, and a distal deep vein thrombosis occurred in 1 patient. CONCLUSIONS Total en bloc sacrectomy using a posterior-only approach is feasible and safe in selected patients and is an important procedure for the treatment of primary malignant tumor involving the entire sacrum or only the top portion.
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Affiliation(s)
- Jie Zang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Wei Guo
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
| | - Dasen Li
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Beijing, China
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26
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He X, Hu YC, Yu XC, Yuan BB. Resection of inferior pubic ramus tumors through a femoribus internus-perineal approach. Orthop Surg 2014; 6:65-8. [PMID: 24590997 DOI: 10.1111/os.12082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 11/26/2013] [Indexed: 11/28/2022] Open
Abstract
An operative approach to the inferior pubic ramus that was utilized in four patients with various bone tumors in the inferior pubic ramus is described here. These patients were successfully managed though a femoribus internus (inner thigh)-perineal approach. Data concerning preoperative and postoperative symptoms, surgical procedures, and outcomes are presented. There was no recurrence in the four cases and the pain associated with an initial pelvic floor had completely resolved except one case. The slight limitation in range of motion of the left hip joint and pain were performed in the same case postoperatively. The Musculoskeletal Tumor Society scores were 28, 15, 25, and 18 at the final follow-up. A typical case is described in full and our experience concerning surgical indications, and intraoperative issues in tumor patients discussed. The purpose of this paper is to recommend that the femoribus internus-perineal approach be used to resect the inferior pubic ramus, whether affected by osteomyelitis, bone tumor, or tuberculosis, but especially in patients with tumors.
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Affiliation(s)
- Xin He
- School of Graduate, Tianjin Medical University, Tianjin, China
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27
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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.
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28
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Kayani B, Sewell MD, Hanna SA, Saifuddin A, Aston W, Pollock R, Skinner J, Molloy S, Briggs TW. Prognostic Factors in the Operative Management of Dedifferentiated Sacral Chordomas. Neurosurgery 2014; 75:269-75; discussion 275. [DOI: 10.1227/neu.0000000000000423] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Dedifferentiated chordomas are rare high-grade malignant spinal tumors for which there is minimal information to help guide treatment.
OBJECTIVE:
To identify prognostic factors associated with increased risk of local recurrence, metastases, and reduced survival in a cohort of patients undergoing sacrectomy for de novo dedifferentiated sacral chordoma.
METHODS:
Ten patients undergoing sacrectomy for histologically confirmed dedifferentiated chordoma at a specialist center were reviewed. There were 6 male and 4 female patients with a mean age of 66.7 years (range, 57-80 years) and mean follow-up of 36.7 months (range, 3-98 months). Data on prognostic factors were collected.
RESULTS:
The commonest presenting symptom was lumbar/gluteal pain. Mean duration of preoperative symptoms was 3.6 months (range, 2-7 months). Local recurrence was seen in 7 patients; metastases occurred in 5 patients. After sacrectomy, 7 patients died at a mean of 41 months (range, 3-98 months). Tumor size >10 cm in diameter, amount of dedifferentiation within the conventional chordoma, sacroiliac joint infiltration, and inadequate resection margins were associated with increased risk of recurrence and reduced survival. Surgical approach, cephalad extent of primary tumor, and adjuvant radiotherapy did not affect oncological outcomes.
CONCLUSION:
Dedifferentiated chordomas are aggressive malignant tumors with a higher risk of local recurrence, metastases, and early mortality than conventional chordomas. Tumor diameter >10 cm, marginal resection, and sacroiliac joint infiltration may be associated with increased risk of local recurrence and mortality. Those with a smaller burden of dedifferentiated disease (<1 cm2) within the primary chordoma have a better prognosis. Patients should be counseled about these risks before surgery and should have regular follow-up for the detection of local recurrence and metastases.
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Affiliation(s)
- Babar Kayani
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Mathew D. Sewell
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Sammy A. Hanna
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Asif Saifuddin
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - William Aston
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Robin Pollock
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - John Skinner
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Sean Molloy
- The Royal National Orthopaedic Hospital, Stanmore, United Kingdom
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George B, Bresson D, Bouazza S, Froelich S, Mandonnet E, Hamdi S, Orabi M, Polivka M, Cazorla A, Adle-Biassette H, Guichard JP, Duet M, Gayat E, Vallée F, Canova CH, Riet F, Bolle S, Calugaru V, Dendale R, Mazeron JJ, Feuvret L, Boissier E, Vignot S, Puget S, Sainte-Rose C, Beccaria K. [Chordoma]. Neurochirurgie 2014; 60:63-140. [PMID: 24856008 DOI: 10.1016/j.neuchi.2014.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 02/14/2014] [Accepted: 03/11/2014] [Indexed: 12/28/2022]
Abstract
PURPOSES To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature. MATERIALS The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine. METHODS In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups. RESULTS In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection. CONCLUSIONS Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.
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Affiliation(s)
- B George
- Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - D Bresson
- Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Bouazza
- Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Froelich
- Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - E Mandonnet
- Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Hamdi
- Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - M Orabi
- Service de neurochirurgie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - M Polivka
- Service d'anatomopathologie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - A Cazorla
- Service d'anatomopathologie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - H Adle-Biassette
- Service d'anatomopathologie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - J-P Guichard
- Service de neuroradiologie, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - M Duet
- Service de médecine nucléaire, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - E Gayat
- Service d'anesthésie-réanimation, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - F Vallée
- Service d'anesthésie-réanimation, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - C-H Canova
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - F Riet
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - S Bolle
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - V Calugaru
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - R Dendale
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J-J Mazeron
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Feuvret
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Boissier
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - S Vignot
- Service de radiothérapie et d'oncologie médicale, hôpital de la Salpêtrière, institut Gustave-Roussy, institut Curie, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - S Puget
- Service de neurochirurgie, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
| | - C Sainte-Rose
- Service de neurochirurgie, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
| | - K Beccaria
- Service de neurochirurgie, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
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Possover M, Uehlinger K, Ulrich Exner G. Laparoscopic assisted resection of a ilio-sacral chondrosarcoma: A single case report. Int J Surg Case Rep 2014; 5:381-4. [PMID: 24862027 PMCID: PMC4064397 DOI: 10.1016/j.ijscr.2014.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/01/2014] [Accepted: 04/06/2014] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Sacral tumor often involves en bloc surgical resection with tumor-free margins and functional reconstruction challenges. Such a management is challenging because of difficulties in accessing the lesion, risks for damages of neighboring organs, and risks for massive blood loss. In posterior approach, because first elevation of the sacrum allows dissection of presacral structures, such risks for damages intrapelvic structures and hemorrhage are especially high. PRESENTATION OF CASE We report here about a laparoscopic assisted posterior resection of a ilio-sacral chondrosarcoma in a women, 6 weeks after vaginal delivery. Primary laparoscopic approach consisted in dissection of the ureter and of the colon with control to the pelvic vessels and nerves and determination of limits of the resection. The iliac osteotomy was performed from posterior approach with saw and osteotomes at the predetermined extralesional level. The defect was replaced with a structural fresh frozen femoral allograft and stabilization performed by lumbo-ischial screw/rod fixation. DISCUSSION Surgical time was about 360 min. No intra-postoperative complications occurred. Blood loss was estimated to about 1000 cm3. Histologic examination of the specimen showed tumor-free margins. At 8 months follow-up, the patient appears to be without recurrence. Because of the denervation of the nerve root L5 and below, she mostly uses two canes, but she has a functioning quadriceps. Continence and voiding functions for urine and stool have fully recovered. CONCLUSION Primary laparoscopic approach appeared to be a good way for preparation orthopedics sacroiliac resection to reduce postoperative morbidity, intraoperative blood loss and better assure macroscopic tumor-free margins.
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Affiliation(s)
- Marc Possover
- Possover International Medical Center, Zürich, Switzerland; Department of Gynecology & Neuropelveology, University of Aarhus, Aarhus, Denmark.
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Clark AJ, Tang JA, Leasure JM, Ivan ME, Kondrashov D, Buckley JM, Deviren V, Ames CP. Gait-simulating fatigue loading analysis and sagittal alignment failure of spinal pelvic reconstruction after total sacrectomy: comparison of 3 techniques. J Neurosurg Spine 2014; 20:364-70. [PMID: 24460580 DOI: 10.3171/2013.12.spine13386] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Reconstruction after total sacrectomy is a critical component of malignant sacral tumor resection, permitting early mobilization and maintenance of spinal pelvic alignment. However, implant loosening, graft migration, and instrumentation breakage remain major problems. Traditional techniques have used interiliac femoral allograft, but more modern methods have used fibular or cage struts from the ilium to the L-5 endplate or sacral body replacement with transiliac bars anchored to cages to the L-5 endplate. This study compares the biomechanical stability under gait-simulating fatigue loading of the 3 current methods. METHODS Total sacrectomy was performed and reconstruction was completed using 3 different constructs in conjunction with posterior spinal screw rod instrumentation from L-3 to pelvis: interiliac femur strut allograft (FSA); L5-iliac cage struts (CSs); and S-1 body replacement expandable cage (EC). Intact lumbar specimens (L3-sacrum) were tested for flexion-extension range of motion (FE-ROM), axial rotation ROM (AX-ROM), and lateral bending ROM (LB-ROM). Each instrumented specimen was compared with its matched intact specimen to generate an ROM ratio. Fatigue testing in compression and flexion was performed using a custom-designed long fusion gait model. RESULTS Compared with intact specimen, the FSA FE-ROM ratio was 1.22 ± 0.60, the CS FE-ROM ratio was significantly lower (0.37 ± 0.12, p < 0.001), and EC was lower still (0.29 ± 0.14, p < 0.001; values are expressed as the mean ± SD). The difference between CS and EC in FE-ROM ratio was not significant (p = 0.83). There were no differences in AX-ROM or LB-ROM ratios (p = 0.77 and 0.44, respectively). No failures were noted on fatigue testing of any EC construct (250,000 cycles). This was significantly improved compared with FSA (856 cycles, p < 0.001) and CS (794 cycles, p < 0.001). CONCLUSIONS The CS and EC appear to be significantly more stable constructs compared with FSA with FE-ROM. The 3 constructs appear to be equal with AX-ROM and LB-ROM. Most importantly, EC appears to be significantly more resistant to fatigue compared with FSA and CS. Reconstruction of the load transfer mechanism to the pelvis via the L-5 endplate appears to be important in maintenance of alignment after total sacrectomy reconstruction.
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Li D, Guo W, Tang X, Yang R, Tang S, Qu H, Yang Y, Sun X, Du Z. Preservation of the contralateral sacral nerves during hemisacrectomy for sacral malignancies. 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 2013; 23:1933-9. [PMID: 24363081 DOI: 10.1007/s00586-013-3136-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE This study aimed to evaluate the oncologic and functional outcome of the cases treated with hemisacrectomy through a sagittal plane in the sacrum and simultaneous en bloc resection together with the ipsilateral sacroiliac joint without sacrificing the contralateral sacral nerves and summarize tumor resection techniques and reconstruction strategy. METHODS En bloc resection of a sacral malignancy with ipsilateral sacroiliac joint and preservation of the contralateral sacral nerves by sagittal hemisacrectomy had been performed in 15 patients. An intra-abdominal aortic balloon was used in all these cases and a combined posterior-anterior approach was adopted. A modified Galveston technique was used to reestablish spinopelvic stability and a nonvascularized fibula autograft was used in selected cases. RESULTS Contralateral sacral nerves were preserved in all 15 patients. Adequate margins (wide and marginal margin) were accomplished in 10 patients. Local recurrence occurred in seven (47%) patients, and four of these had an inadequate margin. There was no perioperative death. Four (27%) patients had wound problems. No mechanical breakdown occurred until the last follow-up. All the patients were able to walk without the use of a walking aid. Sphincter function was partially preserved in all these patients. At the last follow-up, seven (47%) patients survived without evidence of disease, two (13%) patients lived with disease, and six (40%) patients had died of disease. CONCLUSIONS This procedure has an oncologic outcome that is similar to that of other high sacrectomy and a much better function outcome. Although demanding, it is indicated in selected patients.
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Affiliation(s)
- Dasen Li
- Musculoskeletal Tumor Center, People's Hospital, Peking University, Xizhimen Nan 11#, Xicheng District, Beijing, 100044, China
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Gebert C, Wessling M, Gosheger G, Aach M, Streitbürger A, Henrichs MP, Dirksen U, Hardes J. Pelvic reconstruction with compound osteosynthesis following hemipelvectomy: A clinical study. Bone Joint J 2013; 95-B:1410-6. [PMID: 24078542 DOI: 10.1302/0301-620x.95b10.31123] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing's sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively. We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing's sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27). This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates.
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Affiliation(s)
- C Gebert
- Orthopaedic Hospital Volmarstein, Department of Tumour & Revision Surgery, Lothar-Gau-Str. 11, D-58300 Wetter, and The University of Muenster, Germany
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The primary stability of pelvic reconstruction after partial supraacetabular pelvic resection due to malignant tumours of the human pelvis: A biomechanical in vitro study. Med Eng Phys 2013; 35:1731-5. [DOI: 10.1016/j.medengphy.2013.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 07/08/2013] [Accepted: 07/19/2013] [Indexed: 11/21/2022]
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Surgical techniques for spinopelvic reconstruction following total 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 2013; 23:305-19. [PMID: 24150036 DOI: 10.1007/s00586-013-3075-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 10/12/2013] [Accepted: 10/13/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE To identify all available reconstruction methods for a total sacrectomy. Secondarily, we aimed to evaluate outcomes based on different interventions. METHODS We searched PubMed to identify sacral resections for tumors requiring internal fixation for stabilization. Demographic information, fixation techniques and postoperative outcomes were abstracted. RESULTS Twenty-three publications (43 patients) met inclusion criteria from an initial search of 856 (κ 0.93). Mean age was 37 years and follow-up was 33 months. Fixation methods included a combination of spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and/or anterior spinal column fixation (ASCF). For the purposes of analysis, patients were segregated based on whether they received ASCF. Postoperative complications including wound/instrument infections, GI or vascular complications were reported at a higher rate in the non-ASCF group (1.63 complications/patient vs. 0.7 complications/patient). Instrument failure was seen in 5 (16.1 %) out of the 31 patients with reported outcomes. Specifically, 1 out of 8 patients (12.5 %) with ASCF compared with 4 out of 23 patients (17.4 %) without ASCF had hardware failure. At final follow-up, 35 of 39 patients were ambulating. CONCLUSION While surgical treatment of primary sacral tumors remains a challenge, there have been advances in reconstruction techniques following total sacrectomy. SPF has shifted from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems for improved rigidity. PPRF and ASCF have adapted for deficiencies in the posterior ring and anterior column. A trend toward a lower rate of hardware failure emerged in the group utilizing anterior spinal column support. Despite a more involved reconstruction with ASCF, surgical complications such as infection rates and blood loss were lower compared to the group without ASCF. While we cannot definitively say one system is superior to the other, based on the data gleaned from this systematic review, it is our opinion that incorporation of ASCF in reconstructing the spinopelvic junction may lead to improved outcomes. However, most importantly, we recommend that the treating surgeon operate on patients requiring a total sacrectomy based on his or her level of comfort, as these cases can be extremely challenging even among experts.
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Long-term outcome of giant cell tumor of bone involving sacroiliac joint treated with selective arterial embolization and curettage: a case report and literature review. World J Surg Oncol 2013; 11:72. [PMID: 23497322 PMCID: PMC3615942 DOI: 10.1186/1477-7819-11-72] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 02/23/2013] [Indexed: 11/30/2022] Open
Abstract
Background Giant cell tumor of the sacrum, especially involving the sacroiliac joint, is rare, but is particularly challenging to treat. The long term outcome of a patient was studied with giant cell tumor involving the sacroiliac joint treated with selective arterial embolization and curretage. Method One patient with giant cell tumor involving the sacroiliac joint was treated with selective arterial embolization and curettage in our hospital in October 2002. The curettage and bone grafting was done after two times of selective arterial embolization;1600 ml of blood were transfused and no complications developed during the operation. Results At the final follow-up of 9 years after the operation, no local recurrence and metastasis developed and she retained normal activity in daily life. Conclusion We think it is an optimal treatment for giant cell tumor involving the sacroiliac joint, with repeated selective arterial embolization and curettage, which has the advantage of less injury, less blood loss and fewer complications.
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Shen CC, Li H, Shi ZL, Tao HM, Yang ZM. Current treatment of sacral giant cell tumour of bone: a review. J Int Med Res 2012; 40:415-25. [PMID: 22613402 DOI: 10.1177/147323001204000203] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Sacral giant cell tumour of bone has an insidious onset and slow growth rate, making early diagnosis difficult. The tumour has a high recurrence rate and is often fatal. Magnetic resonance imaging and computed tomography (CT), including CT-guided fine-needle biopsy, are useful for early diagnosis. Although therapy for sacral giant cell tumour often involves surgical resection and reconstruction challenges, improvements in various treatment modalities, including arterial embolization and radiotherapy, have widened the effective treatment options. The current surgical and adjuvant treatment modalities available for the management of sacral giant cell tumour are systematically reviewed and a suggested treatment algorithm is provided. En bloc excision remains the surgical procedure of choice, with functional reconstruction important in cases where the lesion is high in the sacrum. The use of adjuvant radiotherapy and chemotherapy remains controversial and should be studied further. Determination of the optimum treatment for sacral giant cell tumour will require randomized controlled trials. Early diagnosis, complete surgical resection with tumour-free margins and comprehensive treatment are important for local tumour control and improved outcome.
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Affiliation(s)
- C C Shen
- Department of Orthopaedics, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Zhu R, Cheng LM, Yu Y, Zander T, Chen B, Rohlmann A. Comparison of four reconstruction methods after total sacrectomy: a finite element study. Clin Biomech (Bristol, Avon) 2012; 27:771-6. [PMID: 22705158 DOI: 10.1016/j.clinbiomech.2012.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 05/15/2012] [Accepted: 05/16/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND After total sacrectomy, it is mandatory to reconstruct the continuity between the lumbar spine and the pelvis. Only few biomechanical analyses exist which compare different reconstructions. Therefore, the aim of this study was to compare the lumbo-pelvic motion and the relative risk of implant breakage for four different reconstructions after total sacrectomy. METHOD Finite element analyses were performed for four general different reconstructions after total sacrectomy: sacral-rod reconstruction, four-rod reconstruction, bilateral fibular flaps reconstruction, and improved compound reconstruction. The rotations between L5 vertebra and ilium, the L5 shift-down displacement, and the maximum von Mises stress in the implants were calculated and evaluated for flexion, extension, lateral bending and axial rotation. FINDINGS The decreasing order of the rotations between L5 vertebra and ilium as well as of the L5 shift-down displacement for the studied reconstruction methods was four-rod reconstruction>sacral-rod reconstruction>bilateral fibular flaps reconstruction>improved compound reconstruction. The decreasing order of the maximum von Mises stress in the implants was sacral-rod reconstruction>four-rod reconstruction>bilateral fibular flaps reconstruction>improved compound reconstruction. INTERPRETATION From the mechanical point of view, improved compound reconstruction is superior to the other methods studied here as it shows the highest stability and the lowest maximum von Mises stress. However, clinical aspects must also be regarded when choosing a reconstruction method for a specific patient.
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Affiliation(s)
- Rui Zhu
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, 200065 Shanghai, PR China
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Garvey PB, Clemens MW, Rhines LD, Sacks JM. Vertical rectus abdominis musculocutaneous flow-through flap to a free fibula flap for total sacrectomy reconstruction. Microsurgery 2012; 33:32-8. [DOI: 10.1002/micr.21990] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 02/27/2012] [Accepted: 03/02/2012] [Indexed: 11/07/2022]
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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: 38] [Impact Index Per Article: 3.2] [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.
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Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, ATTIKON University Hospital, Athens University Medical School, Athens, Greece
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Mavrogenis AF, Soultanis K, Patapis P, Papagelopoulos PJ. Anterior thigh flap extended hemipelvectomy and spinoiliac arthrodesis. Surg Oncol 2011; 20:e215-21. [PMID: 21798737 DOI: 10.1016/j.suronc.2011.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 07/02/2011] [Accepted: 07/06/2011] [Indexed: 12/01/2022]
Abstract
We present the technique of anterior thigh flap extended external hemipelvectomy with spinoiliac arthrodesis in treatment of the patient with recurrent low-grade pelvic chondrosarcoma extending to the lower lumbar spine. Extended hemipelvectomy involves skeletal resection beyond the standard hemipelvectomy that is the SI joint by removal of contiguous musculoskeletal structures, such as elements of the sacral and lumbar spine or contralateral pelvic bone, in addition to the affected innominate bone. Spinoiliac arthrodesis reestablishes spinopelvic stability; the anterior thigh musculocutaneous flap provides reliable well-vascularized soft tissue coverage. This technique may serve an important role in the surgical management of patients with low-grade pelvic malignancies.
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Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopaedics, Attikon University Hospital, Athens University Medical School, 41 Ventouri Street, 15562 Holargos, Athens, Greece
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Surgical classification of different types of en bloc resection for primary malignant sacral tumors. 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 2011; 20:2275-81. [PMID: 21713454 DOI: 10.1007/s00586-011-1883-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 05/10/2011] [Accepted: 06/04/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of the study was to develop a surgical classification system for primary malignant sacral tumors. METHODS The sacrum is divided into three regions 1, 2 and 3 by the S1-S2 and S2-S3 junctions. En bloc resections were classified into five types: type I involves regions 1, or 1 and 2, or regions 1, 2 and 3, type II involves regions 2 and 3, and type III involves only region 3. Type IV includes sagittal hemisacrectomy and resection of a portion of the adjacent ilium. Type V includes the sacrum and the fifth lumbar vertebra. 117 patient cases (68 females and 49 males) were reviewed. RESULTS There were two perioperative deaths. Of the 35 patients who should have undergone type I resection, local recurrence (LR) occurred in four of the 14 patients who underwent type I resection with free margins without tumor rupture. The other 21 patients underwent piecemeal resection, and LR occurred in 15 (P = 0.013). 35 patients underwent type II resection. Free margin without tumor rupture was accomplished in 26 and LR occurred in 6. Tumor rupture (TR) occurred in the other 9 and LR occurred in seven (Yates' P = 0.012). All 33 patients underwent type III resection with free margins without tumor rupture. LR occurred in five. 11 patients had type IV resection. Free margin without tumor rupture was accomplished in seven and LR occurred in three. TR occurred in the other four, and LR occurred in two (Yates' P = 0.689). One patient underwent type V resection with free margin without tumor rupture and LR occurred. Postoperatively, less than 1/3 needed long-term urethral catheterization. No patients received colostomy for postoperative fecal incontinence. All the patients were able to ambulate. CONCLUSION Our classification system and the corresponding surgical approaches are helpful in dealing with primary malignant sacral tumors. Better oncologic results could be expected if free margin without tumor rupture was accomplished.
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Alfieri A, Campello M, Broger M, Vitale M, Schwarz A. Low-back pain as the presenting sign in a patient with a giant, sacral cellular schwannoma: 10-year follow-up. J Neurosurg Spine 2011; 14:167-71. [DOI: 10.3171/2010.10.spine1015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Giant sacral tumors present unique challenges to surgeons because there is no established consensus regarding the best treatment options. The authors report on the care of and outcome in a patient presenting with low-back pain only, who underwent preoperative biopsy sampling and subsequent embolization of the feeding vessels of a giant, sacral cellular schwannoma. The main procedure was performed via a combined posterior-anterior approach with complete microsurgical removal of the tumor, without the use of instrumentation, bracing, or adjuvant radio- and chemotherapy. At the 10-year follow-up, no evidence of residual tumor, recurrence, or instability was recognizable. Giant, sacral cellular schwannomas can be aggressively completely removed without any significant morbidity, achieving long-term control of the disease.
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Affiliation(s)
- Alex Alfieri
- 1Neurosurgery, Martin Luther University Hospital Halle-Wittenberg, Germany; and
- 2Department of Neurosurgery, General Regional Hospital, Bolzano/Bozen, Italy
| | - Mauro Campello
- 2Department of Neurosurgery, General Regional Hospital, Bolzano/Bozen, Italy
| | - Maximilian Broger
- 2Department of Neurosurgery, General Regional Hospital, Bolzano/Bozen, Italy
| | - Mario Vitale
- 2Department of Neurosurgery, General Regional Hospital, Bolzano/Bozen, Italy
| | - Andreas Schwarz
- 2Department of Neurosurgery, General Regional Hospital, Bolzano/Bozen, Italy
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Gallia GL, Suk I, Witham TF, Gearhart SL, Black JH, Redett RJ, Sciubba DM, Wolinsky JP, Gokaslan ZL. Lumbopelvic reconstruction after combined L5 spondylectomy and total sacrectomy for en bloc resection of a malignant fibrous histiocytoma. Neurosurgery 2011; 67:E498-502. [PMID: 20644377 DOI: 10.1227/01.neu.0000382972.15422.10] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Primary sacral neoplasms that extend superiorly to involve the distal lumbar spine represent complex surgical problems. Treatment options for these patients are often limited to hemicorporectomy. OBJECTIVE To detail our surgical technique for en bloc resection of a sarcoma involving the L5 vertebral segment and sacrum and the reconstruction of the lumbopelvic junction. METHODS A 52-year-old woman presented with intractable pain secondary to a sarcoma involving the L5 vertebral segment and sacrum. She underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of her neoplasm. A novel lumbopelvic reconstruction technique was used to establish a liaison between the lumbar spine and pelvis. RESULTS Operative complications included a venous vascular injury and a nonviable myocutaneous flap. Postoperatively, the patient had complete resolution of her pain. Unfortunately, the patient developed metastatic disease and died 5 months after her initial surgical procedure. CONCLUSION We describe a patient who underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of a lumbosacral sarcoma. Additionally, we report a novel technique to reconstruct the lumbopelvic junction. The operative procedures are detailed with the aid of radiographs, intraoperative photographs, and illustrations.
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Affiliation(s)
- Gary L Gallia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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Gottfried ON, Omeis I, Mehta VA, Solakoglu C, Gokaslan ZL, Wolinsky JP. Sacral tumor resection and the impact on pelvic incidence. J Neurosurg Spine 2011; 14:78-84. [DOI: 10.3171/2010.9.spine09728] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Pelvic incidence (PI) directly regulates lumbar lordosis and is a key determinant of sagittal spinal balance in normal and diseased states. Pelvic incidence is defined as the angle between the line perpendicular to the S-1 endplate at its midpoint and the line connecting this point to a line bisecting the center of the femoral heads. It reflects an anatomical value that increases with growth during childhood but remains constant in adulthood. It is not altered by changes in patient position or after traditional lumbosacral spinal surgery. There are only 2 reports of PI being altered in adults, both in cases of sacral fractures resulting in lumbopelvic dissociation and sacroiliac (SI) joint instability. En bloc sacral amputation and sacrectomy are surgical techniques used for resection of certain bony malignancies of the sacrum. High, mid, and low sacral amputations result in preservation of some or the entire SI joint. Total sacrectomy results in complete disruption of the SI joint. The purpose of this study was to determine if PI is altered as a result of total or subtotal sacral resection.
Methods
The authors reviewed a series of 42 consecutive patients treated at The Johns Hopkins Hospital between 2004 and 2009 for sacral tumors with en bloc resection. The authors evaluated immediate pre- and postoperative images for modified pelvic incidence (mPI) using the L-5 inferior endplate, as the patients undergoing a total sacrectomy are missing the S-1 endplate postoperatively. The authors compared the results of total versus subtotal sacrectomies.
Results
Twenty-two patients had appropriate images to measure pre- and postoperative mPI; 17 patients had high, mid, or low sacral amputations with sparing of some or the entire SI joint, and 5 patients underwent a total sacrectomy, with complete SI disarticulation. The mean change in mPI was statistically different (p < 0.001) for patients undergoing subtotal versus those undergoing total sacrectomy (1.6° ± 0.9° vs 13.6° ± 4.9° [± SD]). There was no difference between patients who underwent a high sacral amputation (partial SI resection, mean 1.6°) and mid or low sacral amputation (SI completely intact, mean 1.6°).
Conclusions
The PI is altered during total sacrectomy due to complete disarticulation of the SI joint and discontinuity of the spine and pelvis, but it is not changed if any of the joint is preserved. Changes in PI influence spinopelvic balance and may have postoperative clinical importance. Thus, the authors encourage attention to spinopelvic alignment during lumbopelvic reconstruction and fixation after tumor resection. Long-term studies are needed to evaluate the impact of the change in PI on sagittal balance, pain, and ambulation after total sacrectomy.
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Yu BS, Zhuang XM, Li ZM, Zheng ZM, Zhou ZY, Zou XN, Lu WW. Biomechanical effects of the extent of sacrectomy on the stability of lumbo-iliac reconstruction using iliac screw techniques: What level of sacrectomy requires the bilateral dual iliac screw technique? Clin Biomech (Bristol, Avon) 2010; 25:867-72. [PMID: 20655639 DOI: 10.1016/j.clinbiomech.2010.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 06/08/2010] [Accepted: 06/16/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although both single and dual iliac screw techniques are used in spino-pelvic reconstruction following sacrectomy for treating sacral tumors, the basis for choosing between the two techniques for different instability types remains undetermined. The purpose of this study was to evaluate the effects of the extent of sacrectomy on the stability of the lumbo-iliac fixation construct using single and dual iliac screw techniques. METHODS Nine human L2-pelvic specimens were tested for their intact condition simulated by L3-L5 pedicle screw fixation. Sequential partial sacrectomies and L3-iliac fixation using bilateral single and dual iliac screws were conducted on the same specimens as follows: under-S1 sacrectomy+single screw, under-½S1 sacrectomy+single screw, one-side sacroiliac joint resection+single screw, total sacrectomy+single screw, and total sacrectomy+dual screw. Biomechanical testing was performed on a material testing machine for evaluating the stiffness of the L3-iliac fixation construct in compression and torsion. FINDINGS Single iliac screw technique was found to effectively restore the local stability in under-½S1 sacrectomy. However, it could not provide adequate stability for further resection of one-side sacroiliac joint in torsion and total sacrectomy in compression (P<0.05). On the other hand, dual iliac screw technique could restore the stability to the intact condition after total sacrectomy in both compression and torsion. INTERPRETATION The single iliac screw technique for L3-iliac fixation could effectively restore the local stability for under-½S1 sacrectomy. However, for instabilities of the under-½S1 sacrectomy with one-side sacroiliac joint resection or total sacrectomy, the dual iliac screw technique should be considered.
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Affiliation(s)
- Bin-Sheng Yu
- Department of Spine Surgery, the First Affiliated Hospital of Sun Yat-sen University, 183 Huangpu East Road, Guangzhou, China, 510700.
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Ruggieri P, Angelini A, Ussia G, Montalti M, Mercuri M. Surgical margins and local control in resection of sacral chordomas. Clin Orthop Relat Res 2010; 468:2939-47. [PMID: 20635173 PMCID: PMC2947680 DOI: 10.1007/s11999-010-1472-8] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The treatment of choice in sacral chordoma is surgical resection, although the risk of local recurrence and metastasis remains high. The quality of surgical margins obtained at initial surgery is the primary factor to improve survival reducing the risk of local recurrence, but proximal sacral resections are associated with substantial perioperative morbidity. QUESTIONS/PURPOSES We considered survivorship related to local recurrence in terms of surgical margins, level of resection, and previous surgery. METHODS We retrospectively reviewed 56 patients with sacral chordomas treated with surgical resection. Thirty-seven were resected above S3 by a combined anterior and posterior approach and 19 at or below S3 by a posterior approach. Nine of these had had previous intralesional surgery elsewhere. The minimum followup was 3 years (mean, 9.5 years; range, 3-28 years). RESULTS Overall survival was 97% at 5 years, 71% at 10 years, and 47% at 15 years. Survivorship to local recurrence was 65% at 5 years and 52% at 10 years. Thirty percent of patients developed metastases. Wide margins were associated with increased survivorship to local recurrence. We found no differences in local recurrence between wide and wide-contaminated margins (that is, if the tumor or its pseudocapsule was exposed intraoperatively, but further tissue was removed to achieve wide margins). Previous intralesional surgery was associated with an increased local recurrence rate. We observed no differences in the recurrence rate in resections above S3 or at and below S3. CONCLUSIONS Surgical margins affect the risk of local recurrence. Previous intralesional surgery was associated with a higher rate of local recurrence. Intraoperative contamination did not affect the risk of local recurrence when wide margins were subsequently attained.
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Affiliation(s)
- Pietro Ruggieri
- Department of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna (BO), Italy
| | - Andrea Angelini
- Department of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna (BO), Italy
| | - Giuseppe Ussia
- Department of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna (BO), Italy
| | - Maurizio Montalti
- Department of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna (BO), Italy
| | - Mario Mercuri
- Department of Orthopedics, University of Bologna, Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna (BO), Italy
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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.
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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
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Zhang Z, Hua Y, Li G, Sun W, Hu S, Li J, Cai Z. Preliminary proposal for surgical classification of sacral tumors. J Neurosurg Spine 2010; 13:651-8. [PMID: 21039159 DOI: 10.3171/2010.5.spine09443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe authors propose a new surgical classification method for sacral tumors that improves the guidance for specific surgical decisions and approaches.MethodsThe authors retrospectively studied the clinical courses of 92 patients with sacral tumors treated at the Changhai Hospital; all patients underwent tumor resection between January 2000 and August 2005. The clinical characteristics, imaging features, and pathological classifications were carefully assessed in each case. The tumors were classified according to the imaging features and intraoperative findings. The surgical approach and the resection area were determined according to the tumor classification.ResultsThe proposed surgical classification system divided the sacral tumors into 2 major types according to the lesion's anatomical position in the sagittal plane. The tumors were further divided into 4 subtypes according to the length of the tumor's anterior protrusion into the pelvic cavity. Finally, each tumor subtype was classified into 16 areas according to the anatomical position in the cross-sectional plane. This classification method was used to categorize the sacral tumors, all of which were totally resected under the naked eye. Postoperatively symptoms were improved to varying degrees.ConclusionsThe appropriate classification of sacral tumors and the selection of a corresponding surgical approach can improve the rate of total resection and the surgical safety, as well as decrease the recurrence rate.
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Affiliation(s)
- Zhiyu Zhang
- 3Department of Orthopedics, The 4th Affiliated Hospital, China Medical University, Shenyang, China
| | - Yingqi Hua
- 1Musculoskeletal Oncology Center, Shanghai 10th People's Hospital, Tongji University School of Medicine, Shanghai
- 2Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai; and
| | - Guodong Li
- 1Musculoskeletal Oncology Center, Shanghai 10th People's Hospital, Tongji University School of Medicine, Shanghai
| | - Wei Sun
- 1Musculoskeletal Oncology Center, Shanghai 10th People's Hospital, Tongji University School of Medicine, Shanghai
| | - Shuo Hu
- 2Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai; and
| | - Jian Li
- 2Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai; and
| | - Zhengdong Cai
- 1Musculoskeletal Oncology Center, Shanghai 10th People's Hospital, Tongji University School of Medicine, Shanghai
- 2Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai; and
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Cloyd JM, Acosta FL, Polley MY, Ames CP. En Bloc Resection for Primary and Metastatic Tumors of the Spine. Neurosurgery 2010; 67:435-44; discussion 444-5. [DOI: 10.1227/01.neu.0000371987.85090.ff] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
The efficacy of en bloc resection for spinal tumors is unknown because most of the current evidence is provided by small, single-institution clinical series or case reports.
OBJECTIVE
To combine all previously published reports of en bloc resection for primary and metastatic spinal tumors, to describe the overall pattern of disease-free survival, and to investigate potentially prognostic factors for recurrence.
METHODS
A complete MEDLINE search for all articles reporting survival data for en bloc resection of spinal tumors was undertaken; 44 articles met inclusion criteria from which 306 eligible patients were identified.
RESULTS
There were 229 cases of primary tumors with a mean follow-up of 65.0 months and 77 cases of solitary metastatic tumors with a mean follow-up of 26.5 months. Median time to recurrence was 113 months for the primary group and 24 months for the metastatic group. Disease-free survival rates at 1, 5, and 10 years were 92.6%, 63.2%, and 43.9%, respectively, for the primary group and 61.8%, 37.5%, and 0%, respectively, for the metastatic group; 5-year disease-free survival rates were 58.4% for chordoma and 62.9% for chondrosarcoma. After adjusting for covariates, age, male sex, metastatic tumors, and osteosarcomas were significantly associated with a tumor recurrence.
CONCLUSION
This study provides the largest published series of patients undergoing en bloc resection for spinal tumors. Median time to recurrence reached almost 10 years in patients with primary tumors; however, it was only 2 years in those with isolated metastatic tumors.
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Affiliation(s)
- Jordan M. Cloyd
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Frank L. Acosta
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Mei-Yin Polley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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