Surgical treatment of primary malignant tumors of the sacrum

Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor

BACKGROUND

The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome.

METHODS

A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups.

RESULTS

Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001).

CONCLUSIONS

This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.

A feasibility study into the use of the tilt table in the early postoperative rehabilitation of patients undergoing sacrectomy surgery with plastic reconstruction within the Orthopaedic Oncology Service

PURPOSE

Standard post-operative care following sacrectomy requiring plastic surgical reconstruction limits hip flexion and avoids wound pressure. Extended bed rest adversely affects patient function, strength and range of movement. This feasibility study assessed whether early postoperative use of the tilt table was possible and promoted faster mobilisation.

METHODS

Data from 10 patients were collected; five from a "standard tilt table group" and five from an "early tilt table group". Number of days post-operatively patients stood, walked, and were discharged was recorded.

RESULTS

Patients had undergone partial or sub-total sacrectomy with wound closure using a variety of plastic surgical techniques. The "early tilt table" group started on the tilt table at 4.8 ± 2.8 days whereas the "standard tilt table" group started at 13 ± 5.1 days (p = 0.01*). Patients in the "early tilt table group" walked significantly earlier [10.6 ± 2.7*] than the standard group (28 ± 13) (p = 0.02*). LOS in the "early" group was 37.11 ± 11.9 days compared to 58.2 ± 21.8 days in the standard group (p = 0.10). No difference in complications between the groups.

CONCLUSIONS

Early tilt table use after sacrectomy was safe and enabled a faster achievement of functional goals, thereby reducing LOS. This highlights the need for further evaluation of rehabilitation practice for this group of patients.IMPLICATIONS FOR REHABILITATIONMultidisciplinary discussion between the plastic surgeon, the tissue viability nurse and the physiotherapist about post-operative precautions and their impact on rehabilitation is essential and may enable earlier use of the tilt table.Early use of the tilt table can enable quicker mobilisation leading to the faster achievement of functional milestones and potentially a reduced length of stay (LOS) without detriment to patient outcomes/complications.The early use of the tilt table can support the central goal of surgery of enabling independence, especially as with such extensive surgery there is a big risk of institutionalisation and prolonged disability.There are potential mental health benefits to earlier mobilisation; however, this needs further investigation.

Complication Pattern of Sacral Primary Tumor Resection: A Study on the Risk Factors of Surgical Site Infection and Bowel or Bladder Dysfunction and Their Associations with Length of Hospital Stay

STUDY DESIGN

Retrospective open cohort study.

PURPOSE

The current study aimed to explore the pattern of complications after primary sacral tumor resection, to investigate the possible effect of several perioperative parameters on the development of complications, and to identify which complications are associated with the length of hospital stay (LOS).

OVERVIEW OF LITERATURE

Primary sacral tumor (pST) resection is associated with a high complication rate. However, the number of studies on these complications and their effect on LOS is limited.

METHODS

The clinical data of 140 patients with pST surgeries and 106 subsequent patients with local recurrence surgeries in four subgroups (index surgery, local recurrence surgery, malignant, and benign tumor) were prospectively collected and analyzed. The prognostic value of several perioperative factors on the development of surgical site infection (SSI), bowel and bladder dysfunction (BBD), and LOS was investigated using the logistic and linear regression models.

RESULTS

The overall complication rates were 61.2% after index surgeries and 50.9% after local recurrence surgeries. The most frequent complications were SSI, vegetative dysfunction, urinary tract infections, and neurological deterioration. Age >55 years, malignant tumors, and red blood cell transfusion had a predictive effect on the development of SSI in the logistic model (p<0.01, R2=0.43). Bilateral S2 or S3 resection commonly caused postoperative BBD (chi-square test=62.5, degrees of freedom=4, p<0.001). In the multiple linear regression model, wound dehiscence, BBD, systemic and urinary tract infection, cerebrospinal fluid leak, and neurologic deterioration were associated with a significantly long LOS (p<0.01, R2=0.62).

CONCLUSIONS

Surgical resection of pSTs has a high complication rate. Its common complications are SSI and BBD, both of which can have a significant influence on global therapeutic outcome. Malignant tumor diagnosis, old age, and red blood cell transfusion can remarkably increase the risk of SSI. Further, the development of BBD is significantly associated with the number of resected sacral nerve roots. By decreasing perioperative complications, LOS can decrease significantly.

Safety and effectiveness of a posterior approach alone for surgical treatment of sacral-presacral tumors

Aim

We aimed to examine the safety and effectiveness of a posterior approach alone in the surgical treatment of sacral-presacral tumors. In addition, we investigate factors that determine the selection of a posterior approach alone.

Materials and Methods

Patients with sacral-presacral tumors who underwent surgery in our institution between 2007 and 2019 were examined in this study. Data regarding patient age, gender, tumor size (>6 cm and <6 cm), tumor localization (below or above S1), tumor pathology (benign or malignant), surgical approach (anterior alone, posterior alone, or combined), and extent of resection were recorded. The Spearman's correlation analyses were conducted between surgical approach and tumor size, localization, and pathology. Factors influencing the extent of resection were also examined.

Results

Complete tumor resection was achieved in 18 of 20 patients. A posterior approach alone was used in 16. No strong or significant relation was detected between surgical approach and tumor size (r = 0.218; P = 0.355). There was no strong or significant relationship between surgical approach and tumor localization (r = 0.145; P = 0.541) or tumor pathology (r = 0.250; P = 0.288). Tumor size, localization, and pathology were not independent factors that determined surgical approach. The only significant independent determining factor for incomplete resection was tumor pathology (r = 0.688; P = 0.001).

Conclusion

A posterior approach is safe and effective in the surgical treatment of sacral-presacral tumors independent of tumor localization, size, or pathology and is a feasible first-line treatment option.

Association between intraoperative fluid overload and postoperative debridement in major sacrum tumor resection: A propensity score matching study

Intra-aortic balloon occlusion (IABO) is used to reduce intraoperative bleeding and facilitate successful sacrum tumor resection. Up to 20% of patients experience postoperative wound healing problems, but the risk factors related to this complication have not been clearly defined. The anesthetic database of Peking University People's Hospital, Beijing, China, was searched for all patients (aged 14-70 years old) who underwent sacrum tumor surgery with the application of IABO from 2014 to 2017. Data from 278 patients with an aortic occlusion duration of 72 ± 33 minutes were collected. Fifty-six patients required postoperative debridement because of wound infection. The independent risk factor identified by logistic regression was fluid excess (calculated as volume infused minus blood loss and urine output divided by body weight [kg]), and decision tree analysis revealed that the cutoff point for fluid excess was 38.5 mL/kg. Then patients were then divided into high fluid excess group (fluid excess > 38.5 mL/kg) and low fluid excess group (fluid excess ≤ 38.5 mL/kg) and 91 pairs of patients were generated through propensity score matching (PSM). Fluid excess was significantly higher in the high fluid excess group (46 vs 30 mL/kg, P < .001), and more patients required postoperative debridement than in the low fluid excess group (24 (26.3%) vs 12 (13.1%), P < .001). In this retrospective PSM study on sacrum tumor resection, fluid overload was related to postoperative debridement and further studies are needed to improve the clinical prognosis.

Complications in spinal tumor surgery (review of literature)

Combined anterior and posterior approaches are required in spinal tumor surgery and considered highly invasive. Anatomical and physiological features of the surgical intervention area should be taken into consideration as well. Thus, these criteria reflect the severity of intraoperative complications during the surgical treatment of spinal tumors. The authors reviewed the scientific literature on the frequency and nature of complications in surgical interventions for spinal tumors.The most significant risk factors for intraoperative complications have been considered, the main of which are: the proximity of the location of the main vessels and viscera, the development of postoperative liquorrhea, as well as surgical site infection. Based on the studied information, we presented the methods of prevention and surgical tactics options in complications.

Multidisciplinary Management of Primary Sacral Tumors: A Tertiary Care Center's Experience and Literature Review

Sacral tumors are rare and can be benign or malignant. Their management is multifactorial and is based on the pathology, extent, and local and distant spread. Managing sacral tumors is challenging due to their proximity to visceral and neural structures. Surgical wide excision has been the standard of care for aggressive benign and malignant tumors. Our purpose was to evaluate the outcomes of a multimodal approach to managing primary sacral tumors in Sakra World Hospital, a tertiary spine care center in Bengaluru, India and perform a literature review to determine a workflow pathway. Our study was a retrospective review of patient records and included 15 patients with primary sacral tumors. Eleven surgically treated patients were evaluated clinically and radiologically and underwent biopsy before surgical excision by an all-posterior approach. A multidisciplinary approach that included intraoperative neural monitoring, plastic reconstruction, adjuvant chemotherapy, and radiotherapy was implemented whenever necessary. Sacral root preservation was attempted whenever feasible. Functional outcomes (based on the Visual Analog Scale [VAS] and Biagini scoring system) were analyzed along with disease control, with a minimum of 2 years of follow-up. The mean follow-up was 29±9.8 months. The mean VAS score significantly improved from 7.8±2.6 to 3.7±3.8 (p=0.026). Bowel function showed statistically significant improvement, from a mean score of 0.81±0.47 to 0.63±0.52 (p=0.026) at 2 years of follow-up. The mean pretreatment motor and bladder function scores were 0.53±0.31 and 0.74±0.44, respectively, improving to 0.48±0.33 and 0.68±0.56 at follow-up but without statistical significance. There was no significant loss of function, which is expected in radical sacral resections. In conclusion, primary sacral tumors require a multidisciplinary approach and management for optimal outcomes. A stand-alone posterior approach can be employed to treat most sacral lesions. En-bloc wide resection is the optimal treatment for primary malignant and aggressive benign tumors. Preservation of at least one functional S2 nerve root is imperative to preserve bowel and bladder function.

COMPLICATIONS AFTER PARTIAL, TOTAL OR EXTENDED SACRECTOMY: A CASE SERIES

ABSTRACT Objective The aim of this study was to conduct a survey of the different complications of partial, total or extended sacrectomy for the treatment of spinal tumors. Method This study is a descriptive analysis of medical records from a series of 18 patients who underwent sacrectomy between 2010 and 2019 at a tertiary center specializing in spinal tumor surgeries. The variables analyzed were sex, age, hospitalization time, oncologic diagnosis, posterior fixation pattern, rate of complications, and Frankel, ASA and ECOG scales. Results Of the 18 patients, 10 (55.5%) were male and 8 (44.5%) were female, and the mean age was 48 years. The mean hospitalization time was 23 days. Of the 18 patients, 8 (44.5%) contracted postoperative infections requiring surgery. Perioperative complications included liquoric fistula (22.25%), hemodynamic instability requiring vasoactive drugs in the immediate postoperative period (22.25%), wound dehiscence (11.1%), acute obstructive abdomen (11.1%), occlusion of the left external iliac artery (11.1%), immediate postoperative death due to acute myocardial infarction (11.1%), and intraoperative death due to hemodynamic instability (11.1%). Conclusions Partial, total or extended sacrectomy is a complex procedure with high morbidity and mortality, even in centers specializing in the treatment of spinal tumors. Level of evidence IV; case series study.

Impact of Multidisciplinary Intraoperative Teams on Thirty-Day Complications After Sacral Tumor Resection

OBJECTIVE

To evaluate the impact of multidisciplinary intraoperative teams on surgical complications in patients undergoing sacral tumor resection.

METHODS

We reviewed all patients with primary or metastatic sacral tumors managed at a single comprehensive cancer center over a 7-year period. Perioperative complication rates were compared between those treated by an unassisted spinal oncologist and those treated with the assistance of at least 1 other surgical specialty. Statistical analysis involved univariable and stepwise multivariable logistic regression models to identify predictors of multidisciplinary management and 30-day complications.

RESULTS

A total of 107 patients underwent 132 operations for sacral tumors; 92 operations involved multidisciplinary teams, including 54% of metastatic tumor operations and 74% of primary tumor operations. Patients receiving multidisciplinary management had higher body mass indexes (29.8 vs. 26.3 kg/m²; P = 0.008), larger tumors (258 vs. 55 cm³; P < 0.001), and higher American Society of Anesthesiologists scores (3 vs. 2; P = 0.049). Only larger tumor volume (odds ratio [OR], 1.007 per cm³; P < 0.001) and undergoing treatment for a malignant primary versus a metastatic tumor (OR, 23.4; P < 0.001) or benign primary tumor (OR, 29.3; P < 0.001) were predictive of multidisciplinary management. Although operations involving multidisciplinary teams were longer (467 vs. 231 minutes; P < 0.001) and had higher blood loss (1698 vs. 774 mL; P = 0.004), 30-day complication rates were similar (37 vs. 27%; P = 0.39). On multivariable analysis, only larger tumor volume (OR, 1.004 per cm³; P = 0.005) and longer surgical duration (OR, 1.002 per minute; P = 0.03) independently predicted higher 30-day complications.

CONCLUSIONS

Although patients managed with multidisciplinary teams had larger tumors and worse baseline health, 30-day complications were similar. This finding suggests that the use of multidisciplinary teams may help to mitigate surgical morbidity in those with high baseline risk.

Free Vascularized Fibula Flap Reconstruction of Total and Near-total Destabilizing Resections of the Sacrum

BACKGROUND

Vascularized bone grafts (VBGs) are associated with improved union and fewer instrumentation complications in the mobile spine. It is not known if VBGs are similarly efficacious after sacrectomy.

METHODS

We conducted a retrospective chart review of all patients who underwent total sacrectomy and immediate reconstruction with VBG between 2005 and 2019. Patient and surgical characteristics in addition to union and functional outcomes were analyzed.

RESULTS

We identified 10 patients (6 women and 4 men) with a mean age of 42 years (range, 12-71 years). All patients received iliolumbar instrumentation as well as a free fibula flap as a VBG. There were no complications at the fibula flap donor site or specifically related to the VBG. Bony union was achieved in 7 (88%) of 8 patients with an average union time of 6.3 months (range, 2-10 months). Surgical complications occurred in 5 patients, 4 patients required reoperation for wound dehiscence, and 1 patient required conversion to a 4-rod construct and bone grafting for instrumentation loosening and partial nonunion. Instrumentation failure developed in 1 patient, but no surgical intervention was required. One patient was able to walk independently without any limitation, 5 patients required a walker, 2 were wheelchair-bound except for short (<15 ft) distances, and 2 were lost to follow-up.

CONCLUSIONS

The free vascularized fibula flap is a safe and effective option for supplementing spinal reconstruction after destabilizing sacrectomy.

Clinical manifestations, classification, and surgical management of sacral tumors and the need for personalized approach to sacrectomy

Background:

Although comprising 7% of all spinal tumors, sacral tumors present with a litany of issues due to their slow growth and difficulty in detection. As a result, sacral tumors can grow unperturbed for years until a patient presents for an incidental workup of an unassociated minor trauma or an offending primary tumor source that has metastasized to the sacrum; in most cases, this includes primary tumors of the breast, prostate, and lung. The goal of this review is to outline the pathophysiology underlying sacral tumors including the various tissues and structures that can be targeted for treatment, along with a discussion of the surgical approach to sacrectomy.

Methods:

An extensive review of the published literature was conducted through PubMed database with articles simultaneously containing both search terms “sacral tumors” and “sacrectomy.” No date restrictions were used.

Results:

The search yielded 245 related articles. Cross-checking of articles was conducted to exclude of duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic.

Conclusion:

Once a sacral tumor has reached the point of diagnostic detection, invasive sacrectomy is typically utilized (through an anterior, posterior, or combination approach) to locally isolate and resect the tumor and minimize risk of future tumor growth and additional bone loss. While institutions have varying criteria for surgical approaches, a combination of anterior and posterior approach has traditionally been used in total and high sacrectomies due to the control it provides surgeons toward the rectum and vasculature anterior to the sacrum. A posterior-only approach can be performed for tumors that failed to invade pelvic organs or extend past the lumbosacral junction. Early detection with screenings can help avoid invasive sacrectomy by identifying the onset of tumor formation in the sacrum, particularly for highly metastatic cancers.

Dorsal approach with tailored partial sacrectomy and gluteal V-Y fasciocutaneous advancement flap for the management of recurrent pelvic sepsis; case report

Background

Pelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue.

Case presentations

Three male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity.

Conclusion

The dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.

Total sacrectomy with a combined antero-posterior surgical approach for malignant sacral tumours

Purpose

To investigate the indications, approaches, resection methods, and complications of total sacrectomy with a combined antero-posterior approach for malignant sacral tumours.

Methods

Fourteen cases of primary malignant sacral tumours treated with total sacrectomy between January 2012 and 2018 were retrospectively analysed. All patients presented with pre-operative lumbosacral pain or constipation. A combined antero-posterior approach was used for tumour resection, and the spinal pedicle screw rod system was used to achieve ilio-lumbar stability. The visual analogue scale (VAS) and Musculoskeletal Tumor Society (MSTS) scores were used to assess pain and lower limb function, respectively. The mean operative time and intra-operative blood loss were 6.54 hours and 2935 mL, respectively. The mean follow-up period was 62 months.

Results

None of the patients died peri-operatively. At the last follow-up, ten patients were continuously disease-free, three were alive with disease, and one died of disease from lung metastasis. Tumour recurrence occurred in three patients. The MSTS scores ranged from 6 to 28 (20.00–93.33%, 6/30–28/30) with an average of 20 (66.67%, 20/30). Seven patients could walk independently in public, five could only walk at home using a walking aid, and two could only lie down and stand for a short time. Thirteen patients developed post-operative complications such as skin necrosis, screw loosening, connecting rod fracture, neuropathic pain, sciatic nerve injury, dysuria, and urinary incontinence.

Conclusion

Total sacrectomy can effectively treat malignant sacral tumours with good resection boundaries and prognosis. However, the high incidence of post-operative complications may impact post-operative neurological function.

Surgical Treatment of Sacral Chordoma: The Role of Laparoscopy

Sacral chordoma is a rare tumour that represents the most common malignancy of the sacral region. Its diagnosis can be delayed because of unclear clinical manifestation. This tumour can involve surrounding anatomical structure such as the rectum, and its surgical treatment is still challenging. We report on 3 patients with sacral chordoma. Two of them were successfully treated using a laparoscopic approach and one by open surgery. We present all details of the surgical technique and patients' outcome. Minimally invasive methods in the surgical treatment of chordoma allow to perform a radical dissection of the tumour, minimizing the operative trauma. A laparoscopic approach can be considered safe and radical for sacral chordoma treatment.

Preliminary investigation of bilateral internal iliac artery ligation and anterior tumor separation through laparoscopy before posterior resection of a giant sacral tumor

BACKGROUND

Surgical is the optimal therapeutic strategy for sacral tumors, and complete resection can effectively improve the recurrence and survival rates. However, the specialized anatomy, massive bleeding and adhesion to the anterior tissue, especially that caused by giant sacral tumors, makes complete resection difficult. The laparoscopic technique provides a new method to resect sacral tumors.

METHODS

34 patients with primary giant sacral tumors who underwent surgical resection were enrolled. After bilateral internal iliac artery ligation and anterior laparoscopic tumor separation, the sacral tumors were successfully resected posteriorly. The clinical, radiological and follow-up data were collected and analyzed.

RESULTS

The average operative time was 276.47 min and that for laparoscopy was 76.24 min. The average intraoperative blood loss was 1757.64 ml. No complications associated with laparoscopic surgery, such as intestinal, urinary tract, or vascular injuries, occurred. Ten patients (29.41%) had perioperative complications, including infection, unhealed wounds, and cerebrospinal fluid leaks in 10, 5 and 2 patients, respectively. Patients with complications had significantly longer total (55.00 ± 34.53 vs 25.13 ± 14.60, P = 0.001) and postoperative (39.10 ± 30.61 vs 14.83 ± 10.00, P = 0.002) hospitalization stays than patients without complications. Postoperatively, bowel and bladder dysfunction, intestinal obstruction, pain, and perianal numbness occurred in 21, 5, 8, and 2 patients, respectively. The recurrence rate was 11.76%.

CONCLUSIONS

Laparoscopically assisted sacral tumor resection is a technically feasible and effective surgical method to resect giant sacral tumors, with the advantages of reduced operative blood loss during internal iliac artery ligation and anterior tumor separation.

International consensus recommendations for target volume delineation specific to sacral metastases and spinal stereotactic body radiation therapy (SBRT)

BACKGROUND AND PURPOSE

To interrogate inter-observer variability in gross tumour volume (GTV) and clinical target volume (CTV) delineation specific to the treatment of sacral metastases with spinal stereotactic body radiation therapy (SBRT) and develop CTV consensus contouring recommendations.

MATERIALS AND METHODS

Nine specialists with spinal SBRT expertise representing 9 international centres independently contoured the GTV and CTV for 10 clinical cases of metastatic disease within the sacrum. Agreement between physicians was calculated with an expectation minimisation algorithm using simultaneous truth and performance level estimation (STAPLE) and with kappa statistics. Optimised confidence level consensus contours were obtained using a voxel-wise maximum likelihood approach and the STAPLE contours for GTV and CTV were based on an 80% confidence level.

RESULTS

Mean GTV STAPLE agreement sensitivity and specificity was 0.70 (range, 0.54-0.87) and 1.00, respectively, and 0.55 (range, 0.44-0.64) and 1.00 for the CTV, respectively. Mean GTV and CTV kappa agreement was 0.73 (range, 0.59-0.83) and 0.59 (range, 0.41-0.70), respectively. Optimised confidence level consensus contours were identified by STAPLE analysis. Consensus recommendations for the CTV include treating the entire segment containing the disease in addition to the immediate adjacent bony anatomic segment at risk of microscopic extension.

CONCLUSION

Consensus recommendations for CTV target delineation specific to sacral metastases treated with SBRT were established using expert contours. This is a critical first step to achieving standardisation of target delineation practice in the sacrum and will serve as a baseline for meaningful pattern of failure analyses going forward.

Factors Associated With Spinopelvic Fixation Mechanical Failure After Total Sacrectomy

STUDY DESIGN

We retrospectively analyzed factors associated with spinopelvic mechanical failure after total sacrectomy.

OBJECTIVE

To find the rate and type of mechanical fixation failure after total sacrectomy and to identify the associated risk factors.

SUMMARY OF BACKGROUND DATA

Although rigid fixation has been achieved, mechanical failure is sometimes encountered in reconstruction after total sacrectomy. The incidence and factors associated with spinopelvic fixation mechanical failure after total sacrectomy are still not clear.

METHODS

The study comprised 63 patients who underwent spinopelvic reconstruction after total sacrectomy. The potential risk factors for fixation mechanical failure after total sacrectomy were evaluated, which included age, sex, body mass index, type of tumor (benign or malignant), and adjuvant treatment received (e.g., chemotherapy, radiation therapy). The surgery-related factors included the classification of tumor resection (en bloc or piecemeal resection) and the type of iliosacral resection. Adoption of anterior spinal column fixation (ASCF), posterior pelvic ring fixation (PPRF), four-rod technique (FRT) of spinopelvic fixation (SPF), and structural or morselized bone grafting after total sacrectomy in patients were considered reconstruction-related factors. Cox regression models were used to analyze associations between postoperative fixation failure and risk factors for all models.

RESULTS

Postoperative fixation mechanical failure occurred in 25% of patients (16/63) who underwent total sacrectomy. Univariate analysis showed that the factors associated with spinopelvic fixation mechanical failure after total sacrectomy were the non-adoption of FRT of SPF and ASCF, the adoption of Type II sacroiliac resection, and female sex, whereas multivariate analysis demonstrated similar results, except for the adoption of Type II sacroilliac resection.

CONCLUSION

FRT connection of SPF and ASCF should be adopted in reconstruction after total sacrectomy, especially in female patients.

LEVEL OF EVIDENCE

3.

Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy

BACKGROUND

Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL).

METHODS

A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit.

RESULTS

The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions.

DISCUSSION

Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri‑operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.

The challenges of providing rehabilitation for patients undergoing sacrectomy: two case reports

BACKGROUND

Sacral neoplasms often present as large masses that often require sacrectomy. Multiple sacral nerve roots may be compromised post-sacrectomy and postoperative complications may result in impaired mobility, pain, orthostasis, and neurogenic bowel and bladder.

CASE SERIES

Case 1, 58 year-old female with a sacral solitary fibrous tumor underwent a high-level sacrectomy and bilateral gluteal muscle flaps. Her rehabilitation course included management of pain, orthostasis, and neurogenic bowel and bladder. Case 2, 67 year-old male with sacral chordoma underwent high-level sacrectomy and bilateral gluteal muscle flaps. His rehabilitation course was complicated by refractory orthostatic hypotension, pain, and wound impairment, which resulted in slow rehabilitation progression and bowel and bladder training. Progression of activity in both cases was limited by surgical restrictions to support wound healing.

CLINICAL REHABILITATION IMPACT

Multidisciplinary efforts after a sacrectomy are vital to successful rehabilitation. Highly functional outcomes are seen, including independent bowel and bladder management and return to preoperative ambulatory status.

Robot-assisted sacral tumor resection: a preliminary study

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.

Sacral Osteoneogenesis after Complete Sacrectomy in a Patient with Ewing Sarcoma

Ewing sarcomas are the second most common primary malignant bone tumors in childhood and adolescence which rapidly metastasize. Due to improvement of treatment options in recent years, the survival rate has significantly increased. Nevertheless, lethality is still high, and neurologic symptoms are frequent. To the best of our knowledge, this is the first reported case of a sacral osteoneogenesis after complete sacrectomy in a patient with Ewing sarcoma.

Soft Tissue and Bone Defect Management in Total Sacrectomy for Primary Sacral Tumors: A Systematic Review With Expert Recommendations

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.

Gelfoam embolization or 125I seed implantation may be a more effective treatment than surgical treatment for giant benign sacral neurogenic tumors

Background

The goal of the present study was to assess the effects of computed tomography (CT)-guided iodine-125 (¹²⁵I) seed implantation or gelatin sponge particle (GSP) embolization on patients with giant benign sacral neurogenic tumors.

Methods

A total of 24 cases with giant sacral neurogenic tumor were performed in a retrospective study between 2000 and 2012. Nineteen cases received surgical resection, and five cases received non-surgical treatment. In surgical group, patients with type III sacral tumor had received a combined anterior-posterior approach and patients with type IV were treated with simple anterior approach. In non-surgical group, CT-guided ¹²⁵I seed implantation or GSP embolization was applied to occlude vessels. Besides, CT scanning or magnetic resonance imaging was used to assess the size and development of tumors.

Results

Two of the five patients were treated three times with GSP embolization, one had received GSP embolization combined with CT-guided ¹²⁵I seed implantation, one case did not receive any treatment, and one patient was lost to follow-up. Patients in non-surgical group were followed up for 2–8 years.

Conclusions

Our study suggested that CT-guided ¹²⁵I seed implantation or GSP embolization treatment is very useful to slow down the development of giant benign sacral neurogenic tumors.

Surgical treatment of sacral chordoma: prognostic variables for local recurrence and overall survival

PURPOSE

Sacral chordomas (SC) are rare, locally invasive, malignant neoplasms. Despite surgical resection and adjuvant therapies, local recurrence (LR) is common and overall survival (OS) is poor. The objective of this study was to identify prognostic factors that have an impact on the local recurrence-free survival (LRFS) and OS of patients with SC.

METHODS

Utilizing the AOSpine Knowledge Forum Tumor multicenter ambispective database, surgically treated SC cases were identified. Cox regression modeling was used to assess the effect of several clinically relevant variables on OS and LRFS.

RESULTS

A total of 167 patients with surgically treated SC were identified. The male/female ratio was 98/69 with a mean age of 57 ± 15 years at the time of surgery. The LR was 35% (n = 57), death occurred in 30% of patients (n = 50) during the study period. The median OS was 6 years post-surgery and LRFS was 4 years. In the univariate analysis, previous tumor surgery at the same site (P = 0.002), intralesional resection (P < 0.001), and larger tumor volume (P = 0.030) were significantly associated with LR. Increasing age (P < 0.001) and a preoperative motor deficit of C or D (P = 0.003) were significantly associated with poor OS, and nerve root sacrifice showed a trend towards significance (P = 0.088). In the multivariate models, previous surgery and intralesional resection were significantly related to LR, while increasing age and motor deficit of C or D were associated with poor OS.

CONCLUSIONS

This study identified two predictive variables for LRFS (previous tumor surgery and type of surgical resection) and two for OS (age and impaired motor function) in surgically treated SC patients. Our results indicate that en bloc resection reduces LR but does not influence OS. However, this was likely due to short follow-up (3.2 years).