Subtotal Sacrectomy Research Articles

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 REHABILITATION Multidisciplinary 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.

VP3: Pelvic Reconstruction After Large Sacral Chordoma Resection Using Acellular Dermal Matrix and Double Pedicled Gracilis Muscle Flap Combined with Gluteal Fasciocutaneous Rotation Flap

INTRODUCTION: Sacral chordomas are rare, malignant primary bone tumors. Surgical resection with wide margins, combined or not with radiotherapy, is the only effective treatment with near 50% remission at 10 years. Surgery results in large three dimensional defects, as total or subtotal sacrectomy is often required. The treatment is challenging and requires a multidisciplinary approach. Several reconstructive approaches have been described, classically including rectus abdominis or gluteus musculocutaneus flap and omental flap. We aim at presenting an innovative method of pelvic floor reconstruction using acellular dermal matrix and double pedicled Gracilis muscle flap combined with gluteal fasciocutaneous rotation flap. MATERIALS AND METHODS: We report the case of a 70 yo patient affected by locally invasive sacral chordoma. The oncological treatment included neuronavigation-assisted subtotal sacrectomy with en bloc resection at the level of S1-S2 intervertebral disc and laparoscopic abdomino-perineal amputation with terminal colostomy. After the R0 resection was confirmed, pelvic floor was reconstructed with an acellular dermal matrix and a double-breasted pedicled muscle Gracilis flap to avoid herniation of the abdominal cavity organs. The overlying soft tissue defect was reconstructed with an unilateral gluteal fasciocutaneous rotation flap partially deepitelialized to fill the dead space. The donor sites were closed directly. RESULTS: No surgical complications were observed, with flaps and donor sites healing uneventfully. After 3 days in intermediate intensive care and 22 days in plastic surgery department, he was transferred to rehabilitation center. Walking was reassumed after 2 weeks, sitting after 4 weeks. Satisfying outcomes both functionally and cosmetically for both patient and surgeons were observed at 3 months follow-up. CONCLUSION: Large sacral defect can successfully be reconstructed with double pedicled muscle Gracilis flap combined with gluteal rotation flap. The association with acellular dermal matrix is recommended to avoid abdominal cavity organs herniation. The oncological, functional results at 3 months are satisfying with minimal donor site morbidity. Presentation Type

Subtotal Sacrectomy followed by Maximally Tolerated 3D Conformal Radiation for High-Level Chordomas with Neural Integrity: Technique and Outcome

Background data: Chordomas are the most common sacral tumors, usually treated by wide resections with free margins. Radical resections are likely followed by significant neurological deficits that may not be accepted for some patients who presented with preserved neural functions. Purpose: To present local institutional experience in the technique and outcome of subtotal sacrectomy followed by maximally tolerated radiation therapy in a cohort of patients having high sacral (S1-S2) chordomas who presented with intact neurological functions and were not previously treated. Study design: Retrospective case series. Patients and Methods: This is a retrospective case series conducted over 7 years, including 14 consecutive patients with high-level sacral chordomas who refused radical resection and underwent subtotal sacrectomy aiming to preserve as many neural structures as possible, followed by 3D conformal radiotherapy given at a maximum dose tolerated by the surrounding viscera. The surgical resection, perioperative management, including radiotherapy techniques, and their functional and oncologic outcomes were reviewed. Results: The mean age was 44.6 ± 4.7 years, and 10 cases (71.4%) were males. Patients complained of sacral pain for 2–9 months before diagnosis, and all were continent with no gross sensorimotor deficits. Resections were performed through posterior-only approaches using T-shaped or inverted U-shaped incisions. Surgeries went uneventful, with two incisions indicated for further plastic management. Negative margins were achieved in 1 case. Bladder/bowel functions were lost postoperatively in 28.6% of cases. Ten cases had disease progression at a mean duration of 62.4 ± 27.9 months. The median survival was 99 months. The 5-year absolute survival rate was 78.6% and the 5-year disease progression was 42.9%. The overall survival in this study was found to be 35.7%, with a median follow-up of 6.3 years. Conclusion: Despite the promising outcomes at 5 years, the used strategy was associated with sphincteric dysfunctions in a substantial proportion of patients and failed to achieve an adequate overall survival. We recommend radical resections for young patients to improve survival. Subtotal sacrectomy followed by 3D conformal radiation can be a valid alternative for older patients with shorter life expectancy. (2021ESJ250)

Outcome of Sacropelvic Resection and Reconstruction Based on a Novel Classification System.

Sacral tumor resections require a multidisciplinary approach to achieve a cure and a functional outcome. Currently, there is no accepted classification system that provides a means to communicate among the multidisciplinary teams in terms of approach, osseous resection, reconstruction, and acceptable functional outcome. The purpose of this study was to report the outcome of sacral tumor resection based on our classification system. In this study, 196 patients (71 female and 125 male) undergoing an oncologic en bloc sacrectomy were reviewed. The mean age (and standard deviation) was 49 ± 16 years, and the mean body mass index was 27.2 ± 6.4 kg/m. The resections included 130 sarcomas (66%). The mean follow-up was 7 ± 5 years. Resections included total sacrectomy (Type 1A: 20 patients [10%]) requiring reconstruction, subtotal sacrectomy (Type 1B: 5 patients [3%]) requiring reconstruction, subtotal sacrectomy (Type 1C: 104 patients [53%]) not requiring reconstruction, hemisacrectomy (Type 2: 29 patients [15%]), external hemipelvectomy and hemisacrectomy (Type 3: 32 patients [16%]), total sacrectomy and external hemipelvectomy (Type 4: 5 patients [3%]), and hemicorporectomy (Type 5: 1 patient [1%]). The disease-specific survival was 66% at 5 years and 52% at 10 years. Based on the classification, the 5-year disease-specific survival was 34% for Type 1A, 100% for Type 1B, 71% for Type 1C, 65% for Type 2, 57% for Type 3, 100% for Type 4, and 100% for Type 5 (p < 0.001). Tumor recurrence occurred in 67 patients, including isolated local recurrence (14 patients), isolated metastatic disease (31 patients), and combined local and metastatic disease (22 patients). At 5 years, the local recurrence-free survival was 77% and the metastasis-free survival was 68%. Complications occurred in 153 patients (78%), most commonly wound complications (95 patients [48%]). Following the procedure, 154 patients (79%) were ambulatory, and the mean Musculoskeletal Tumor Society (MSTS93) score was 60% ± 23%. Although resections of sacral malignancies are associated with complications, they can be curative in a majority of patients, with a majority of patients ambulatory with an acceptable functional outcome considering the extent of the resection. At our institution, this classification allows for communication between surgical teams and implies a surgical approach, staging, reconstruction, and potential functional outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip Arthroplasty Following Subtotal Sacrectomy for Chordoma.

Chordomas often affect the sacrum with a high predilection for local-regional recurrence. Patients typically retain their ability to ambulate, and the development of metastatic disease in the periacetabular region can have significant morbidity and pain with ambulation. The purpose of the study was to describe the outcome of patients undergoing a hip arthroplasty following resection of a sacral chordoma. From 1990 to 2015, 84 patients underwent sacrectomy for chordoma, while four of these (5%) patients underwent hip arthroplasty. The most common level of nerve root sacrifice was S2-5 (n=2). The mean time between sacrectomy and hip arthroplasty was 7 years. Indications for arthroplasty included metastatic disease (n=3) and coxarthrosis (n=1). Postoperatively two patients ambulated with a gait aid, and no patient had a Trendelenburg gait. The mean Harris Hip Score significantly improved from 49 to 80 postoperatively (p=0.02). The results of this study indicate that hip arthroplasty is a durable treatment option for patients with metastatic disease or coxarthrosis following subtotal sacrectomy for chordoma.

Marginal Resection of Sacral Chordoma through Posterior Approach: Study of 18 Cases

The study was carried out to report the results of marginal resection in sacral chordoma using a posterior midline approach. The study was carried out between July 2008 to June 2016, there were 21 patients who underwent the operation. Fourteen patients were male and seven were female and age ranging from 28 and 76 years. All most of the patients presented with pain, sacral mass and neurological deficit. Total sacrectomy and bone reconstruction were carried out in 11 patients. Subtotal sacrectomy was carried out in the remaining ten patients. Patients were followed up for at least seven years. Recovery after the operation was good. Duration of operation ranged between three to six hours. Three to five units blood was transfused in all patients after operation .Bowel and bladder dysfunction were almost all patients. After surgery following local complications including infection and wound disruption occurs in three patients and seroma occurs in two patients. Three patients (14%) had tumor recurrence and one patient expired three years after operation. 18 patients were still tumor-free at long term (seven years) follow-up. Marginal resection of sacral chordoma through posterior approachcan be a management plan for sacral chordoma with acceptable results.TAJ 2017; 30(1): 21-26

Wide local resection of sacral chordoma through posterior midline approach

This study was performed in 21 patients with sacral chordoma from July 2008 to June 2017 and posterior surgical approach was used for resection. Out of 21 patients, 12 had done subtotal sacrectomy and the remaining 9 had done partial sacrectomy. Their follow-up periods were at least five years. Operative time ranged between two to four hours. All patients recovered well from operation and two to five units of blood transfusion were needed for each. After operation, majority of the patients developed some bowel and bladder dysfunction and five patients developed wound infection. During the follow-up, two patients had tumor recurrence and one patient expired two years after operation. The remaining 18 patients were tumor-free at the 5-years follow-up. Wide surgical resection via the posterior midline approach could be a good management plan for the sacral chordoma. However, complete removal with surgical margin varies according to the location of the tumor.

Prevalence of neuropathic pain after radical sacral chordoma resection: an observational cohort study with 10-year follow-up.

This study was carried out to discover the prevalence, characteristics and severity of neuropathic pain after wide resection of chordoma of the sacrum by the use of posterior approach. Patients who had chordoma of their sacrums and underwent wide resection via posterior approach, during 1990-2002, were followed up as a prospective cohort. Pain assessment was carried out in terms of onset, characteristics, intensity (numerical rating scale), response to pain medication and associated symptoms. The correlation between patients' biographic data, preoperative neuropathic pain, type and levels of surgery and pain were analyzed. There were 21 patients; 14 male and 7 female patients. Their ages ranged between 29 and 75 years. Subtotal sacrectomy was carried out in 9 patients and total sacrectomy was carried out in 12 patients. All patients survived the operation. Neuropathic pain was found in 11 patients (52.4%). Male patients and presentation of preoperative neuropathic pain were significantly related to postoperative neuropathic pain. The other factors were not related to the postoperative pain. Recurrent of severe pain with different characteristics after the operation might indicate tumor recurrent. Early detection of the pain and proper treatment could minimize pain intensity and improved pain management satisfaction.

Wide resection of sacral chordoma via a posterior approach

The study was carried out to report the results of wide resection in sacral chordoma using a posterior approach and gauze packing technique. The study was carried out between 1990 and 2002; there were 21 patients who underwent the operation. Fourteen patients were male and seven were female. Their ages ranged between 29 and 75 years. Most of the patients presented with sacral mass, pain and neurological deficit. Total sacrectomy and bone reconstruction were carried out in 12 patients. Subtotal sacrectomy was carried out in the remaining nine patients. All patients were followed up for at least seven years. All survived after the operation. Operative time ranged between five and ten hours. All patients needed blood transfusion which ranged between four and 11 units. After the operation, all patients had a certain degree of bowel and bladder dysfunction. Five patients had local complications including infection in three patients with wound disruption and two patients with a seroma. During the follow-up, three patients (14%) had tumour recurrence and one of the patients expired. The remaining 18 patients were still tumour-free at the seven-year follow-up. Wide resection via the posterior approach and gauze packing technique could be used for management of sacral chordoma with acceptable results.

Giant cell tumour of the sacrum: a suggested algorithm for treatment

To investigate the outcome of our management of patients with giant cell tumour of the sacrum and draw lessons from this. A retrospective review of medical records and scans for all patients treated at our unit over the past 20 years with a giant cell tumour of the sacrum. Of the 517 patients treated at our unit for giant cell tumour over the past 20 years, only 9 (1.7%) had a giant cell tumour in the sacrum. Six were female, three male with a mean age of 34 (range 15-52). All, but two tumours involved the entire sacrum and there was only one purely distal to S3. The mean size was 10 cm and the most common symptom was back or buttock pain. Five had abnormal neurology at diagnosis, but only one presented with cauda equina syndrome. The first four patients were treated by curettage alone, but two patients had intraoperative cardiac arrests and although both survived all subsequent curettages were preceded by embolisation of the feeding vessels. Of the seven patients who had curettage, three developed local recurrence, but all were controlled with a combination of further embolisation, surgery or radiotherapy. One patient elected for treatment with radiotherapy and another had excision of the tumour distal to S3. All the patients are alive and only two patients have worse neurology than at presentation, one being impotent and one with stress incontinence. Three patients required spinopelvic fusion for sacral collapse. All patients are mobile and active at a follow-up between 2 and 21 years. Giant cell tumour of the sacrum can be controlled with conservative surgery rather than subtotal sacrectomy. The excision of small distal tumours is the preferred option, but for larger and more extensive tumours conservative management may well avoid morbidity whilst still controlling the tumour. Embolisation and curettage are the preferred first option with radiotherapy as a possible adjunct. Spinopelvic fusion may be needed when the sacrum collapses.

Biomechanical evaluation of lumbosacral reconstruction after subtotal sacrectomy: A three-dimensional finite element analysis

Objective The aim of this study was to investigate the biomechanical property of lumbosacral reconstruction after subtotal sacrectomy.

One-Staged Subtotal Sacrectomy for Primary Sacral Tumor

Sacrectomy with adequate margins is challenging because of the complexity of the surgical approach and morbidities. Two-staged sequential approach, therefore, has been advocated. This study was designed to demonstrate the modification of this technique. This is a case presentation of a 45-year-old man with chordoma involving the lower border of S2, who underwent one-staged subtotal sacrectomy. The technique involved the following: midline incision, mobilization of the rectum, construction of a colostomy and the modified Hartmann stump with intact superior rectal vessels, ligation of internal iliac arteries, ligation of all branches connecting to external iliac veins resulting in "complete isolation" of the external iliac veins, dissection of presacral tissue, anterior osteotomy at the S1-S2 junction and the sacroiliac joints, and abdominal closure. The posterior approach involved a three-limbed incision, dissection of the gluteus muscle and ligaments from the sacrum, subperiosteal dissection, S1 laminectomy, posterior osteotomy corresponding with the anterior osteotomy line with preservation of S1 nerves, division of S2-S4 nerves from sciatic nerves, and specimen removal. Closure of the large sacral defect was undertaken using the Hartmann stump and bilateral gluteus maximus flaps. En bloc resection with free margins without tumor rupture was accomplished. Operative time was 12 hours. Blood transfusion was 6 units. This patient had a good recovery without complications. He was able to ambulate within 1 week and walk normally within 1 month. No recurrence was found at a 24-month-follow-up. One-staged sacrectomy can be safely performed, obtaining the satisfactory outcomes.

Sacrectomy for Primary Sacral Tumors

En bloc resection with adequate margins has provided a chance for cure of primary sacral tumors. However, high sacral lesions are challenging because of the complexity of the surgical approach. The aims of this study were to describe a modification in technique and to evaluate the outcomes. This is a study of eight sacrectomies performed at King Chulalongkorn Memorial Hospital between February 2000 and July 2007. Cadaveric dissections were carried out prior to surgery. We have modified the technique by ligation of the branches of the external iliac veins, resulting in "isolation" of the external iliac veins. Spinopelvic reconstruction was performed for total and extended total sacrectomy. Closure of the sacral defect was done with use of the Hartmann stump and the gluteus maximus flaps. Two total sacrectomies, one extended total sacrectomy, and five subtotal S1 sacrectomies were performed. En bloc resection with adequate margins was achieved in all patients. The patient who underwent extended total sacrectomy and one patient who underwent total sacrectomy had nonunion requiring removal of the spinopelvic instrumentation. Five patients who underwent subtotal sacrectomy were ambulating well postoperatively, except for one who had an S1 fracture after falling. No sacral hernias were observed. None of the patients developed recurrence of the primary tumor. Mean follow-up time was four years. Sacrectomy for primary sacral tumors can be safely conducted, achieving tumor-free margins and acceptable functional and long-term outcomes.

Surgical treatment of primary tumors of the sacrum.

Twenty-two patients with primary tumors of the sacrum were surgically treated between 1983 and 1997. Seventeen male and 5 female patients were followed up for a mean of 53.6 months (range 12-203 months). The histopathologic diagnoses were giant cell tumor (GCT) in 7 patients, chordoma in 4 patients, aneurysmal bone tumor in 3 patients, chondrosarcoma in 2 patients, osteoblastoma in 2 patients, synovial sarcoma in 2 patients, Ewing's sarcoma in 1 patient, and simple bone cyst in 1 patient. Currettage and thermo- or chemocauterization was applied to 8 patients, a subtotal sacrectomy was done in 11 patients, and total sacrectomy and lumbopelvic stabilization was done in 3 patients. The surgical margins were wide in all patients with GCT. The surgical margins were wide in 3 patients and wide contaminated in 1 patient with chordoma. The 2 patients with chondrosarcoma had high sacral lesions and were managed with total sacrectomy and lumbopelvic fixation. The surgical margin was wide in 1 patient and wide contaminated in the other, who relapsed locally and systemically in the 30th postoperative month. Three patients with aggressive aneurysmal bone cyst and 1 patient with simple bone cyst were managed by curettage and thorough debridement. One patient with low sacral Ewing sarcoma was managed by subtotal sacrectomy with wide margins. The two osteoblastomas were localized to the posterior elements of the sacrum. None of the patients relapsed. Most of the tumors of the sacrum are benign aggressive lesions or low grade malignancies. Intralesional resections in the form of curettage, with the addition of chemo- or thermocauterization, provide a complete cure for benign lesions. In contrast, wide resections are necessary for complete disease control in radio- and chemoresistant malignancies. Nerve root dissection should be performed in order to achieve wide margins.

仙骨亜全摘術を施行した有きょく細胞癌

We performed subtotal sacrectomy for squamous cell carcinoma on the sacral area of a 48-year-old man suffering paralysis of lower extremities for 28 years. Although the resection of the total mass of carcinoma including most part of sacrum (S2-5) was successfully performed, the patient suffered from protracted bacterial infection of the pelvic cavity and osteomyelitis of iliac bone. He died of respiratory failure due to distant metastasis of the tumor to the lung 248 days after surgery. [Skin Cancer (Japan) 2001; 16: 265-2691]