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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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Sun W, Ma XJ, Zhang F, Miao WL, Wang CR, Cai ZD. Surgical Treatment of Sacral Neurogenic Tumor: A 10-year Experience with 64 Cases. Orthop Surg 2017; 8:162-70. [PMID: 27384724 DOI: 10.1111/os.12245] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/07/2016] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To explore the outcomes of surgical treatment of sacral neurogenic tumors METHODS Between 1 January 2003 and 31 December 2012, data on 64 patients with sacral neurogenic tumors treated with surgery were retrospectively analyzed. The mean age of the 64 cases (35 males and 29 females) was 37.2 years (range, 21-69 years); 38 had neurilemmomas and 26 neurofibromas. Thirty-four of the tumors involved S 1 and S 2 , 11 S 3 or lower, and 19 were single presacral soft tissue masses. Tumors were removed via anterior, posterior or combined anteroposterior approaches. Patients with unstable sacroiliac joints underwent iliolumbar fixation. RESULTS Depending on the extent of tumor involvement, one of three surgical approaches was used: a single anterior approach (19 patients), single posterior approach (25 patients), or a combined anteroposterior approach (20 patients). The mean operation time was 3 h (range, 2-6 h) and the mean blood loss 878 mL (range, 400-3120 mL). The mean duration of follow-up was 58.2 months (range, 24-93 months). These surgeries had the following complications. Three patients had massive intraoperative hemorrhage and posterior back pain and discomfort postoperatively. One patient had intraoperative ureteral injuries requiring intraoperative ureteral catheterization. In two patients, the tumor involved the S 1 nerve roots bilaterally, necessitating their removal, which resulted in obvious lower limb motion and sphincteric dysfunction. In 13 patients with unilateral tumor involvement of the nerve roots of S 1 and lower spinal levels, only the contralateral nerve roots of the S1 and lower levels were preserved; eight of these patients had impaired bladder and bowel function. Posterior incisions failed to heal in 10 patients, secondary wound healing occurred in nine of them and one required a gluteus maximus myocutaneous flap. Three patients developed postoperative cerebrospinal fluid leaks that were and alleviated by waist belt compression bandaging and placing them in the Trendelenburg position. Eight patients developed tumor recurrences postoperatively; pathological examination of the tissue excised in the second surgeries revealed malignant changes in the three patients with neurilemmomas. There were no intraoperative deaths. Rod fractures occurred in three of the 18 patients requiring iliolumbar reconstruction. CONCLUSIONS The clinical characteristics of sacral neurogenic tumors make them easy to diagnose. The approach to resection should be determined by the location and size of the tumor. Patients with huge tumors may lose considerable blood intraoperatively and a have higher risk rate of postoperative complications.
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Affiliation(s)
- Wei Sun
- Department of Orthopaedics, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Jun Ma
- Department of Orthopaedics, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fan Zhang
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Shanghai, China
| | - Wei-Liang Miao
- School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chong-Ren Wang
- School of Medicine, Shanghai Tongji University, Shanghai, China
| | - Zheng-Dong Cai
- Department of Orthopaedics, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Kiatisevi P, Piyaskulkaew C, Sukunthanak B, Thanakit V, Bumrungchart S. Total sacrectomy for low-grade malignant peripheral nerve sheath tumour: a case report. J Orthop Surg (Hong Kong) 2014; 22:409-14. [PMID: 25550028 DOI: 10.1177/230949901402200328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report on a 58-year-old woman who underwent total sacrectomy and spinopelvic reconstruction for a low-grade malignant peripheral nerve sheath tumour involving the sacrum. One week later, she developed deep wound infection, and the entire spinopelvic reconstruction was removed. At the 36-month followup, the patient had no pain and was able to walk with a walking frame. There was no sign of recurrence or metastasis.
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Affiliation(s)
- Piya Kiatisevi
- Orthopedic Oncology Unit, Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
| | - Chaiwat Piyaskulkaew
- Spine Unit, Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
| | - Bhasanan Sukunthanak
- Orthopaedic Oncology Unit, Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand
| | - Voranuch Thanakit
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Colibaseanu DT, Dozois EJ, Mathis KL, Rose PS, Ugarte MLM, Abdelsattar ZM, Williams MD, Larson DW. Extended sacropelvic resection for locally recurrent rectal cancer: can it be done safely and with good oncologic outcomes? Dis Colon Rectum 2014; 57:47-55. [PMID: 24316945 DOI: 10.1097/dcr.0000000000000015] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A multimodality approach to patients with locally recurrent rectal cancer that includes surgery is associated with a significant survival advantage when tumor-free margins are achieved. Patients with advanced tumors will require extended sacropelvic resection to optimize oncologic outcomes. OBJECTIVE The aim of this study was to assess the safety, feasibility, and oncologic outcomes of extended sacropelvic resection for locally recurrent rectal cancer at our institution. DESIGN A retrospective review identified 406 patients who had surgery for locally recurrent rectal cancer between 1997 and 2007. From this group, all patients who underwent a curative-intent sacropelvic resection were analyzed. SETTINGS This investigation was conducted at an academic tertiary referral center. PATIENTS Thirty patients (24 male) were identified. Median age was 59 years (range, 25-84). Operations were performed for a first local recurrence (n = 24), a second recurrence (n = 5) and for a third recurrence (n = 1). INTERVENTIONS Twenty-six patients underwent neoadjuvant radiation, and 20 received intraoperative radiation therapy. All patients underwent extended sacropelvic resection. MAIN OUTCOME MEASURES The primary outcomes measured were early (<30 days) and late (>30 days) surgical complications. Overall and disease-free survivals were estimated by using the Kaplan-Meier technique. RESULTS Margin-negative resection was achieved in 93%. The most proximal level of spinal transection was the fourth lumbar space, and 4 patients underwent lower extremity amputation. There was no mortality, and early morbidity was seen in 76%. Median follow-up was 2.7 years (range, 2 months to 10.8 years). Overall survival at 2 and 5 years was 86% and 46%. Disease-free survival at 2 and 5 years was 79% and 43%. LIMITATIONS This study was limited by its retrospective nature and the limited number of patients. CONCLUSIONS We found extended sacropelvic resection for locally recurrent rectal cancer to be feasible and safe with overall and disease-free survival rates in comparison with survival rates seen in patients undergoing nonsacropelvic resections for locally recurrent rectal cancer.
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Affiliation(s)
- Dorin T Colibaseanu
- 1Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 2Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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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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[Sacral gigantocellular tumor treated with total sacrectomy and spinal-pelvic fixation]. VOJNOSANIT PREGL 2011; 68:804-8. [PMID: 22046889 DOI: 10.2298/vsp1109804s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Total sacrectomy with spinal-pelvic fixation is considered to be a successful approach to the radical surgical treatment of extensive sacral tumors, however, technically very demanding, thus only rarely reported in the literature. We presented a patient with sacral gigantocellular tumor managed successfully using this method but with certain standard operative techniques improvements. CASE REPORT A 30-year old patient with a pronounced painful syndrome and sphincter disorders was confirmed to have sacral gigantocellular tumor affecting a greater part of the sacrum. Tumor resection was performed in the first act out off retroperitoneal organs (colon and blood vessels), sacroiliac joints were open by the ventral side, the L5 discus removed, the S2-S5 roots cut off. In the second act, performed three weeks later, sacrectomy was completed by the reconstruction of pelvic ring and spinal-pelvic fixation. Then, the standard technique was modified to provide additional spinal fixation. The results of the operation (duration, blood loss, postoperative deficit) were quite comparable with, and in some aspects even better than the results published in the literature. CONCLUSION Total sacrectomy with spinal-pelvic fixation can be a therapy of choice in patients with extensive sacral tumors requaring, however, the multidisciplinary approach and a considerable experience with instrumental spinal stabilization.
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Dozois E, Privitera A, Holubar S, Aldrete J, Sim F, Rose P, Walsh M, Bower T, Leibovich B, Nelson H, Larson D. High sacrectomy for locally recurrent rectal cancer: Can long-term survival be achieved? J Surg Oncol 2010; 103:105-9. [DOI: 10.1002/jso.21774] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 09/14/2010] [Indexed: 12/12/2022]
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Kazim SF, Enam SA, Hashmi I, Lakdawala RH. Polyaxial screws for lumbo-iliac fixation after sacral tumor resection: experience with a new technique for an old surgical problem. Int J Surg 2009; 7:529-33. [PMID: 19735745 DOI: 10.1016/j.ijsu.2009.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 07/18/2009] [Accepted: 08/22/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although numerous reports have been published about various methods for reconstruction after sacrectomies, there are still biomechanical and technical dilemmas that are unaddressed. This report describes the experience at authors' institution of five cases in which polyaxial pedicle screws construct has been successfully used for lumbo-iliac fixation after sacral tumor resection. METHODS Five cases of sacral tumors, two of Ewing's sarcoma and three of giant cell tumor (GCT) underwent surgical resection and then reconstruction was done with hardware using vertical rods placed alongside the spine bilaterally, transfixing monoaxial and polyaxial pedicle screws in lower lumbar levels and polyaxial screws into the ilium bilaterally. Cross links were also used to connect the two vertical members, thus enhancing biomechanical stability of the construct. Use of autologous bone grafts was relied upon to fill the gap created by sacral resection. RESULTS No instrumentation failure was noted and the continuity of the spine and pelvis was well established with the instrumentation and auto grafts. In follow up of these patients (1-3 years), no complications were seen. CONCLUSION Polyaxial pedicle screws fixation is an effective technique to transmit axial load from spine to the appendicular bone and can be used safely in patients in whom sacral integrity is compromised after surgical resection. However, the long term benefits of this technique need to be evaluated.
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Affiliation(s)
- Syed Faraz Kazim
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Newman CB, Keshavarzi S, Aryan HE. En bloc sacrectomy and reconstruction: technique modification for pelvic fixation. ACTA ACUST UNITED AC 2009; 72:752-6; discussion 756. [PMID: 19665193 DOI: 10.1016/j.surneu.2009.02.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 02/10/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND When the management of sacral tumors requires partial or complete sacrectomy, the spinopelvic apparatus must be reconstructed. This is a challenging and infrequently performed operation, and as such, many spine surgeons are unfamiliar with techniques available to carry out these procedures. CASE DESCRIPTION A 34-year-old man presented with severe low back pain, mild left ankle dorsiflexion weakness, and left S1 paresthesias. Imaging revealed a large sacral mass extending into the L5/S1 and S1/S2 neural foramina as well as the presacral visceral and vascular structures. Needle biopsy of this mass demonstrated a low-grade chondrosarcoma. A 2-stage anterior/posterior en bloc sacrectomy with a novel modification of the Galveston L-rod pelvic ring reconstruction was carried out. Our modification takes advantage of new materials and implant technology to offer another alternative in reconstruction of the spinopelvic junction. CONCLUSION Understanding the anatomy and biomechanics of the spinopelvic apparatus and the lumbosacral junction, as well as having a familiarity with the various techniques available for carrying out sacrectomy and pelvic ring reconstruction, will enable the spine surgeon to effectively manage sacral tumors.
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Affiliation(s)
- C Benjamin Newman
- Division of Neurosurgery, University of California, San Diego Medical Center, CA 92103, USA.
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Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopedics, ATTIKON General University Hospital, Athens University Medical School, Athens, Greece
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Abstract
STUDY DESIGN A case report and review of the literature. OBJECTIVES To describe the en bloc excision and postoperative outcome of an osteochondroma of the sacrum compressing the neural elements, as well as review the literature on solitary osteochondroma involving the sacrum. SUMMARY OF BACKGROUND DATA Osteochondroma is the most common primary benign bone tumor. However, this tumor rarely involves the spine and even more rarely involves the sacrum. To the best of our knowledge, en bloc excision of a solitary osteochondroma of the sacrum has not been previously reported. METHODS An 11-year-old male presented with disabling radicular pain in the right lower extremity. Radiologic studies showed a lesion occurring from the sacral lamina that was compressing the S2 nerve root. The tumor was excised en bloc through a posterior approach. The cavitary defect within the sacrum was reconstructed with crushed cancellous allograft and demineralized bone matrix putty. A literature review of solitary sacral osteochondroma was conducted of the English-based medical literature. RESULTS Histologic studies showed the tumor to be an osteochondroma. After surgery, pain was completely relieved, and neurologic function was normal. At the last follow-up, the sacroiliac joint remained intact, and there was no evidence of local recurrence. A literature review revealed 4 previous cases addressing osteochondroma of the sacrum. CONCLUSIONS Osteochondroma is a rare primary benign bone tumor that can occur in the sacrum. Local contamination and, therefore, the likelihood of local recurrence, are decreased when an en bloc, as opposed to an intralesional, excision is performed.
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Affiliation(s)
- Dino Samartzis
- Graduate Division, Harvard University, Cambridge, MA, USA
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Gallia GL, Haque R, Garonzik I, Witham TF, Khavkin YA, Wolinsky JP, Suk I, Gokaslan ZL. Spinal pelvic reconstruction after total sacrectomy for en bloc resection of a giant sacral chordoma. Technical note. J Neurosurg Spine 2006; 3:501-6. [PMID: 16381216 DOI: 10.3171/spi.2005.3.6.0501] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although radical resection prolongs the disease-free survival period, surgical management of primary sacral tumors is challenging because of their location and often large size. Moreover, in cases of lesions for which a radical resection necessitates total sacrectomy, reconstruction is required. The authors have previously described a modified Galveston technique in which a liaison between the spine and pelvis is achieved using lumbar pedicle screws and Galveston rods embedded into the ilia; additionally, a transiliac bar reestablishes the pelvic ring. Although this reconstruction technique achieves stabilization, several biomechanical limitations exist. In the present report the authors present the case of a patient who underwent spinal pelvic reconstruction after a total sacrectomy was performed to remove a giant sacral chordoma. They describe a novel spinal pelvic reconstruction technique that addresses some of the biomechanical limitations.
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Affiliation(s)
- Gary L Gallia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland 21287-7713, USA
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Min K, Espinosa N, Bode B, Exner GU. Total sacrectomy and reconstruction with structural allografts for neurofibrosarcoma of the sacrum. A case report. J Bone Joint Surg Am 2005; 87:864-9. [PMID: 15805218 DOI: 10.2106/jbjs.d.02299] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kan Min
- Department of Orthopedic Surgery, Balgrist Clinic, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland.
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Doita M, Harada T, Iguchi T, Sumi M, Sha H, Yoshiya S, Kurosaka M. Total sacrectomy and reconstruction for sacral tumors. Spine (Phila Pa 1976) 2003; 28:E296-301. [PMID: 12897508 DOI: 10.1097/01.brs.0000083230.12704.e3] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Report of three patients in whom the lumbosacral junctions were successfully restored by spinal instrumentations after total sacrectomies. OBJECTIVES To describe the surgical technique of the reconstruction of the continuity between the pelvic ring and spinal column by using a transpedicular and iliac screw system. SUMMARY OF BACKGROUND DATA Although there have been case reports about reconstruction methods after total sacrectomy, biomechanical, and technical problems still remain unresolved. METHODS Total sacrectomy was carried out in three cases: two with chordomas and one with a recurrent giant cell tumor. In the first case, reconstruction was achieved with Zielke transpedicular screw and rod system and a sacral rod. The other two patients were reconstructed using a transpedicular and iliac screw system and a sacral rod for bilateral fixation of the iliac wings. In the third patient, the vertical rods were connected to transverse rod with rod connectors. RESULTS No instrumentation failure was observed, and the continuity between the pelvic wing and spinal column was established with the instrumentation and bone grafting. Although one patient died of metastatic chordoma, the lumbosacral junction was successfully reconstructed with the instrumentation. The other two patients could stand with double crutches 13 and 2 years after surgery, respectively. CONCLUSIONS Total sacrectomy is a feasible operation for primary malignant tumors involving the entire sacrum. Reconstruction of the union between the lumbar spine and the ilia with spinal instrumentation achieves stabilization suitable for ambulation.
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Affiliation(s)
- Minoru Doita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan.
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Murakami H, Kawahara N, Tomita K, Sakamoto J, Oda J. Biomechanical evaluation of reconstructed lumbosacral spine after total sacrectomy. J Orthop Sci 2003; 7:658-64. [PMID: 12486469 DOI: 10.1007/s007760200117] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
When a sacral tumor involves the first sacral vertebra, total sacrectomy is necessary. It is mandatory to reconstruct the continuity between the spine and the pelvis after total sacrectomy. In this study, strain and stress on the instruments and the bones were evaluated for two reconstruction methods: a modified Galveston reconstruction (MGR) and a triangular frame reconstruction (TFR). Compressive loading tests were performed using polyurethane vertebral models, and a finite element model of a lumbar spine and pelvis was constructed. Then three-dimensional MGR and TFR models were reconstructed, and finite element analysis was performed to account for the stress on the bones and instruments. With MGR, excessive stress was concentrated at the spinal rod, and there was a strong possibility that the rod between the spine and the pelvis might fail. Although there was no stress concentration on the instruments with TFR, excessive stress on the iliac bone around the sacral rod was more than the yielding stress of the iliac bone. Such stress may cause loosening of the sacral rod from the iliac bone. If the patient were to stand or sit immediately after MGR or TFR, instrumentation failure or loosening might occur.
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Affiliation(s)
- Hideki Murakami
- Department of Orthopaedic Surgery, Kanazawa University, 13-1 Takaramachi, Kanazawa 920-8641, Japan
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Abstract
Total sacrectomy is a rarely used procedure to treat large sacral tumors, and postoperative rehabilitation has not been described in detail in the literature. The following case report describes the rehabilitation of a patient with a large sacral chordoma who underwent multistage surgery, including total sacrectomy. The use of a lumbar-sacral corset allowed earlier functional recovery and contributed greatly to successful pain management.
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Affiliation(s)
- Ying Guo
- Department of Symptom Control and Palliative Care, Section of Physical Medicine & Rehabilitation, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 08, Houston, TX 77030, USA
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Wuisman P, Lieshout O, van Dijk M, van Diest P. Reconstruction after total en bloc sacrectomy for osteosarcoma using a custom-made prosthesis: a technical note. Spine (Phila Pa 1976) 2001; 26:431-9. [PMID: 11224892 DOI: 10.1097/00007632-200102150-00021] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A report of an innovative technique to restore the lumbosacral junction after resection of primary highly malignant osteosarcoma of the sacrum involving the whole sacrum, soft tissues, and adjacent posterior parts of both iliac wings. OBJECTIVES To describe the planning and design of a custom-made sacral prosthesis, the surgical technique, and clinical and functional outcome of the patient. SUMMARY OF BACKGROUND DATA Although there have been case reports about reconstruction methods after total sacrectomy, to date, there has not been a reported clinical case of successful reconstruction using an individual designed prosthesis based on a three-dimensional real-sized model. METHODS A 42-year-old woman was referred with progressive neurologic impairment due to primary osteosarcoma of the sacrum invading surrounding structures. Based on a three-dimensional real-sized model, a detailed surgical plan was developed to assure safe, wide surgical margins. In addition, the model enabled design and testing of a custom-made sacral prosthesis, to provide stable lumbosacral reconstruction. RESULTS After induction chemotherapy, a staged anteroposterior resection-reconstruction was successfully performed. After surgery, a superficial wound dehiscence was promptly treated. Within 3 weeks after surgery, mobilization began, and the adjuvant chemotherapy was continued. At the 36-month follow-up, the patient was disease free, had a stable, painless spinopelvic junction, and could walk short distances using ankle orthoses and crutches. Radiographs show complete incorporation of the pelvic grafts and unchanged position of the implant. CONCLUSIONS In planning and performing a total sacrectomy, including substantial parts of iliac wings, a three-dimensional real-sized model offers surgeons distinct advantages. Wide bony resection margins can be drawn on the model, and an individual custom-made prosthesis to re-establish spinopelvic continuity can be designed and tested before the intervention.
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Affiliation(s)
- P Wuisman
- Departments of Orthopaedic Surgery and Pathology, Free University Hospital, Amsterdam, The Netherlands.
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Wuisman P, Lieshout O, Sugihara S, van Dijk M. Total sacrectomy and reconstruction: oncologic and functional outcome. Clin Orthop Relat Res 2000:192-203. [PMID: 11127656 DOI: 10.1097/00003086-200012000-00023] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The oncologic and functional outcomes of nine patients who were treated by total sacrectomy through L5 (three cases) or L5-S1 (six cases) were reviewed. Histologic diagnoses were one osteosarcoma, two giant cell tumors, two chondrosarcomas, and four chordomas. Patients' ages ranged from 17 to 70 years (mean age, 44.5 years). Resection margins were intralesional (giant cell tumors) in two, marginal in one, and wide in six patients (one contaminated). Reconstruction was performed using polymethylmethacrylate in two, screw and plate fixation in one, and a custom-made device in one. In five patients no reconstruction was performed. Five patients (45.5%) had wound complications: one had a wound dehiscence and two had deep infection; all needed surgical reintervention. In addition, in one a ventral and in another a dorsal hernia developed; only the ventral hernia was revised successfully. One patient had a deep vein thrombosis that was treated with a Coumadin derivate. Three patients (33%) died after 14, 18, and 50 months postoperatively respectively. One died of lung and widespread metastases, and two died of local recurrence and metastases. One patient with a giant cell tumor had a solitary lung metastasis. After resection the patient has been disease-free more than 90 months. At followup, six patients had no evidence of disease (mean followup, 73 months; range, 30-120 months). Functionally, there was no correlation between patients who had a reconstruction and those who had not. Total sacrectomy is a valuable procedure to secure local tumor control and overall survival, despite potential complications and neurologic and sexual dysfunction.
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Affiliation(s)
- P Wuisman
- Department of Orthopaedic Surgery, University Hospital, Vrije Universiteit, Amsterdam, The Netherlands
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Spiegel DA, Richardson WJ, Scully SP, Harrelson JM. Long-term survival following total sacrectomy with reconstruction for the treatment of primary osteosarcoma of the sacrum. A case report. J Bone Joint Surg Am 1999; 81:848-55. [PMID: 10391550 DOI: 10.2106/00004623-199906000-00012] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- D A Spiegel
- Duke University Medical Center, Durham, North Carolina 27710, USA
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Hata M, Kawahara N, Tomita K. Influence of ligation of the internal iliac veins on the venous plexuses around the sacrum. J Orthop Sci 1998; 3:264-71. [PMID: 9732561 DOI: 10.1007/s007760050052] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Excessive bleeding is a significant problem during total sacrectomy. Ligation of the internal iliac veins to control bleeding from the pelvic venous plexus has been reported to be mandatory. However, despite ligation of the internal iliac veins, excessive hemorrhage from the pelvic and epidural venous plexuses is often encountered. We postulated that ligation of the internal iliac veins increases blood loss during total sacrectomy and we investigated the influence of ligation of the internal iliac veins on the pelvic and epidural venous plexuses in white rabbits. We also investigated the influence of the animal's operative position on the epidural venous pressure. Venography was performed to study the differences in blood flow patterns before and after ligation of the internal iliac veins. Without ligation, contrast medium passed into the inferior vena cava, but not into the epidural venous plexus. The epidural venous plexus was contrast-filled when the internal iliac veins were ligated. The pressure in the internal iliac veins was increased with their ligation, and decreased with ligation of the abdominal aorta. The pressure was also decreased with intentional bleeding from the epidural venous plexus, and with changing the animal's position to headdown. Ligation of the internal iliac veins leads to congestion of the pelvic venous and epidural venous plexuses. Ligation of the internal iliac arteries and positioning the animal headdown were effective ways to resolve the congestion in these venous plexuses.
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Affiliation(s)
- M Hata
- Department of Orthopaedic Surgery, School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8640, Japan
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Gokaslan ZL, Romsdahl MM, Kroll SS, Walsh GL, Gillis TA, Wildrick DM, Leavens ME. Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms. Technical note. J Neurosurg 1997; 87:781-7. [PMID: 9347991 DOI: 10.3171/jns.1997.87.5.0781] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although radical resection is the best treatment for malignant sacral tumors, total sacrectomy for such tumors has been performed in only a few instances. Total sacral resection requires reconstruction of the pelvic ring plus establishment of a bilateral union between the lumbar spine and iliac bone. This technique is illustrated in two patients harboring large, painful, sacral giant-cell tumors that were unresponsive to prior treatment. These patients were treated with complete en bloc resection of the sacrum and complex iliolumbar reconstruction/stabilization and fusion. Surgery was performed in two stages, the first consisting of a midline celiotomy, dissection of visceral/neural structures, and ligation of internal iliac vessels, followed by an anterior L5-S1 discectomy. The second stage consisted of mobilization of an inferiorly based myocutaneous rectus abdominis pedicle flap for wound closure, followed by an L-5 laminectomy, bilateral L-5 foraminotomy, ligation of the thecal sac, division of sacral nerve roots, and transection of the ilia lateral to the tumor and sacroiliac joints. Placement of the instrumentation required segmental fixation of the lumbar spine from L-3 down by means of pedicle screws and the establishment of a bilateral liaison between the lumbar spine and the ilia by using the Galveston L-rod technique. The pelvic ring was then reestablished by means of a threaded rod connecting left and right ilia. Both autologous (posterior iliac crest) and allograft bone were used for fusion, and a tibial allograft strut was placed between the remaining ilia. The patients were immobilized for 8 weeks postoperatively and underwent progressive rehabilitation. At the 1-year follow-up review, one patient could walk unassisted, and the other ambulated independently using a cane. Both patients controlled bowel function satisfactorily with laxatives and diet and could maintain continence but required self-catheterization for bladder emptying. The authors conclude that in selected patients, total sacrectomy represents an acceptable surgical procedure that can offer not only effective local pain control, but also a potential cure, while preserving satisfactory ambulatory capacity and neurological function.
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Affiliation(s)
- Z L Gokaslan
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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