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The evaluation and complex treatments of sacral tumors require a multidisciplinary approach. Because of the complex anatomy conditions and biomechanics of the lumbo-pelvic junction, surgical treatment of sacral neoplasms is one of the most challenging fields in spine. Here, diagnostic process and surgical and nonsurgical treatment options for sacra...
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Context 1
... performing diffusion weighted MRI scans, sacral metastases are clearly differentiable from insufficient fractures of the sacrum [11]. Bone scan is used to determine whether the lesion is monoostotic or polyostotic and for searching for bone metastasis (Figure 4/A). Chordomas are represented with positron emission tomography (PET). ...
Context 2
... arising from the lateral-cranial part of the first sacral segment is a special localisation (Figure 4). In our clinical experience, we also use this terminology and follow the surgical principles they summarised in this very well structured article (Table 3). ...
Context 3
... arising from the lateral-cranial part of the first sacral segment is a special localisation (Figure 4). In our clinical experience, we also use this terminology and follow the surgical principles ...
Context 4
... and for searching for bone metastasis ( Figure 4/A). Chordomas are represented with positron emission tomography (PET). This could also be feasible for monitoring non-surgical treatments of the tumor [12], however, it has not yet been accepted as part of everyday clinical practice. In conclusion, regarding the site and extent of the tumor, one of the most important questions to be answered is the extent of involvement of the sacral (or lumbar) segments and the sacroiliac joint since they influence the surgical strategy and may definitely determine the surgical outcome. The CT and MRI scans are necessary tools in the diagnostic process of a sacral mass and very helpful in the preoperative planning, ...
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Citations
... Among the disadvantages is the possibility of an erroneous diagnosis in 44% of cases, the risk of infection and tumor seeding [9,10]. However, in solid, heterogeneous lesions, especially with imaging suspicion of malignancy, preoperative biopsy can be beneficial in the therapeutic strategy since there are some types of tumors that improve survival with neoadjuvant therapy, such as Ewing and osteogenic sarcomas [19,20]. If a biopsy is performed, a perineal or presacral route by TC 18 should guide it. ...
Introduction: Retrorectal tumors constitute a rare and heterogeneous group of neoplasms, which are characterized by being located in the so-called retrorectal space. In most cases these are benign lesions. The main imaging test for its characterization and planning its therapy is magnetic resonance imaging. Surgery is generally the treatment of choice, often without preoperative anatomopathological studies, given the potential risk of malignancy of these tumors and the appearance of compressive symptoms during the course.
... The FRR technique has been analyzed in numerous in vitro and in silico studies [11,20−24], revealing significantly reduced lumbopelvic motion compared to conventional LPRTs [20,22]. In 2009, Varga et al. introduced the closed-loop reconstruction (CLR) technique, consisting of a single U-shaped rod, for lumbopelvic stabilization [4]. The CLR technique is a non-rigid fixation approach, as concluded by a comprehensive six-year retrospective clinical investigation [25]. ...
... In the ICR after LPDR, the fibular grafts were repositioned to align with the modified iliopectineal line (Fig. 2H). The LPRTs analyzed in this current FE analysis are detailed in previous studies [4,15,19,21]. ...
Background Context
Following total sacrectomy, lumbopelvic reconstruction is essential to restore continuity between the lumbar spine and pelvis. However, to achieve long-term clinical stability, bony fusion between the lumbar spine and the pelvic ring is crucial. Reduction of the lumbopelvic distance can promote successful bony fusion. Although many lumbopelvic reconstruction techniques (LPRTs) have been previously analyzed, the biomechanical effect of lumbopelvic distance reduction (LPDR) has not been investigated yet.
Purpose
To evaluate and compare the biomechanical characteristics of four different LPRTs while considering the effect of LPDR.
Study Design/Setting
A comparative finite element (FE) study.
Methods
The FE models following total sacrectomy were developed to analyze four different LPRTs, with and without LPDR. The closed-loop reconstruction (CLR), the sacral-rod reconstruction (SRR), the four-rod reconstruction (FRR), and the improved compound reconstruction (ICR) techniques were analyzed in flexion, extension, lateral bending, and axial rotation. Lumbopelvic stability was assessed through the shift-down displacement and the relative sagittal rotation of L5, while implant safety was evaluated based on the stress state at the bone-implant interface and within the rods.
Results
Regardless of LPDR, both the shift-down displacement and relative sagittal rotation of L5 consistently ranked the LPRTs as ICR<SRR<FRR<CLR, with ICR being the stiffest for both parameters. LPDR decreased the shift-down displacement values by 25% in CLR, by 61% in SRR, by 15% in FRR, and by 46% in ICR, as well as reduced the relative sagittal rotation values by 21% in CLR, by 73% in SRR, by 11% in FRR, and by 53% in ICR. Considering the stress at the bone-implant interface, without LPDR, the ICR yielded the smallest stress values for flexion, lateral bending, and axial rotation with 131.4 MPa, 68.2 MPa, and 70.3 MPa, respectively, and the second smallest in extension with 36.1 MPa. Due to LPDR, these stress values were reduced by 31% in flexion, by 17% in extension, by 29% in lateral bending, and by 29% in axial rotation. Within the rods, without LPDR, the ICR yielded the smallest stress values for flexion, extension, lateral bending, and axial rotation with 346.5 MPa, 108.0 MPa, 186.2 MPa, and 199.7 MPa, respectively. With LPDR, these stress values were reduced by 16% in flexion, by 9% in extension, by 11% in lateral bending, and by 12% in axial rotation.
Conclusions
LPDR significantly improved both lumbopelvic stability and implant safety in all reconstruction techniques after total sacrectomy. LPDR reduced the shift-down displacement of L5, the relative sagittal rotation of L5, and the stress values at the bone-implant interface. Furthermore, in the ICR and SRR techniques, LPDR decreased the peak stress values within the rods. All four investigated LPRTs demonstrated suitability for lumbopelvic reconstruction, with the ICR technique exhibiting the highest lumbopelvic stiffness.
Clinical Significance
LPDR creates a biomechanically advantageous environment following total sacrectomy; therefore, it has the potential to impact the design of custom-made 3D-printed or traditional LPRTs. However, to confirm the findings of the current FE study, long-term clinical trials are recommended.
... The diagnosis is difficult because of the and surgical treatment is one of the most challenging fields in orthopedics and spinal surgery because of the complicated anatomy of the sacral site. 2 Sacral tumors are not so common and consequently there is not much literature and experience in this regard. The objective of this paper is to expose the general and key aspects in the study and treatment of these lesions. ...
... Primary benign and malignant tumors of the sacrum are 2-4% of all primary bone neoplasms 2 and 1-7% of all primary spinal tumors. [2][3][4]7 Most common primary sacral tumors are chordomas, representing 40% of all primary sacral neoplasms, and about half of all sacral tumors are metastasis. 2 The differential diagnosis of these lesions is extensive, and although metastasis are the most common, a broad spectrum of primary bone tumors can arise from sacral components. ...
... [2][3][4]7 Most common primary sacral tumors are chordomas, representing 40% of all primary sacral neoplasms, and about half of all sacral tumors are metastasis. 2 The differential diagnosis of these lesions is extensive, and although metastasis are the most common, a broad spectrum of primary bone tumors can arise from sacral components. 8 Additionally, it should be mentioned that invasive rectal carcinomas can directly infiltrate the sacral bone, increasing the complexity of surgical resections. 2 ...
... 7 Sacral metastases are often diagnosed late in their course, after they have extended beyond the bony anatomy and into the canal and neuroforamina. 8 Because of the complex osseous and neurological anatomy of the sacrum, difficulty in imaging the area, and nonspecific early symptomatology, patients often have a prolonged symptom duration prior to surgical evaluation. 5,6 Surgical management has been associated with a high risk of adverse events, leading surgeons to avoid operating on this population. ...
... The literature on sacral metastases has noted other indications for surgery, including tumor progression, neurological deficit, pain refractory to radiation therapy, spinal instability, need for tissue diagnosis, and prolonging survival in certain histologies such as renal cell cancer. [1][2][3][4][5][6][7][8]10,11 Traditionally, studies have focused on open surgery; in one such study, 40% of patients had complications, and the rate was even higher (62%) among those who had had prior radiotherapy. 1 Given the complication profile and limited life expectancy in this patient population, our approach is to limit surgical indications to mechanical instability and acute neurological compression that is amenable to surgical decompression. ...
BACKGROUND
Because patients with advanced cancer live longer, the number of patients with the sequelae of metastatic spine disease has increased. Pathologic instability of the mobile spine has been classified, and minimally invasive surgery has been well described. However, pathologic sacral instability is uncommon and often underdiagnosed. Although most sacral fractures are stable, patients with unstable U- or H-type fractures have spinopelvic dissociation and can experience progressive pain, sacral kyphosis, and neurological injury. Open lumbopelvic fusion carries a high perioperative risk for this patient population, which has often been previously radiated and is medically frail. The authors investigated the utility and safety of percutaneous lumbopelvic fixation, as previously described for traumatic spinopelvic dissociation, in the oncological setting. The authors retrospectively reviewed five consecutive patients with unstable pathologic sacral fractures who had undergone percutaneous lumbopelvic fixation after conservative management failed.
OBSERVATIONS
Patients experienced significant improvement between pre- and postoperative visual analog scale scores (9.2 and 1.6, respectively) and Eastern Cooperative Oncology Group grades (median 3 and 1, respectively). All patients were independently ambulatory at the final follow-up. Sagittal alignment remained stable in four patients and worsened in one. There were no major medical or surgical complications.
LESSONS
Percutaneous lumbopelvic fixation shows promising results for palliation, durability, and safety for pathologic sacropelvic instability.
... The critical period for the assessment of immediate postoperative pain should be determined in the future. Third, this pilot study involved a small sample size because pelvic and sacral tumors are rare pathologies [29,30]. These results are preliminary, and larger trials are required to confirm these findings. ...
Background
Pain management after pelvic and sacral tumor surgery is challenging and requires a multidisciplinary and multimodal approach. Few data on postoperative pain trajectories have been reported after pelvic and sacral tumor surgery. The aim of this pilot study was to determine pain trajectories within the first 2 weeks after surgery and explore the impact on long-term pain outcomes.
Methods
Patients scheduled for pelvic and sacral tumor surgery were prospectively recruited. Worst/average pain scores were evaluated postoperatively using questions adapted from the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) until pain resolution was reached or up to 6 months after surgery. Pain trajectories over the first 2 weeks were compared using the k-means clustering algorithm. Whether pain trajectories were associated with long-term pain resolution and opioid cessation was assessed using Cox regression analysis.
Results
A total of 59 patients were included. Two distinct groups of trajectories for worst and average pain scores over the first 2 weeks were generated. The median pain duration in the high vs low pain group was 120.0 (95% CI [25.0, 215.0]) days vs 60.0 (95% CI [38.6, 81.4]) days (log rank p = 0.037). The median time to opioid cessation in the high vs low pain group was 60.0 (95% CI [30.0, 90.0]) days vs 7.0 (95% CI [4.7, 9.3]) days (log rank p < 0.001). After adjusting for patient and surgical factors, the high pain group was independently associated with prolonged opioid cessation (hazard ratio [HR] 2.423, 95% CI [1.254, 4.681], p = 0.008) but not pain resolution (HR 1.557, 95% CI [0.748, 3.243], p = 0.237).
Conclusions
Postoperative pain is a significant problem among patients undergoing pelvic and sacral tumor surgery. High pain trajectories during the first 2 weeks after surgery were associated with delayed opioid cessation. Research is needed to explore interventions targeting pain trajectories and long-term pain outcomes.
Trial registration
The trial was registered at ClinicalTrials.gov ( NCT03926858 , 25/04/2019).
... In musculoskeletal lesions, obtaining a sample of tumor tissue for histological examination by the appropriate specialists is necessary for establishing the correct diagnosis and planning further management. 1,2 It may be considered that biopsy itself is a simple technical procedure, but it can have the potential of adversely affecting the outcome of the patient. 2 This procedure, that must be done by surgeons that will perform the definitive surgery or by the interventional radiologist of the team, and always planned and based on previous imaging studies, 3 is labeled as biopsy. ...
... Primary tumors of the sacrum are rare and include benign neoplasms, such as osteochondroma, giant cell tumors, and osteoid osteoma, as well as malignant neoplasms, such as chordoma, chondrosarcoma, osteosarcoma, Ewing's sarcoma, and myeloma [2,3]. The best disease-free survival of patients who undergo sacrectomy is achieved through en bloc resection of the lesion, which usually involves partial or total resection of the sacrum [4]. Tumors in the sacrum area usually induce mild and transient symptoms because of their slow growth. ...
... Several studies have been conducted to clarify various aspects of sacrectomy, with the aim of reducing the morbidity and mortality rates of the procedure. Since a multidisciplinary team, including oncologists, radiologists, pathologists, cancer surgeons, and spine surgeons, is necessary for a complete sacrectomy procedure [4,18], the morbidity and mortality outcomes of the procedure depend on which sacral roots are sacrificed to achieve a wide margin and on the level at which the procedure is performed [1]. Infection, massive hemorrhage, surgical wound infection, flap necrosis, and sphincter and neurological dysfunction are the main complications associated with sacrectomy [1,19,20,8,16]. ...
Background
Sacrectomy is indicated for the resection of life-threatening tumors in the sacrum area. Several studies have been conducted to investigate important aspects of sacrectomy to help reduce the morbidity and mortality of patients who underwent the procedure. This aim of this systematic review was to highlight the prognoses of patients who underwent sacrectomy for the resection of primary bone tumors by analyzing information related to the intraoperative and perioperative periods of the procedure.
Methodology
Several databases were searched for relevant articles using the keywords “sacrectomy” and “survival” associated with the Boolean operators “or” and “and” ([SACRECTOMY OR SACRECTOM*] AND SURVIVAL).
Results
A total of 13 articles were selected for data collection. The studies reported in the articles included a total of 384 patients, 140 of whom underwent partial sacrectomy, whereas 244 underwent total sacral resections. The results of the analysis indicated that the average volume of blood lost during a resection performed using the combined anterior and posterior approaches (average duration, 8.35 h) was 4571.94 mL. Regarding poor outcomes and adverse events in the included studies, 10 patients died in the early postoperative period, whereas four patients had hemorrhagic shock. The most prevalent complications reported were surgical wound infection and sphincter dysfunction.
Conclusion
The optimal surgical approach for sacrectomy depends on the location of the tumor. The anterior approach, preferably with laparoscopy, is currently widely used to reduce the amount of blood lost during the procedure. Although the most prevalent complications of sacrectomy have a high incidence rate, the procedure has a low mortality rate.
... In addition, it was found in 3% among all benign primary bone tumors 1,2 . The incidence of the neoplasm peaks in the second decade of life and 90% of these tumors are diagnosed before the third decade Its incidence in males is double that of females 3 . The tumor may have a vascular osteoid nature or may form bones with a vast number of osteoblastic cells 4 . ...
... Varga 3 stated that nocturnal pain in the lower back or sacrum may be a warning symptom 3,11 . However, the authors also reported that sacral tumors might be diagnosed as non-specific lower back pain or disc hernia, due to difficulties in the evaluation of the radiographs. ...
... Varga 3 stated that nocturnal pain in the lower back or sacrum may be a warning symptom 3,11 . However, the authors also reported that sacral tumors might be diagnosed as non-specific lower back pain or disc hernia, due to difficulties in the evaluation of the radiographs. ...
The aim of this study was assess the results without instrumentation the clinical findings and treatment outcomes of wide resection in sacral osteoblastoma. A retrospective review was conducted in the hospital archive from 1983 to 2017. As a result of the examination, 238 osteoid osteoma and osteoblastoma patients were found. Osteoid osteoma was present in 210 (88.2%) patients and osteoblastoma was present in 28 (11.7%) patients. Five patients who had been operated for osteoblastoma of the sacrum were retrospectively evaluated. Preoperative and postoperative plain radiographs, MR, CT and scintigraphy scans of all patients were taken. The lesion was located at the S4-S5 vertebrae in two patients, at the S2-S3 in one, at the S1in one and at the S4 in the other. Diagnoses were made by either open or closed biopsy. The patients were treated with wide resection. The mean follow-up period was 31.6 (range: 18 to 50) months. One patient developed a superficial wound infection. No local recurrence was observed. All patients were pain-free in the postoperative period. Wide resection of sacral osteoblastoma proved successful results in the short follow-up period of 31.6 months, with no recurrence.
... Sacral tumors are rare pathologies, and their management typically generates a complex medical problem (1). The most common primary sacral tumors are chordomas, representing 40% of all primary sacral neoplasms (2). ...
... There is no gold standard, and relatively high complication rates (i.e., non-union, screw loosening, rod breakage) are reported with all reconstruction strategies (7,8). The "en-bloc" resection of a sacral chordoma by performing a total sacrectomy with soft tissue and bony reconstruction, and lumbopelvic stabilization can be achieved with the closed-loop technique (1,7). The technique uses a "U" shaped rod which is attached to the iliac and transpedicular screws to rebuild the spinopelvic connection (Figure 1). ...
... The technique uses a "U" shaped rod which is attached to the iliac and transpedicular screws to rebuild the spinopelvic connection (Figure 1). The closed-loop technique (CLT) was first introduced by Varga et al. (1), and it was adopted by others (9) and further developed (10). ...
Introduction: En-bloc resection of a primary malignant sacral tumor with wide oncological margins impacts the biomechanics of the spinopelvic complex, deteriorating postoperative function. The closed-loop technique (CLT) for spinopelvic fixation (SPF) uses a single U-shaped rod to restore the spinopelvic biomechanical integrity. The CLT method was designed to provide a non-rigid fixation, however this hypothesis has not been previously tested. Here, we establish a computational method to measure the deformation of the implant and characterize the bony fusion process based on the 6-year follow-up (FU) data.
Materials and Methods: Post-operative CT scans were collected of a male patient who underwent total sacrectomy at the age of 42 due to a chordoma. CLT was used to reconstruct the spinopelvic junction. We defined the 3D geometry of the implant construct. Using rigid registration algorithms, a common coordinate system was created for the CLT to measure and visualize the deformation of the construct during the FU. In order to demonstrate the cyclical loading of the construct, the patient underwent gait analysis at the 6th year FU. First, a region of interest (ROI) was selected at the proximal level of the construct, then the deformation was determined during the follow-up period. In order to investigate the fusion process, a single axial slice-based voxel finite element (FE) mesh was created. The Hounsfield values (HU) were determined, then using an empirical linear equation, bone mineral density (BMD) values were assigned for every mesh element, out of 10 color-coded categories (1st category = 0 g/cm ³ , 10th category 1.12 g/cm ³ ).
Results: Significant correlation was found between the number of days postoperatively and deformation in the sagittal plane, resulting in a forward bending tendency of the construct. Volume distributions were determined and visualized over time for the different BMD categories and it was found that the total volume of the elements in the highest BMD category in the first postoperative CT was 0.04 cm ³ , at the 2nd year, FU was 0.98 cm ³ , and after 6 years, it was 2.30 cm ³ .
Conclusion: The CLT provides a non-rigid fixation. The quantification of implant deformation and bony fusion may help understate the complex lumbopelvic biomechanics after sacrectomy.
... As such, magnetic resonance imaging (MRI) in conjunction with computed tomography (CT) has emerged as the diagnostic tool of choice (Figure 3)[5]. CT is useful for demonstrating the nature of the lesion (cystic-solid) and bone destruction, whereas MRI is more advanced in evaluating soft tissue and adjacent structures' involvement ( Figures 4 and 5) [28][29][30]. ...
Retrorectal or presacral tumors are rare lesions located in the presacral area and considered as being derived from multiple embryological remnants. These tumors are classified as congenital, neurogenic, osseous, inflammatory, or miscellaneous. The most common among these are congenital benign lesions that present with non-specific symptoms, such as lower back pain and change in bowel habit. Although congenital and developmental tumors occur in younger patients, the median age of presentation is reported to be 45 years. Magnetic resonance imaging plays a crucial role in treatment management through accurate diagnosis of the lesion, the evaluation of invasion to adjacent structures, and the decision of appropriate surgical approach. The usefulness of preoperative biopsy is still debated; currently, it is only indicated for solid or heterogeneous tumors if it will alter the treatment management. Surgical resection with clear margins is considered the optimal treatment; described approaches are transabdominal, perineal, combined abdominoperineal, and minimally invasive. Benign retrorectal tumors have favorable long-term outcomes with a low incidence of recurrence, whereas malignant tumors have a potential for distant organ metastasis in addition to local recurrence.
