Complications

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FIGURE23-7Arectusflapmaybeagoodchoicetofillthe

pelvisandthespacespreviouslyoccupiedbythesacrumand pelvicstructures.

(ZhangHY,ThangtranganI,BalabhadraRS,etal.Surgical techniquesfortotalsacrectomyandspinopelvic reconstruction.NeurosurgFocus2003;15(2):E5,with permission.)

FIGURE23-8Posteriorsacrectomy,posteriorapproach.

Theposteriorapproachisshownherewiththepatientinthe proneposition.Theincisionismidline,withbothskinand potentialbiopsysitesresectedenblocwiththesacrum.

FIGURE23-9Divisionofthesacrospinousmusclesand

ligamentslaterallyfacilitatesbonyresection. (ZhangHY,ThangtranganI,BalabhadraRS,etal.Surgical

techniquesfortotalsacrectomyandspinopelvic

reconstruction.NeurosurgFocus2003;15(2):E5,with permission.)

FIGURE23-10Pronepositioningforenblocsacral

resection.Theposteriorapproachtoenblocsacralresection isfacilitatedbypronepositioning.Markingsforpotentialflaps (latissimusdorsi,inthisexample)canalsobecontemplated.

(NewmanCB,KeshavarziS,AryanHE.Enblocsacrectomyand reconstruction:techniquemodificationforpelvic stabilization.SurgNeurol2009;72:752–6,withpermission.)

FIGURE23-11Anumberoflocalrotationalandpedicle

flapscanbeutilizedwhensacrectomyiscompletedviaa

completelyposteriorapproachtoavoidrepositioningthe patient.

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ResectionofthesacrumabovetheS3levelinvolvessacrificeofthe sacroiliacjointandneedforpelvicstabilizationwithfixationprovidedby bonescrews,allograft,anduseoffixationdevices(Fig.23-12).Total sacrectomyproducesunacceptabledestabilizationofthespineandpelvis andrequiresreconstructionandreinforcementofthepelvicring.Studies focusedonbiomechanicsandstresshaveshownthatsacroiliacstabilityis minimallyaffectedbysacralresectiondistaltoS3,withpreservationof thesacroiliacjoint.DivisionofthesacrumbetweentheS1andS2 vertebralbodiesweakensthepelvisby30%.Whenthesacrumcaudalto themidpointoftheS1bodyisremoved,theringweakensby50%. However,inclinicalstudies,patientswhoretainatleast50%oftheS1 bodydonotdemonstrateinstabilityandaretypicallynotstabilizedusing biomechanicalprostheses.Varioustechniquesforpelvicring reconstructionaftertotalsacrectomyhavebeendescribed.Manyhave takenadvantageofaGalveston-typecross-pelvistechniqueusinganL5 pediclescrewtojoinL5andtheilium.Modificationsusingatransiliac rodtobridgethesestructuresarethoughttoimprovebiomechanical stabilization(Fig.23-13).

FIGURE23-12Sacralreconstructionandstabilization

shouldbecompletedwithhardwareifatotalsacrectomyis done.PreservationofS1ormostofthebodyofS1reduces sacralstrength,butprobablydoesnotrequireafixation device.

FIGURE23-13Sacralfixationhardwareradiograph.

(NewmanCB,KeshavarziS,AryanHE.Enblocsacrectomyand reconstruction:Techniquemodificationforpelvic stabilization.SurgNeurol2009;72:752–6,withpermission.)

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Considerationofthefunctionalimpairmentcausedbysacralnerveroot disruptionorresectionshouldbemadepreoperatively.Bilateralnerve transectionabovethelevelofS2orS3isassociatedinallserieswith seriousandpermanentimpairmentoffecalcontinenceandsevere bladderandsexualdysfunction.Whereasunilateralnervesparingatthe

S2levelandbelowisshowntopreservefunctionfairlywellinmost series,someauthorshaveproposedthatbilateralS2preservationwith unilateralS3sparingisassociatedwithless-functionaldisruptionand betterpredictability.

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Somepresacraltumorsmayrequirespecificsurgicalattention.For instance,ASMrepairrequiresduralresectionandclosureandinvolves identificationandligationoftheherniatedduralstalk.Theapproachto thislesiondependsonthelevelofthemeningocele.Sacraldefectsbelow S3maybeapproachedviaaposteriorincision,whereasthosecranialto thislevelmaybemorereadilyaccessedfromtheabdomen.Thedefectis alwaysanteriorlylocated.Therectumismobilizedlaterallyandthestalk isligatedandoversewn.Theareamaybereinforcedwithapatchof autologoustissueoromentumtohelpavoidaduralleak.

COMPLICATIONS

Complicationsassociatedwithexcisionofpresacraltumorsinclude infectionandhematomasandcanbeassociatedwithdermoidor epidermoidcystexcision.Lessthan3%ofcasesarecomplicatedbyrectal fistula,andthiscomplicationcanbeavoidedbycarefulidentificationand preservationoftheposteriorrectalwall.Complicationsfromradical chordomaresectionaremorecommonandsevere,variableinnature,and dependonthestructuresinvolved.Mostseriesareretrospectiveand involvelimitednumbersofpatients.Lossofbowelandbladdercontrol whensacralresectionproceedswithsacrificeofnervesabovetheS2level isuniversallyreported.Byfar,themostcommonimmediatecomplication issomedegreeofwoundbreakdownoccurringinmostseriesinabout 40%ofpatientsandtreatedwithdebridement,hyperbaricoxygen, antibiotics,tissueflaps,andavoidanceofweightbearing.Someauthors advocateroutineuseofomentalflapsandsoft-tissuepedicleflapssuchas thosefromthegracilisandabdominalrectusmusclesinadditiontokeep thesmallboweloutofthepostresectionalpelvis.Becauseofthehighrate oflocalrecurrence,salvageradiotherapyisoftenusedandflapsmaybea waytomitigatetheeffectsofradiationonthesmallbowelandbladder.

RESULTS

Survivalafterresectionofbenignpresacraltumorsisapproximately 100%.However,survivalandrecurrenceratesformalignantpresacral tumorsdependontumorbiologyalongwiththeextentofresection margins.Poormarginscanbeattributedtoalocalrecurrencerateof greaterthan70%.Glasgowetal.demonstratedadiseaserecurrenceofall sevenpatientsdespiteadequateresectionmargins.Themediansurvival ofthisgroupwas61months.Wangetal.reportedon22malignant presacraltumors.Allunderwentsurgicalresectionwithselected postoperativechemotherapyandradiotherapywithanoverall5-year survivalrateof41%.Themajorityoftheliteraturedemonstratesa10-year survivalrateforchordomas,themostcommonmalignantpresacral tumor,rangingfrom15%to84%.Currentprospectivestudiesevaluating newerneoadjuvantandadjuvanttherapiesarestillpending.

CONCLUSIONS

Insummary,presacraltumorsareuncommonbutmostsurgeonscan expecttoencounteratleastonecaseintheircareer,andfarmoreifata largetertiaryreferralcenter.Theypresentwithnonspecificsignsand symptoms,usuallyleadingtodiagnosisatanadvancedstageifmalignant, orasanincidentalfindingifbenign.Familiaritywiththeuseofimaging fordiagnosis,andtheabilitytocarefullyplanisessential.Preoperative biopsymaybeconsideredinsolidheterogeneousmasses,althougha pelvicMRIaloneshouldsufficeinmostcases.Surgicalexcisionfor complicatedlesionsinvolvingmultipleorganscanbeaccomplished throughaposterior,anterior,orcombinedapproachwithpreoperative planningandamultidisciplinaryteam.Neweradvancesinneoadjuvant andadjuvanttherapiesareevolving,andsurvivalratesarerisinginthis patientpopulation.

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