Conversion of high sacral to midsacral amputation via S-2 nerve preservation during partial S-2 sacrectomy for chordoma

Chordomas of the sacrum require en bloc resection to reduce the risk of recurrence, but this may sacrifice nerves vital to bladder, bowel, and sexual function. High, mid-, and low sacral amputations have been previously classified based on nerve root sacrifice, not bony amputation. Sacrifice of the S-2 nerves or those above results in a high sacral amputation, but preserving the S-2 nerves converts it into a midsacral amputation. Preservation of the S-2 nerves has been shown to improve functional outcome, despite the bony osteotomy being unchanged. Thus, keeping the same bony amputation while preserving the S-2 nerve roots may allow for improved functional outcome while still achieving the same goal of oncological resection. Preservation of the S-2 nerves may be particularly difficult during amputation at the S-2 pedicle or above, and the authors describe their technique for preserving the S-2 nerves during partial sacrectomy at or just above the S-2 pedicle. Four cases of sacral chordoma resections are presented to illustrate the technique.