scholarly journals Surgical techniques for total sacrectomy and spinopelvic reconstruction

2003 ◽  
Vol 15 (2) ◽  
pp. 1-10 ◽  
Author(s):  
Ho-Yeol Zhang ◽  
Issada Thongtrangan ◽  
Raju S. V. Balabhadra ◽  
Judith A. Murovic ◽  
Daniel H. Kim
Keyword(s):  
Myocutaneous Flap ◽  
Surgical Techniques ◽  
Rectus Abdominis ◽  
En Bloc ◽  
Pedicle Flap ◽  
Epigastric Vessel ◽  
Iliac Screw ◽  
Pull Through ◽  
Sacral Tumors ◽  
Total Sacrectomy

The surgical management of sacral tumors requires partial or total sacrectomy and spinopelvic reconstruction. These lesions present a great surgical challenge, because most spine surgeons are unfamiliar with the techniques required for these procedures. The authors describe a step-by-step operative technique and provide several illustrations. Total sacrectomy is performed by sequential anterior and posterior approaches that involve a rectus abdominis pull-through pedicle flap reconstruction. The anterior procedure is an intraperitoneal approach used to expose the anterior aspect of the tumor, to ligate the main tumor vessels, and to conduct an anterior partial sacrectomy. After this, the rectus abdominis myocutaneous flap, based on the inferior epigastric vessel, is prepared, and a posterior sacrectomy is performed, dividing all sacral nerve roots in the thecal sac. After complete en bloc extirpation of the sacrum with tumor, spinopelvic reconstruction and closure with a myocutaneous flap are performed. Spinopelvic reconstruction is undertaken using a modified Galveston technique or double iliac screw fixation combined with posterior lumbar segmental fixation. These provide a long lever arm within the ilium to counteract the forces exerted by the lumbar spine. Understanding the nature of the disease as well as the biomechanics of the lumbosacral pelvic area and spinopelvic fixation will help surgeons select the appropriate treatment for sacral tumors.

Sacral tumor resection and the impact on pelvic incidence

2011 ◽  
Vol 14 (1) ◽  
pp. 78-84 ◽  
Author(s):  
Oren N. Gottfried ◽  
Ibrahim Omeis ◽  
Vivek A. Mehta ◽  
Can Solakoglu ◽  
Ziya L. Gokaslan ◽  
...  
Keyword(s):  
Pelvic Incidence ◽  
Tumor Resection ◽  
Surgical Techniques ◽  
Clinical Importance ◽  
Johns Hopkins Hospital ◽  
En Bloc ◽  
Sacral Tumor ◽  
Si Joint ◽  
The Impact ◽  
Total Sacrectomy

Object Pelvic incidence (PI) directly regulates lumbar lordosis and is a key determinant of sagittal spinal balance in normal and diseased states. Pelvic incidence is defined as the angle between the line perpendicular to the S-1 endplate at its midpoint and the line connecting this point to a line bisecting the center of the femoral heads. It reflects an anatomical value that increases with growth during childhood but remains constant in adulthood. It is not altered by changes in patient position or after traditional lumbosacral spinal surgery. There are only 2 reports of PI being altered in adults, both in cases of sacral fractures resulting in lumbopelvic dissociation and sacroiliac (SI) joint instability. En bloc sacral amputation and sacrectomy are surgical techniques used for resection of certain bony malignancies of the sacrum. High, mid, and low sacral amputations result in preservation of some or the entire SI joint. Total sacrectomy results in complete disruption of the SI joint. The purpose of this study was to determine if PI is altered as a result of total or subtotal sacral resection. Methods The authors reviewed a series of 42 consecutive patients treated at The Johns Hopkins Hospital between 2004 and 2009 for sacral tumors with en bloc resection. The authors evaluated immediate pre- and postoperative images for modified pelvic incidence (mPI) using the L-5 inferior endplate, as the patients undergoing a total sacrectomy are missing the S-1 endplate postoperatively. The authors compared the results of total versus subtotal sacrectomies. Results Twenty-two patients had appropriate images to measure pre- and postoperative mPI; 17 patients had high, mid, or low sacral amputations with sparing of some or the entire SI joint, and 5 patients underwent a total sacrectomy, with complete SI disarticulation. The mean change in mPI was statistically different (p < 0.001) for patients undergoing subtotal versus those undergoing total sacrectomy (1.6° ± 0.9° vs 13.6° ± 4.9° [± SD]). There was no difference between patients who underwent a high sacral amputation (partial SI resection, mean 1.6°) and mid or low sacral amputation (SI completely intact, mean 1.6°). Conclusions The PI is altered during total sacrectomy due to complete disarticulation of the SI joint and discontinuity of the spine and pelvis, but it is not changed if any of the joint is preserved. Changes in PI influence spinopelvic balance and may have postoperative clinical importance. Thus, the authors encourage attention to spinopelvic alignment during lumbopelvic reconstruction and fixation after tumor resection. Long-term studies are needed to evaluate the impact of the change in PI on sagittal balance, pain, and ambulation after total sacrectomy.

scholarly journals Sacroplasty Augmentation of Instrumented Pelvic Reconstruction After High Sacrectomy: A Technical Case Report

2021 ◽  
Author(s):  
Amanda N Sacino ◽  
Sutipat Pairojboriboon ◽  
Ian Suk ◽  
Daniel Lubelski ◽  
Robin Yang ◽  
...  
Keyword(s):  
Mechanical Stability ◽  
Pelvic Ring ◽  
Surgical Techniques ◽  
Extent Of Resection ◽  
En Bloc Resection ◽  
Bloc Resection ◽  
En Bloc ◽  
Mobile Spine ◽  
Sacral Tumors ◽  
Fibrous Tumor

Abstract BACKGROUND AND IMPORTANCE En bloc resection of sacral tumors is the most effective treatment to help prevent recurrence. Sacrectomy, however, can be destabilizing, depending on the extent of resection. Various surgical techniques for improving stability and enabling early ambulation have been proposed. CLINICAL PRESENTATION Here, we report a case in which we use PMMA (poly[methyl methacrylate]) to augment pelvic instrumentation to improve mechanical stability after sacrectomy for en bloc resection of a solitary fibrous tumor. CONCLUSION We highlight the use of sacroplasty augmentation of pelvic ring reconstruction to provide biomechanical stability without the need for fusion of any mobile spine segments, which allowed for early patient ambulation and no appreciable loss of range of motion or mobility.

Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms

1997 ◽  
Vol 87 (5) ◽  
pp. 781-787 ◽  
Author(s):  
Ziya L. Gokaslan ◽  
Marvin M. Romsdahl ◽  
Stephen S. Kroll ◽  
Garrett L. Walsh ◽  
Theresa A. Gillis ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Pelvic Ring ◽  
Pedicle Screws ◽  
Radical Resection ◽  
Malignant Neoplasms ◽  
Giant Cell Tumors ◽  
En Bloc ◽  
Pedicle Flap ◽  
Content Type ◽  
Total Sacrectomy

✓ 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.

Lumbopelvic Reconstruction After Combined L5 Spondylectomy and Total Sacrectomy for En Bloc Resection of a Malignant Fibrous Histiocytoma

Neurosurgery ◽  
2010 ◽  
Vol 67 (2) ◽  
pp. E498-E502 ◽  
Author(s):  
Gary L. Gallia ◽  
Ian Suk ◽  
Timothy F. Witham ◽  
Susan L. Gearhart ◽  
James H. Black ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Myocutaneous Flap ◽  
Treatment Options ◽  
En Bloc Resection ◽  
Bloc Resection ◽  
Reconstruction Technique ◽  
Intractable Pain ◽  
En Bloc ◽  
Total Sacrectomy ◽  
Vertebral Segment

Abstract BACKGROUND Primary sacral neoplasms that extend superiorly to involve the distal lumbar spine represent complex surgical problems. Treatment options for these patients are often limited to hemicorporectomy. OBJECTIVE To detail our surgical technique for en bloc resection of a sarcoma involving the L5 vertebral segment and sacrum and the reconstruction of the lumbopelvic junction. METHODS A 52-year-old woman presented with intractable pain secondary to a sarcoma involving the L5 vertebral segment and sacrum. She underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of her neoplasm. A novel lumbopelvic reconstruction technique was used to establish a liaison between the lumbar spine and pelvis. RESULTS Operative complications included a venous vascular injury and a nonviable myocutaneous flap. Postoperatively, the patient had complete resolution of her pain. Unfortunately, the patient developed metastatic disease and died 5 months after her initial surgical procedure. CONCLUSION We describe a patient who underwent a combined L5 spondylectomy and total sacrectomy for en bloc resection of a lumbosacral sarcoma. Additionally, we report a novel technique to reconstruct the lumbopelvic junction. The operative procedures are detailed with the aid of radiographs, intraoperative photographs, and illustrations.

scholarly journals Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms

1997 ◽  
Vol 3 (3) ◽  
pp. E2
Author(s):  
Ziya L. Gokaslan ◽  
Marvin M. Romsdahl ◽  
Stephen S. Kroll ◽  
Garrett L. Walsh ◽  
Theresa A. Gillis ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Pelvic Ring ◽  
Pedicle Screws ◽  
Bowel Function ◽  
Radical Resection ◽  
Malignant Neoplasms ◽  
Giant Cell Tumors ◽  
En Bloc ◽  
Pedicle Flap ◽  
Total Sacrectomy

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.

Reconstruction of Extensive Partial or Total Sacrectomy Defects with a Transabdominal Vertical Rectus Abdominis Myocutaneous Flap

2005 ◽  
Vol 116 (Supplement) ◽  
pp. 194-196
Author(s):  
Brian S. Glatt ◽  
Andrea L. Pusic ◽  
Babak J. Mehrara ◽  
Joseph J. Disa ◽  
Patrick Boland ◽  
...  
Keyword(s):  
Myocutaneous Flap ◽  
Rectus Abdominis ◽  
Rectus Abdominis Myocutaneous Flap ◽  
Total Sacrectomy ◽  
Vertical Rectus Abdominis Myocutaneous

scholarly journals Use of a 3D-Printed Patient-Specific Surgical Jig and Ready-Made Total Sacral Endoprosthesis for Total Sacrectomy and Reconstruction

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
Qianyu Shi ◽  
Tao Ji ◽  
Siyi Huang ◽  
Xiaodong Tang ◽  
Rongli Yang ◽  
...  
Keyword(s):  
Surgical Margin ◽  
Operation Time ◽  
Patient Specific ◽  
En Bloc ◽  
Sacral Tumor ◽  
3D Printed ◽  
The Mean ◽  
Sacral Tumors ◽  
Single Posterior Approach ◽  
Total Sacrectomy

Objective. In the present study, the authors aimed to optimize the workflow of utilizing a 3D printing technique during surgical treatment for malignant sacral tumors, mainly on preparation of patient-specific surgical jigs and ready-made 3D-printed total sacral endoprosthesis. Methods. Three patients with a malignant sacral tumor received total sacrectomy with preoperative design of a patient-specific 3D-printed cutting jig and endoprosthetic reconstruction. Size of ready-made 3D-printed endoprosthesis was determined based on preoperative images, planned surgical margin, and size of the endoprosthesis. A patient-specific cutting jig was designed with a bilateral cutting slot matching the bilateral planes of the implant precisely. The tumor was removed en bloc through a single posterior approach only, being followed by reconstruction with ready-made total sacral endoprosthesis. Results. The mean time for preoperative design and manufacture of the surgical jig was 6.3 days. Surgical jigs were successfully used during surgery and facilitated the osteotomy. The mean operation time was 177 minutes (range 150-190 minutes). The mean blood loss was 3733 ml (range 3600-4000 ml). R0 resections were achieved in all the three cases proven by pathology. Evaluation of osteotomy accuracy was conducted by comparing preoperative plans and postoperative CT scans. The mean osteotomy deviation was 2.1 mm (range 0-4 mm), and mean angle deviation of osteotomy was 3.2° (range 0-10°). At a mean follow-up of 18.7 months, no local recurrence was observed. One patient had lung metastasis 15 months after surgery. Two patients were alive with no evidence of the disease. Conclusions. The patient-specific surgical jig and ready-made 3D-printed total sacral endoprosthesis can shorten the surgical preparation time preoperatively, facilitating accurate osteotomy and efficient reconstruction intraoperatively. The workflow seems to be feasible and practical.

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