Demystifying Sacral Masses: A Pictorial Review

The sacrum is a triangular shaped bone made up of five fused vertebral bodies. It is composed of bone, cartilage, marrow elements as well as notochord remnants and is a common site for both benign and malignant (primary and secondary) tumors. Familiarity with the imaging features and clinical presentations of sacral bone tumors could be helpful in narrowing the differential diagnosis. Magnetic resonance imaging and computed tomography are the preferred imaging modalities for evaluating sacral masses. This pictorial review will highlight imaging features of common sacral tumors with pathologic correlation. Additionally, this article will review some critical principles and helpful tips to successfully biopsy these lesions.

Primary Tumors of the Sacrum: Imaging Findings

The diagnosis of sacral neoplasms is often delayed because they tend to remain clinically silent for a long time. Imaging is useful at all stages of managing sacral bone tumors: from the detection of the neoplasm to the long-term follow-up. Radiographs are recommended as the modality of choice to begin the imaging workup of a patient with known or suspected sacral pathology. More sensitive examinations such as computerized tomography (CT), magnetic resonance (MRI), or scintigraphy are often necessary. The morphological features of the lesions on CT and MRI help to orientate the diagnosis. Although some imaging characteristics are helpful to limit the differential diagnosis, an imaging-guided biopsy is often ultimately required to establish a specific diagnosis. Imaging is of paramount importance even in the long-term follow-up in order to assess any residual tumor when surgical resection is incomplete, to assess the efficacy of adjuvant chemotherapy and radiotherapy, and to detect recurrence.

Removal of sacral neuromodulation quadripolar tined-lead using a straight stylet: description of a surgical technique

Background Up to 7.5% of tined-lead removals in patients having sacral neuromodulation (SNM) therapy are associated with a lead breakage. It is still unclear what adverse effects can be caused by unretrieved fragments. The aim of our study was to describe the lead removal technique we have been using for the last 2 years in our centre. Methods We retrospectively enrolled patients who had lead removal between January 2018 and January 2020 using our standardized technique. The novelty of the technique is in the use of the straight stylet, which is available in the quadripolar tined-lead kit. The stylet gives the electrode greater stiffness, reducing interactions with surrounding tissues and probability of damage or breakage during removal. Results In 59 patients (42 women, mean age 57.2 years [range 40–79 years]) the lead was removed using our standardized technique. In 44 of 59 patients, the tined-lead was removed within 2 months from the SNM-test, due to lack of beneficial effects. In 15 patients the electrode was removed because of failure of definitive implantation. Meantime from definitive implantable pulse generator (IPG) implantation to lead removal was 67.9 months. We recorded only 1 case of lead-breakage during removal: a female patient with a non-tined lead fixed on sacral bone, placed 18 years previously using an open technique. Conclusions Lead breakage during removal is not uncommon and adverse effects of retained fragments may occur. Our technique has been safely used for the last 2 years in our centre, with no episodes of lead breakage or retained fragments, except for one non-tined electrode.

Statistical Analysis of Sacral Bone Density using a CNN-based Atlas Creation on a Large-scale CT database

Fragility fracture of the sacrum has been an issue for elderly people. Research has been limited for the sacrum partly because its shape is complex with large inter-subject variation. Also, large-scale statistical analysis of its shape and density distribution has been limited mainly due to the computational load in establishment of the voxel correspondences, i.e., deformable registration.In this study, we employed a convolutional neural network (CNN)-based deformable registration algorithm in the analysis of the sacral bone. The algorithm we employed, VoxelMorph (Dalca et al. Med Image Anal 2019), is characterized as an unsupervised algorithm where no ground truth deformation field is required. The algorithm also allows to create a conditional deformable template, which is a volume image exhibiting smallest deformation field from all samples with specific attributes (e.g., age, sex, etc.), which in short represents the “average” (or “centroid”) image among the specific age and sex group. We applied it on a database consisting of 837 CTs (149 males, 688 females, 58.14 ± 14.73 y.o.) of the pelvis region, where the sacral bone was segmented and masked. We computed the templates corresponding to ages of 20 to 80 for male and female. The templates visually illustrated reduction of the bone density with aging in both male and female. The quantitative analysis showed that the average CT value over the sacrum region was reduced from 135.73 HU to 39.88 HU for 20 y.o. template to 80 y.o. template.

V. Zhemchuzhnikov. A case of long-term retention of the fetal head in the uterine cavity after decapitation. (Protocol of the meeting of the obstetric-gynecological society in Kiev; year 5, volume 5. Issues 9 and 10)

The author gives a detailed history of a patient suffering from a tumor emanating from the region of the sacral bone, the size of a child's head, dense fibrous consistency, so much narrowed the anterior-posterior size of the pelvis that the last one was barely 2 - ctm. Due to such a contraction, at the 6th birth, the subsequent head could not be removed, and, after decapitation, was left in the uterine cavity; three months later, the patient was admitted to the clinic of prof. Rake, and in the continuation of this time the bones of the skull of the detained head were arbitrarily protruded, which was accompanied by a feverish state.

Revision by S2-alar-iliac instrumentation reduces caudal screw loosening while improving sacroiliac joint pain—a group comparison study

Lumbosacral instrumentation continues to be challenging due to complex biomechanical force distributions and poor sacral bone quality. Various techniques have therefore been established. The aim of this study was to investigate the outcome of patients treated with S2-alar-iliac (S2AI), S2-alar (S2A), and iliac (I) instrumentation as the most caudal level. Sixty patients underwent one of the 3 techniques between January 2012 and June 2017 (S2AI 18 patients, S2A 20 patients, I 22 patients). Mean age was 70.4 ± 8.5 years. Screw loosening (SL) and sacroiliac joint (SIJ) pain were evaluated during the course at 3-month and maximum follow-up (FU). All patients completed 3-month FU, the mean FU period was 2.5 ± 1.5 years (p = 0.38), and a median of 5 segments was operated on (p = 0.26), respectively. Bone mineral density (BMD), derived opportunistically from computed tomography (CT), did not significantly differ between the groups (p = 0.66), but cages were more frequently implanted in patients of the S2A group (p = 0.04). SL of sacral or iliac screws was more common in patients of the S2A and I groups compared with the S2AI group (S2AI 16.7%, S2A 55.0%, I 27.3% of patients; p = 0.03). SIJ pain was more often improved in the S2AI group not only after 3 months but also at maximum FU (S2AI 61.1%, S2A 25.0%, I 22.7% of patients showing improvement; p = 0.02). Even in shorter or mid-length lumbar or thoracolumbar constructs, S2AI might be considered superior to S2A and I instrumentation due to showing lower incidences of caudal SL and SIJ pain.