Tumor Sacrum

1. dr Syah Reza Manefo
Tumor/Vascular
Anterior/Posterior Sacral Tumor Resection
Departement of Neurosurgery
Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin General Hospital
Bandung 2022

2. Paraplegia (incomplete or complete) Difficulty maintaining balance and walking
Diminished control/dysfunction of bowel/bladder
(including urinary retention) and external genitalia
(men: problems with erection and ejaculation;
women: problems with lubrication)
Reduced hip mobility
Moderate/severe numbness in lower
extremities and perianal area (saddle
anesthesia)
Myelopathy
Paresthesia in lower body extremities Leg Pain (Sciatica)
Lower back/hip/pelvis/butt pain and loss of
mobility due to the pain
Local pain around tumor focus
Muscle weakness in legs (paresis) or
paralysis
Local pain at Sacroiliac Joint(s)
Radicular pain extending into legs
Symptoms and Signs

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Diagnostic Modalities
• Physical/Neurologic examination and patient history
• CT of sacral spine with and without contrast
• MRI of sacral spine with and without contrast (see ̂Fig. 4.7)
• PET scan of body to look for other foci of tumor
• CT of abdomen/pelvis to rule out metastatic disease and
appendicitis
• Biopsy to examine tissue sample benign or malignant, and
what cancer type?
• Endoscopic rectal examination
• Bone scan (to determine whether lesion is polyostotic)

4. - Sacral spine
benign/malignant
tumor
Surgical Pathology

5. - Sacral spine benign/malignant tumor
Surgical Pathology

6. Metastatic Tumor
(Breast, prostate, lung,
renal cell, head/neck,
gastrointestinal cell, skin
(melanoma)
Differential Diagnosis
• Pseudotumor
- Giant cell tumor
– Aneurysmal bone cyst
– Osteoblastoma

7. •
– Chordoma
– Lymphoma
– Multiple myeloma
– Ewing’s sarcoma (in pediatrics)
– Chondrosarcoma (in adults)
– Osteosarcomas
Differential Diagnosis

8. asymptomatic or
mildly symptomatic
with lower body
pain/radiculopathy
with small focus of
tumor:
If symptomatic
with cord/nerve
root compression
Acute pain control
with medications and
pain management
Treatment Options
a. Radiation treatment (radiation
oncology consultation) Some
metastatic tumors are radioresistant
b. Chemotherapy (medical oncology
consultation) Some metastatic tumors
are radioresistant
c. Kyphoplasty (to treat pain)
d. Surgical instrumentation and fusion
(if there is concern for deformity,
instability, or cord compression)

9. Symptomatic with
cord compression
and myelopathy with
large tumor burden
Treatment Options – Urgent surgical decompression and fusion
tumor resection (candidate for surgery);followed
by radiation treatment after resection (consulted by
the radiation oncologist )̑
a. Oncologist will need to determine overall
prognosis, Karnofsky performance score, and
extent of visceral disease
b. If poor surgical candidate with poor life
expectancy Medical management
recommended
c. Surgery may be done anteriorly, posteriorly, or
combined two-stage approach for added
stabilization (see ̂Fig. 4.8)
– Preoperative embolization may be indicated for
select vascular tumors to the spine such as: renal
cell cancer, thyroid cancer, breast cancer, etc.
in order to decrease vascularity intraoperatively

12. Indications for
Surgical
Intervention
No improvement after nonoperative therapy
(physical therapy, pain management, radiation
treatment, and chemotherapy)
Spinal stenosis
Paraplegia
Severe canal and nerve root compression with
or without myelopathy
To obtain diagnosis if no other site for biopsy
is available
Risk of pathological fractures without
stabilization

13. PREPARATION Informed consent signed, preoperative labs normal, no Aspirin/Plavix/
Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/
other anticoagulants and anti-inflammatory drugs for at least 2 weeks
Preoperative antibiotics delivered via IV injection
Appropriate intubation and sedation and lines (if necessary) as per the
anesthetist (endotracheal delivery preferred)
Patient placed prone in neutral alignment on radiolucent
table, enabling use of C-arm fluoroscope
Neuromonitoring not needed
Place sterile drapes after properly cleansing the
abdominal region
Time out is performed with agreement from everyone in the room for
correct patient and correct surgery with consent signed

14. Surgical Procedure for Anterior/Posterior Sacral
Spine (En Bloc Resection)
1. Make incision over the rectus abdominis,
exposing the internal iliac artery
2. Ligate the artery in an extraperitoneal
manner and free rectum sacral space
3. Place large pieces of collagen sponge
between ventral sacrococcyx and dorsal
rectum
4. Close the anterior muscle and skin
incisions in appropriate fashion
5. Transition patient into prone position
6. Make a sacral transverse incision,
cutting deep fascia
7. Free the erector to expose the posterior
sacral spine
8. Once the bone of interest is exposed, it
is recommended to localize and verify it
via fluoroscopic imaging and confirming
with at least two people in the room
9. Separate attachment point of sacrum
from surrounding muscles and ligaments

15. 10. one finger touch the
previously placed gelatin sponge
through the sacrum–rectal space
11.Push the rectum to the head,
separating to S2–S3 junction
12. Perform bone resection
behind S2–S3 gap, exposing
dural sac
13. Ligate the dural sac a.
Resect entire S3 nerve root or
leave side unmolested, on a
caseby-case basis
14. Isolate the sacrum using a
bone knife, removing the
sacrococcygeal bone below S3
Using
Surgical Procedure for Anterior/Posterior
Sacral Spine (En Bloc Resection)

16. Surgical Procedure for Anterior/Posterior Sacral Spine (En Bloc
Resection)
15. Flush incisions with hydrogen peroxide
and diluted povidone-iodine, before
immersing in distilled water
16. Leave drainage tube in left cavity
17. After appropriate hemostasis is
obtained, muscle and skin incisions can
then be closed in appropriate fashion
18. Then place patient prone and perform
incision and identify the sacral region of
interest on X-ray
19. Complete the decompression and
remove sacrum with associated tumor/
lesion
20. Perform hemostasis, leave drain and
close in multiple layers

18.  • Intraoperative CSF leak
 • Temporary enteroplegia
 • Temporary gatism
 • Perianal skin hypoesthesia
 • Blood clot (deep vein thrombosis, or more severe
pulmonary embolism)
 • Damage to spinal nerves and/or cord
 • Postoperative weakness or numbness or continued pain
 • Postoperative wound infection
 • Continued symptoms postsurgically/unresolved
symptoms with no improvement to quality of life
 • Loss of sensation
Pitfalls

19. PROGNOSIS
 • Hospitalization rates depend on the type of procedure
performed, preoperative examination status, and patient’s
age/comorbidities
 • Pain medications for postsurgical pain
 •Physical therapy and occupational therapy will be needed
postoperatively, immediately and as outpatient to regain
strength
 • Back brace placed after discharge to immobilize to
increase rate of healing

20. THANK
YOU