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Sacrectomy and Spinopelvic Reconstruction

Jason C. Eck, DO, MS,* Michael J. Yaszemski, MD, PhD,†,‡ and Franklin H. Sim, MD†

Patients with malignant lumbosacral pelvic lesions present a difficult surgical challenge.
Because of the insidious onset of symptoms, lesions are often diagnosed late in their course,
and by that time they have attained a large size. Surgical resection is made more difficult by
the complex surrounding anatomy and involvement of the sacral nerves responsible for bowel,
bladder, and sexual function. Spinopelvic reconstruction is often required after resection. This
article presents techniques for sacral resection and subsequent spinopelvic reconstruction.
Biomechanical studies are summarized on construct stability, and recommendations are made
as to when reconstruction is required. The expected bowel and bladder functional outcomes
are summarized, based on the level of sacral resection.
Semin Spine Surg 21:99-105 © 2009 Elsevier Inc. All rights reserved.

KEYWORDS sacrectomy, spinopelvic reconstruction, tumor, chordoma

Involving the sacrum presents a very difficult
tumors
surgical challenge. These tumors typically have an in
sidious onset that results in a delayed diagnosis. The tu
mors are difficult to identify on examination because they
often expand anteriorly into the pelvic cavity. Consequently,
these tumors can reach a very large size before diagnosis.
Although they can generally be palpated on a digital rectal
examination, they are most often identified using axial
imaging studies. At the time of diagnosis, the tumors often
involve much of the sacrum and the sacral plexus nerve
roots.
As with other musculoskeletal sarcomas, the goals of
surgery are to resect the tumor with negative surgical
margins while maximizing postoperative function. These
goals are much more difficult to achieve when dealing with
sacral tumors because of the complex anatomy. Of ten,
some or all sacral nerves must be sacrificed to achieve
negative specimen margins. This may lead to either loss or
diminished control of bowel and bladder function. When the
tumor involves the pelvis, the sacrectomy can be combined
with either an internal or external hemipelvectomy.
These cases require the collaboration of specialists from
multiple disciplines, including spine surgery, orthopedic
oncology, colorectal surgery, urology, vascular surgery,
*Department of Orthopedics and Physical Rehabilitation, University of
Massachusetts, Worcester,
MA. †Department of Orthopedic Surgery, Mayo Clinic, Rochester,
MN. ‡Department of Biomedical Engineering, Mayo Clinic, Rochester, MN.
Address reprint requests to Jason C. Eck, DO, MS, Department of Orthopedics
and Physical Rehabilitation, University of Massachusetts, 119 Belmont St.,
Worcester, MA 01605. E-mail: Jason.Eck@umassmemorial.org
plastic surgery, anatomic pathology, radiology, critical care
anesthesiology, and medical and radiation oncology.
physiological
Consequences of Sacrectomy
An important consideration during surgical treatment of
sacral tumors is the involvement of the sacral nerves. In
most cases, sacrectomy involves sacrificing some of the
sacral nerves to obtain negative surgical margins. The nerve
supply of the bowel and bladder originates from the
autonomic and somatic systems. The autonomic innervation
comes from the hypogastric plexus and travels through the
S2-S4 sacral nerves. The somatic innervation comes from
the pudendal nerve that originates from S2 and S3 sacral
nerves. The sym pathetic system acts to constrict the
internal anal sphincter and internal urethral orifice. The
somatic system acts to contract the rectum and bladder.1
Gunterberg et al2,3 reported that unilateral resection of
the sacral nerves did not affect bowel and bladder function.
Bilateral resection of the S3 and S4 roots did result in bowel
and bladder dysfunction, but the levels responsible were
not finished. The sexual function response was similar in
that unilateral resection of the S2, S3, and S4 roots resulted
in retained sexual function but brought about numbness on
the side of the
resection.4 Todd et al5 performed a retrospective review
of 53 patients undergoing partial or total sacrectomy to
determine the effect of osteotomy level on postoperative
bowel and bladder function. Only patients with normal
preoperative bowel and bladder function were included in the analysis.

1040-7383/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. 99

doi:10.1053/j.semss.2009.03.009
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100 JC eck et al

Table 1 Bowel and Bladder Function After Sacral Resection caudal to the S2 foramina; a group with transverse sacrectomy
Normal Normal performed just caudal to the S1 ventral foramina; and a group with
spared
Resection level Bowel Bladder transverse sacrectomy performed cephalad to the S1 for ramina. The
specimens were supported through the acetabulum by two 46-mm
Bilateral S2-S5 Both S1 0/10 (0%) 0/10 (0%) 2/5 (40%)
Bilateral S3-S5 Both S2 3/12 (25%) 4/4 (100%) 9/13 metallic spheres on vertical posts. The posts allowed for unrestricted
Bilateral S4-S5 Both S3 (69%) 3/5 (60%) 8 /9 (89%) translation in the coronal plane. A curved anterior blocking plate
Variable Unilateral S3 2/3 (67%) stabilized the specimens at the pubic symphysis against sagittal plane
Unilateral S1-S5 Contralateral 7/8 (87%) rotation. The mean load
S1-S5
Adapted with permission from Todd et al.5

are summarized in Table 1. It was determined that preservation of at

least 1 S3 nerve root allowed preservation of bowel and bladder
function in most patients.

Biomechanics of
Spinopelvic Reconstruction
The sacrum serves a crucial biomechanical role as the sole
mechanical link between the axial skeleton and the pelvis and lower
extremities. Fortunately, the sacroiliac joints are inherently stable
because of their anatomy. The sacrum's wedged shape fits between
the 2 iliac wings with irregular interlocking surfaces to resist vertical
migration. The ligamentous structures about the sacrum are among
the strongest ones in the body, and include the sacrotuberous,
sacrospinous, and lumbosacral ligaments. It is important to consider
the biomechanical effects of partial sacral resection and the potential
need for complex reconstruction to avoid postoperative instability.

Gunterberg et al6 carried out some of the initial studies on the

biomechanics of sacrectomy. They performed biomechanical studies
on transverse partial sacrectomies to determine the load to failure
and subsequent need for reconstruction. The partial sacrectomies
were performed either through the S1 foramina or S1 body. These
resections were found to reduce the strength of the remaining sacrum
by 30% and 50%, respectively. On the basis of their results, they did
not recommend the need for reconstruction after either of these types
of resections.

Two design faults of this study have been subsequently raised in

regard to the simulation of in vivo loading conditions.7 The first flaw
was that the specimens were stabilized by potting the ischial rami in
an epoxy resin.6 In the actual in vivo loading situation , the reactive
forces would be applied through the hips, not through the ischium. A
reaction force applied through the ischium is closer to the midline than
a force applied through the hips. This results in a decreased bending
moment when loading through the ischium versus. loading through
the hips. The second flaw was that with the ischial rami potted, the
iliac wings were not able to angulate or splay during loading, further
stabilizing the construct and underestimating the actual in vivo loading
conditions.

Recently, Hugate et al7 investigated the biomechanical effects of

high partial transverse sacrectomy and the need for spinopel vic
reconstruction. Cadaveric specimens were divided into 3 groups: a
control group, with transverse sacrectomy performed
Figure 1 Diagram of various types of sacrectomy. (A) Partial trans verse
sacrectomy, (B) combined sagittal and transverse partial sa crectomy, (C)
sagittal partial sacrectomy (Reprinted with permission from Dickey et al.8)
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sacrectomy
Figure 2 Diagram detailing the anterior presacral space anatomy
with elevation of the contents away from the anterior portion of the
sacrum (Reprinted with permission from Dickey et al.8)
to failure decreased with more cephalad location of the osteotomy
(below S2 control group: 3014 N; below S1 group: 2166 N; at S1
group: 1044 N). The differences were statistically significant
between the S2 group and S1 group (P 0.03), and be tween the
below S1 and at S1 groups (P 0.04). There was also a decrease in
the mean construct stiffness with more cephalad osteotomies (below
S2 group: 353 N/mm; below S1 group: 248 N/mm; at S1 group: 101
N/mm). The difference was statistically significant between the
below S1 and at S1 groups (P 0.04).
On the basis of these results, the authors concluded that patients in
the below S1 group would be able to weight bear immediately
postoperatively, whereas those in the S1 group should undergo
reconstruction because of the increased risk for fracture.
Figure 3 Laminectomy and ligation of the dural sac. (A) The piriformis muscles are divided to expose the sciatic notch.
The gluteal vessels are then identified and divided to expose the proposed osteotomy site. (B) The laminectomy is
performed. (C) The dural sac is ligated by passing a double silk suture around the dural tube in the axilla of the most
proximal level to remain with the patient. (D) The exiting nerve roots are ligated as necessary (Reprinted with
permission from Dickey et al.8)
101
Sacrectomy Technique
Depending on the location of the lesion, there are various resection
techniques available. These include total sacrec tomy, partial
transverse sacrectomy, combined sagittal and transverse partial
sacrectomy, and sagittal partial sacrectomy (Fig. 1).
Preoperatively, patients receive a bowel preparation, ureteral
stents, central venous access, and broad-spectrum anti biotics.
The sacrectomy is generally performed first through an anterior
approach followed by a posterior approach, less the resection is at
or distal to the S3 foramina. These distal resections can be done
from a posterior approach alone. The anterior approach is performed
either through a transabdominal (used for total sacrectomy) or a
retroperito neal approach (used for partial sacrectomy and internal
hemipelvectomy). The goal of the anterior surgery is to free the
tumor and sacrum from the presacral space. In most cases, a
diverting colostomy is not required, unless there is a high risk for
positive margins if the rectum is left in place. The descending colon,
rectum, iliac vessels, and ureters are mobilized away from the
sacrum (Fig. 2). The posterior divisions of the internal iliac vessels
and middle and lateral sacral vessels are ligated and divided. The
exact level of vessel ligation depends on the location of the tumor.
The anterior divisions of the internal iliac vessels are saved if this is
oncologically appropriate. The dissection is carried above the
planned level of resection, and either a discectomy or vertebral
osteotomy is performed at this level. The sacral nerve roots involved
in the tumor are divided anterior to the ventral sacral foramina if
there is no anterior soft tissue mass that involves them. If such a
mass exists, the involved roots are cut in a location so as not to risk
entering the sarcoma.
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102 JC eck et al

Figure 4 Modified Galveston technique for spinopelvic reconstruction. Pedicle screws are placed from L3-L5 bilaterally.
Rods are attached to the screws and to a transiliac bar. Bilateral iliac screws are connected with a rod (Reprinted with
permission from Gallia et al.16) (Color version of figure is available online.)

Often a vertical rectus abdominis myocutaneous (VRAM) vascularized Reconstruction Techniques

flap is mobilized and packed into the wound for use in posterior
As detailed earlier in the text, after sacrectomy, there is often a need
coverage in the second stage of the procedure.9,10 The posterior
for complex spinopelvic reconstruction. There are numerous clinical
approach can
and biomechanical reports that have in
be performed either the same day, or in a delayed fashion based
on the patient's hemodynamic stability. The usual routine for our
group is to stop after the anterior surgery has been completed, and
to start the posterior portion of the case on a second day. A direct
posterior approach is used, taking care to incorporate any previous
biopsy tracts. The gluteus maximus is dissected laterally to expose
the sacrum, unless there is a posterior soft tissue mass, in which
case the muscles, fascia, subcutaneous fat, and skin are left with the
specimen as needed to achieve margins on the specimen that are
free of tumor. The dissection is carried proximally at least 2 full levels
above the planned level of resection for subsequent reconstruction.
The sacrospinous and sacrotuberous ligaments, piriformis muscles,
and gluteal vessels are divided. A laminectomy is per formed and the
dural sac is ligated in the axillae of the most caudal roots that are to
remain in place (Fig. 3). Osteotomies are then performed above the
level of the tumor margins. The VRAM flap is pulled posteriorly and
sutured to the gluteal fascia.
Figure 5 Triangular fibular strut graft configuration along with spi
nopelvic screw-rod construct (Reprinted with permission from Dickey
et al.8)
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sacrectomy 103

Figure 6 Postoperative AP (A) and lateral (B) radiographs showing the triangular fibular strut graft configuration,
along with the spinopelvic screw-rod construct (Reprinted with permission from Dickey et al.8)

Vestigated spinopelvic reconstruction techniques. Some of the earliest

reported techniques used Harrington rods and sacral bars11 Harrington
rods and AO plates,12 the modified Galveston technique,13-16
followed by more advanced ones using various pedicle screw
constructs.8,17-19 The Galveston technique for
spinopelvic fixation was Initially described by Allen and Ferguson
for use in scoliosis surgery.13 This technique was subsequently
modified for use in spinopelvic reconstruction for sacrectomy.14,15
However, this modified technique had biomechanical limitations in that
the transmitted forces were concentrated at the junction of the L5
pedicle screws and the iliac section of the Galveston rods. A newer
modification reported by Gallia et al16 allows for force transmission
through a transiliac bar and to a rod connecting the iliac screws by use
of a cross connector (Fig. 4). This permits transmission of the forces
to the pelvis at 2 different points and through 2 different planes.

Dickey et al8 reported on results of 9 patients undergoing partial or

total sacrectomy and spinopelvic reconstruction using a triangular
construct along the anatomic force transmission mission vectors from
the femoral heads to the lumbar spine.
After the anterior approach to the sacrectomy is completed, oval-
shaped defects are created in the ilia bilaterally, using a high-speed
burr. These docking sites serve as the receptacles for placement of
bilateral fibular strut grafts. The sites are located at the intersection of
the iliopectineal line, and an imaginary line connecting the center of
the lowest involved vertebra and the center of the hip joint. This
allowed the forces from the patient's body weight to be transmitted
directly from the distal aspect of the remaining spinal column to the
hip joints as in the preresection situation. An additional oval-shaped
defect is created on the inferior aspect of the lowest remaining
vertebra. Pedicle screws are placed bilater ally in the lowest 4
remaining vertebrae, and 2 iliac screws were placed bilaterally in Figure 7 Diagram A and x-ray (B) demonstrating the “straight
each ilium. The fibular grafts are ahead” method for pedicle screw placement (Reprinted with
permission from Shen et al.18)
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104 JC eck et al

located between the sciatic nerve and the iliac vessels when the
sciatic nerve is not resected with the specimen. Two fib ular strut
grafts are then placed from the docking site on the inferior vertebra
to the iliac docking sites in a triangular con struct (Figs. 5 and 6). As
we have continued to gain experience with this technique, we have
discontinued the use of the transsacral bars shown in Figure 6.
Several patients had longitudinal rod breakage at the point where
those rods crossed the sacral bars. We have not had any patients
suffer pelvic widening since making this change. We do place
crosslinks between the left and right longitudinal rods. Others have
performed a similar construct using tibial strut grafts.17

Recently, we and others (Shen et al and Kelly et al)18,19 have

used a four-rod technique for spinopelvic reconstruction. This
construct allows for a rod breakage on each side without the need to
reoperate if the fusion is not solid at the time of rod breakage.
Typically, when a rod breaks, the fusion is not yet solid. The key to
using this technique is placing the pedicle screws in a way to allow
for attachment of 2 rods on each side. There are 2 main techniques
for pedicle screw placement. The first is the Roy-Camille “straight
ahead” method that is started more medially (Fig. 7). the other

Figure 9 Model of lumbar spine instrumented using the 4-rod tech

nique. (Reprinted with permission from Shen et al.18)

method is the Magerl “lateral to medial converging” method that is

started more laterally (Fig. 8). By alternating these techniques, half
of the screw heads are medial for 1 rod and the other half are more
lateral for another rod (Fig. 9). Biomechanical studies have
determined that the 4-rod technique was more stable than the
conventional 2-rod technique in flexion and extension motions, and
in axial rotation when cross links were added.19

conclusion
Malignant tumors of the sacrum present a surgical challenge to resect
the tumor with negative surgical margins, maximize postoperative
function, and restore biomechanical stability.
As detailed earlier in the text, there have been numerous
advancements in these techniques in regard to both tumor resection
and spinopelvic reconstruction. These are difficult cases that require
extensive preoperative planning and the collaboration of multiple
specialists to appropriately care for this challenging patient population.

References
1. Nakai S, Yoshizawa H, Kobayaski S, et al: Anorectal and bladder
Figure 8 (A) and x-ray (B) demonstrating the “lateral to medial con function after sacrifice of the sacral nerves. Spine 25:2234-2239,
verging” method for pedicle screw placement (Reprinted with per 2000 2. Gunterberg B, Norlen L, Stener B, et al: Neurological evaluation
mission from Shen et al.18) after resection of the sacrum. Invest Urol 13:183-188, 1975
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sacrectomy
3. Gunterberg B, Kewenter J, Petersen I, et al: Anorectal function after
major resections of the sacrum with bilateral or unilateral sacrifice of
sacral nerves. Br J Surg 63:546-554,
1976 4. Gunterberg B, Petersen I: Sexual function after major resections
of the sacrum with bilateral or unilateral sacrifice of sacral nerves. Fertile Sterile sacral tumors. Spine 15:1223-1227, 1990
27:1146-1153, 1976
5. Todd LT, Yaszemski MJ, Currier BL, et al: Bowel and bladder function
after major sacral resection. Clin Orthop Relat Res 397:36-39,
2002
6. Gunterberg B, Romanus B, Stener B: Pelvic strength after major
amputation of the sacrum. An experimental study. Acta Orthop Scand
47: 635-642,
1976 7. Hugate RR Jr, Dickey ID, Phimolsarnti R, et al: Mechanical effects
of partial sacrectomy. When is reconstruction necessary? Clin Orthop
Relat Res 450:82-88, 2006
8. Dickey ID, Hugate RR, Fuchs B, et al: Reconstruction after total
sacrectomy. Early experience with a new surgical technique. Clin
Orthop Relat Res
438:42-50, 2005 9. Glatt BS, Disa JJ, Mehrara BJ, et al: Reconstruction
of extensive partial or total sacrectomy defects with a transabdominal
vertical rectus abdomi nis myocutaneous flap. Ann Plast
Surg 56:526-531, 2006 10. Miles WK, Chang DW, Kroll SS, et al:
Reconstruction of large sacral defects following total sacrectomy.
Plast Reconstr Surg 105:2387-2394, 2000
105
11. Shikata J, Yamamuro T, Kotoura Y, et al: Total sacrectomy and
reconstruction for primary tumors. Report of two cases. J Bone Joint
Surg 70A:122-125, 1988
12. Tomita K, Tsuchiya H: Total sacrectomy and reconstruction for huge
13. Allen BL Jr, Ferguson RL: The Galveston technique for L rod
instrumentation of the scoliotic spine. Spine 7:276-284,
1982 14. Gokaslan ZL, Romsdahl MM, Kroll SS, et al: Total sacrectomy
and Galveston L-rod reconstruction for malignant neoplasms.
Technical note. J Neurosurg 87:781-787, 1997
15. Jackson RJ, Gokaslan ZL: Spinal-pelvic fixation in patients with lum
bosacral neoplasms. J Neurosurg 92:61-70, 2000 (suppl)
16. Gallia GL, Haque R, Garonzik I, et al: Spinal pelvic reconstruction after
total sacrectomy for en bloc resection of a giant sacral chordoma. J
Neurosurg Spine 3:501-506,
2005 17. Min K, Espinosa N, Bode B, et al: Total sacrectomy and
reconstruction with structural allografts for neurofibrosarcoma of the
sacrum. J Bone Joint Surg
87A:864-869, 2005 18. Shen FH, Harper M, Foster WC, et al: A novel “four-
rod technique” for lumbopelvic reconstruction: theory and technical
considerations. Spine 31:1395-1401, 2006
19. Kelly BP, Shen FH, Schwab JS, et al: Biomechanical testing of a novel
four-rod technique for lumbopelvic reconstruction. Spine 33:E400-
E406, 2008