Excision techniques for sacral chordoma: A case report

Journal of Orthopaedic Surgery,  Dec 1997  by Osaka, Shunzo,  Taira, Katsunari,  Yoshida, Yukihiro,  Sakurada, Eisaku,  Toriyama, Masato

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ABSTRACT

It is so difficult to excise a sacral that recurrence of this tumour is frequent. Wide resection of a + is a lengthy procedure and is accompanied by bleeding. It also requires a considerable time to perform an osteotomy of the pars lateralis of the sacrum. We have devised a flexible silver guide probe connected by a suture thread to a threadwire saw (T-saw) to make osteotomy easier and faster than the old method where the bilateral sacral root canals are sectioned with a T-saw. However, care must still be taken not to injure the nerve. The sacrectomy was performed by 2 doctors from the posterior approach bilaterally at the same time.

Key words: partial sacrectomy, flexible silver guide probe, osteomy of sacral canaI

INTRODUCTION

It is difficult to excise a sacral + and this surgery has a very poor prognosis.2,3 Tomita et al.4 devised a threadwire saw (T-saw) with a guide, in place of a Gigli saw, to section the bone more easily during spinal surgery. However, the guide they used was curved and still had the risk of injuring the nerve roots. Therefore, instead of their curved guide, we have devised a flexible silver guide probe connected with a T-saw by a suture thread to protect the nerve roots during excision of a sacral + during the osteotomy. This technique not only protects the nerve roots but also results in less bleeding and less procedural time.

CASE REPORT

The patient, a 43-year-old male, was diagnosed by open biopsy as having a sacral chordoma. CT scan and MRI showed that the bilateral S1 roots could possibly be preserved (Figs. la, b). A chest X-ray showed no abnormalities and laboratory data were normal.

Surgical techniques

Surgery was performed by the anterior and posterior combined approach. The internal iliac arteries were ligated bilaterally, and the median sacral vessels were also ligated and severed. The rectum and the tumour were then dissected apart. Then, by the posterior approach, using a reverse Y-shaped incision, the gluteus maximus muscles were cut along the sacrum and the piriformis muscles were cut on both sides laterally. Two doctors, one on either side, performed the surgery simultaneously. L5 and S1 laminectomies were performed, and the bilateral S1roots were isolated by electric stimulation. A flexible silver guide probe was connected by a suture thread with a Tsaw (width 1 mm). The flexible probe was inserted into and passed through the sacral canal (S1 root) distally to protect the sciatic nerves (L5 and S1 nerve roots) and superior gluteal arteries. Then it was pushed up into position with the finger (Fig. 2). By pulling out the probe from the canal, the T-saw passed easily through the canal. The modified secondary T-saw performed the bilateral osteotomy of the pars lateral of the sacrum much more easily and quickly (Fig. 3). The dura was ligated preserving the S1 roots. An osteotomy of the distal first sacral body was performed at a 45 deg angle to the cranial side with an osteotome. The tumour was excised after cutting the sacrotuberous ligaments, the sacrospinous ligaments with ischial spines and the S2-5 roots bilaterally. The tumour and rectum were separated from the posterior area. The operative time, in this case, was 15 hours with 4000 g of blood loss. The patient had no recurrence or metastasis in the 3 years following surgery.

DISCUSSION

It is difficult to widely excise a sacral +. Excision of the tumour is frequently accompanied by massive blood loss, nerve injury and infection. Usually laminectomy is performed at levels L5 and S1. Preserving the roots is important because it contributes to the quality of postoperative life. Hata et al.1 devised a T-saw4 to section the bone more easily during the sacral surgery. However, the guide they used was curved, and still had the risk of injuring the nerve roots. We devised a flexible silver guide probe connected with a T-saw by a suture thread to protect the nerve roots during the excision of the sacral + during the osteotomy.

The first author performed the same surgery on 4 different occasions, using the old method of a bone punch or chisel, on chordomas of the same size at approximately the same location. The operative time was from 13 to 20 hours (average 16.5 hours) and bleeding was from 5000 g to 10,000 g (average 7500 g). Using the new modified T-saw, the operative time was 15 hours and bleeding 4000 g, which was a significant improvement for the patient.

CONCLUSION

Using a flexible silver probe connected with a T-saw by a suture thread to perform an osteotomy of the pars lateral of the sacrum, proved to be easier and faster than osteotomies performed using the old method.

REFERENCES

1Hata M, Kawahara N, Mizuno K, Tomita K. Innovative oncological resection of sacral tumors, using threadwire saw. Rinsho Seikeigeka 1997, 32:499-505. (In Japanese)

2Osaka S, Toriyama S. Treatment and prognosis of sacrococcygeal chordoma: Study of bone tumor registry in Japan. J Jpn Orthop Assoc 1989, 63:240-4.

3. Stener B, Gunterberg B. High amputation of the sacrum for extirpation of tumors: Principles and techniques. Spine 1978, 3:351-66.