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Open access

Percutaneous lumbopelvic fixation for pathologic sacral fractures and spinopelvic dissociation: patient series

Nikolas Baksh, Caleb Yeung, and Max Vaynrub

BACKGROUND

Because patients with advanced cancer live longer, the number of patients with the sequelae of metastatic spine disease has increased. Pathologic instability of the mobile spine has been classified, and minimally invasive surgery has been well described. However, pathologic sacral instability is uncommon and often underdiagnosed. Although most sacral fractures are stable, patients with unstable U- or H-type fractures have spinopelvic dissociation and can experience progressive pain, sacral kyphosis, and neurological injury. Open lumbopelvic fusion carries a high perioperative risk for this patient population, which has often been previously radiated and is medically frail. The authors investigated the utility and safety of percutaneous lumbopelvic fixation, as previously described for traumatic spinopelvic dissociation, in the oncological setting. The authors retrospectively reviewed five consecutive patients with unstable pathologic sacral fractures who had undergone percutaneous lumbopelvic fixation after conservative management failed.

OBSERVATIONS

Patients experienced significant improvement between pre- and postoperative visual analog scale scores (9.2 and 1.6, respectively) and Eastern Cooperative Oncology Group grades (median 3 and 1, respectively). All patients were independently ambulatory at the final follow-up. Sagittal alignment remained stable in four patients and worsened in one. There were no major medical or surgical complications.

LESSONS

Percutaneous lumbopelvic fixation shows promising results for palliation, durability, and safety for pathologic sacropelvic instability.

Open access

Carbon fiber lumbopelvic reconstruction following sacral giant cell tumor resection: illustrative case

Jon Raso, Jialun Chi, Lawal A. Labaran, Charles Frank, and Francis H. Shen

BACKGROUND

The use of carbon fiber or polyetheretherketone spine constructs has proven to be a safe and effective alternative to standard metal alloy. The mechanical properties of carbon fiber while unique provide a construct that is comparable in strength to previous titanium-based constructs and have additionally shown greater fatigue resistance. These constructs have been especially useful for the mechanical stabilization of the spine following tumor resection. The subsequent interference seen when imaging a patient with a traditional metallic construct is reduced and allows for improved tumor surveillance after the procedure, and a more accurate delivery of radiotherapy when indicated.

OBSERVATIONS

This case report details the treatment of a 25-year-old female diagnosed with a sacral giant cell tumor. The authors discuss the use of a carbon fiber-reinforced polyetheretherketone for lumbopelvic reconstruction.

LESSONS

Carbon fiber-reinforced polyetheretherketone with its radiolucency and rigidity is a reliable option for complex spinal reconstruction after tumor resection.

Open access

Spinal epidural lipomatosis in a pediatric patient with a malignant brain tumor: illustrative case

Reed Berlet, Daphne Li, and John Ruge

BACKGROUND

Spinal epidural lipomatosis (SEL) in pediatric patients with concomitant malignant brain neoplasms is rare and can present with rapid deterioration in neurological function.

OBSERVATIONS

A 4-year-old boy with SEL became paraplegic 4 months after completion of chemoradiation for his previously resected, intracranial atypical teratoid rhabdoid tumor. The patient presented with rapid deterioration in lower extremity sensory and motor function, which, given his oncological history, was concerning for disease progression. Of note, 8 months prior, the patient was started on corticosteroid therapy for respiratory dysfunction. Magnetic resonance imaging revealed significant progression of lumbosacral SEL requiring surgical decompression with subsequent neurological improvement.

LESSONS

When evaluating pediatric patients with primary or metastatic brain tumors with new or worsening myelopathy and motor or sensory deficits, it is important to consider SEL.

Open access

Pineal parenchymal tumor of intermediate differentiation with late spinal dissemination 13 years after initial surgery: illustrative case

Hiroyuki Kato, Takafumi Tanei, Yusuke Nishimura, Yoshitaka Nagashima, Motonori Ishii, Tomoya Nishii, Nobuhisa Fukaya, Takashi Abe, and Ryuta Saito

BACKGROUND

Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare in the pineal gland. A case of PPTID that disseminated to the lumbosacral spine 13 years after the total resection of a primary intracranial tumor has been reported.

OBSERVATIONS

A 14-year-old female presented with headache and diplopia. Magnetic resonance imaging revealed a pineal tumor that induced obstructive hydrocephalus. A biopsy and endoscopic third ventriculostomy were performed. Histological diagnosis revealed a grade II PPTID. Two months later, the tumor was removed via craniotomy because the postoperative Gamma Knife surgery was ineffective. Histological diagnosis confirmed PPTID, although the grade was revised from II to III. Postoperative adjuvant therapy was not performed, because the lesion had been irradiated and gross total tumor removal was achieved. She has had no recurrence in 13 years. However, pain around the anus newly appeared. Magnetic resonance imaging of the spine revealed a solid lesion in the lumbosacral spine. The lesion was subtotally resected, and histological diagnosis revealed grade III PPTID. Postoperative radiotherapy was performed, and she had no recurrence 1 year after radiotherapy.

LESSONS

Remote dissemination of PPTID can occur several years after the initial resection. Regular follow-up imaging, including the spinal region, should be encouraged.

Open access

Navigation-assisted resection of tumoral calcinosis of the lumbosacral spine: illustrative case

Oliver Y. Tang, Patricia Zadnik Sullivan, Teddi Tubre, Joshua Feler, Belinda Shao, Jesse Hart, and Ziya L. Gokaslan

BACKGROUND

Tumoral calcinosis is an uncommon disease resulting from dystrophic calcium phosphate crystal deposition, with only 7% of cases involving the spine, and it may diagnostically mimic neoplasms.

OBSERVATIONS

In this case, a 54-year-old woman with history of systemic scleroderma presented with 10 months of progressive left lumbosacral pain. Imaging revealed an expansile, 4 × 7-cm, well-circumscribed mass in the lumbosacral spine with L5–S1 neuroforaminal compression. Because intractable pain and computed tomography (CT)-guided needle biopsy did not entirely rule out malignancy, operative management was pursued. The patient underwent L4–S2 laminectomies, left L5–S1 facetectomy, L5 and S1 pediculectomies, and en bloc resection, performed under stereotactic CT-guided intraoperative navigation. Subsequently, instrumented fusion was performed with L4 and L5 pedicle screws and S2 alar-iliac screws. Pathological examination was consistent with tumoral calcinosis, with multiple nodules of amorphous basophilic granular calcified material lined by histiocytes. There was no evidence of recurrence or neurological deficits at 5-month follow-up.

LESSONS

Because spinal tumoral calcinosis may mimic neoplasms on imaging or gross intraoperative appearance, awareness of this clinical entity is essential for any spine surgeon. A review of all case reports of lumbosacral tumoral calcinosis (n = 14 from 1952 to 2016) was additionally performed. The case featured in this report presents the first known case of navigation-assisted resection of lumbosacral tumoral calcinosis.

Open access

Sacral myolipoma with involuntary contraction causing tethered cord syndrome: illustrative case

So Fujimoto, Takashi Agari, Takashi Komori, and Keisuke Takai

BACKGROUND

Spinal lipomas sometimes involve various ectopic tissues originating from the ectoderm, mesoderm, and endoderm in the process of morphological development.

OBSERVATIONS

A 29-year-old male patient with myolipoma of the conus medullaris at the S2 and S3 levels was described. The unusual finding, involuntary muscle contraction, was presented in an operative video and a literature review. In the present case, sacral myolipoma with involuntary contraction caused tethered cord syndrome in adulthood, and untethering surgery resolved continuous buttock and leg pain.

LESSONS

This rare finding is considered a surgical indication for adult patients with myolipoma.

Open access

Giant sacrococcygeal teratoma in a neonate: illustrative case

Durga Neupane, Alok Dahal, Nimesh Lageju, Lokesh Shekher Jaiswal, Nimesh Bista, and Aakriti Sapkota

BACKGROUND

Sacrococcygeal teratomas (SCTs) are tumors that emerge in the sacrococcygeal area and contain tissue from all three germ layers. SCT affects about 1 in every 35,000–40,000 live births, with malignant transformation becoming more common as the patient gets older. Ultrasound helps in prenatal diagnosis. Surgical resection is the mainstay of treatment.

OBSERVATIONS

A couple gave birth to a neonate with a small mass over his sacral region that progressively increased in size. Diagnostic magnetic resonance imaging was performed, and a diagnosis of giant SCT was established. Complete resection with flap reconstruction was performed. In regular follow-up, he is in a good state of health.

LESSONS

One of the most common tumors in infancy, SCT should be carefully diagnosed. SCT is often confused with neural tube defects such as myelocystocele or myelomeningocele. Complete resection with appropriate reconstruction can ensure better treatment, and close follow-up until adulthood is recommended to keep a close view on its possible recurrence and to improve prognosis. Postoperative complications such as infection, bleeding, and urethral complications should be carefully watched.

Open access

Sacral insufficiency fractures are a risk of massive bleeding during sacrectomy: patient series

David C. Kieser, Scheherezade Soltani, Niels Hammer, Amir Koutp, Eleanor Hughes, and Jeremy J. Reynolds

BACKGROUND

Sacrectomy carries significant risk of bleeding; however, specific risk factors, apart from medical comorbidities and tumor type, for this life-threatening complication remain unclear. This study describes two cases of massive bleeding, including one death during sacrectomy attributable to adherence of the internal iliac vein (IIV) and its neuroforaminal tributaries from sacral insufficiency fractures.

OBSERVATIONS

The authors presented two cases involving patients who received sacrectomy for a chordoma and experienced massive bleeding from the IIV due to adherence of the IIV and its neuroforaminal tributaries around sacral insufficiency fractures. They assessed their institution’s previous two decades’ experience of sacrectomies to determine risk factors for massive bleeding and performed anatomical dissection of 20 hemipelvises, which revealed the close proximity of the IIV to the sacral foraminae and the consistency of neuroforaminal tributaries arising from the foraminae.

LESSONS

Sacral insufficiency fractures may cause scarring that adheres to the IIV and its neuroforaminal tributaries, which risks massive bleeding during sacrectomy.

Open access

Nerve preservation during partial sacrectomy by two-stage anterior and posterior approach: illustrative case

Parménides Guadarrama-Ortíz, Ingrid Montes de Oca-Vargas, José Alberto Choreño-Parra, André Garibay-Gracián, Deyanira Capi-Casillas, Alondra Román-Villagomez, Citlaltepetl Salinas-Lara, Ulises Palacios-Zúñiga, and Ángel Daniel Prieto-Rivera

BACKGROUND

Preserving the neurological function of sacral nerves during total or partial sacrectomy is challenging.

OBSERVATIONS

The authors describe a case of an osseous desmoplastic fibroma of the sacrum in a 51-year-old woman. The patient attended the authors’ institution with loss of muscle strength and sensitivity impairment in both legs, gait instability, bowel constipation, urinary incontinence, and weight loss. Preoperative magnetic resonance imaging and positron emission tomography/computed tomography showed intrapelvic and posterior extension of the tumor but sparing of S1 and the sacroiliac and lumbosacral joints. After a multidisciplinary discussion of the case, a staged anterior–posterior approach to the sacrum was chosen. The abdominal approach allowed full mobilization of the uterus, ovaries, bladder, and colon and protection of iliac vessels. After tumor resection, a synthetic surgical mesh was placed over the sacrum to minimize soft tissue defects. Then, the posterior stage allowed the authors to perform a bicortical osteotomy, achieving wide tumor excision with minimal nerve root injury. Spinopelvic fixation was not necessary, because both sacroiliac and lumbosacral joints remained intact. A few days after the surgery, the patient restarted ambulation and recovered sphincter control.

LESSONS

Multidisciplinary planning and a staged abdominal and posterior approach for partial sacrectomy were fundamental to preserve neurological function in this case.