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Robert J. Jackson and Ziya L. Gokaslan

ilium fixation, thereby bypassing the sacrum. Allen and Ferguson 2–5 originally described performing a lumbar—ilium L-rod pelvic fixation to treat scoliosis, pelvic obliquity, and degenerative processes of the LSJ, which became known as the Galveston technique of pelvic fixation. We have modified this fixation technique by using lumbar pedicle screw fixation in place of sublaminar wire in patients with spinal—pelvic instability secondary to lumbosacral tumors. With particular attention to method, pain relief, and neurological status, we have retrospectively

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Robert J. Jackson, Ziya L. Gokaslan, and Shang-Chuin Arvinloh

junction were stabilized with the modified Galveston spinal—pelvic fixation technique as previously described. 15 Extensive tumors involving both the anterior and posterior aspects of the spine were approached and stabilized from both directions or the posterior transpedicular vertebrectomy technique was used, as described by Akeyson and McCutcheon 1 ( Fig. 3 ). Postoperative external immobilization was not used in any patient. Fig. 3. Left: Axial MR image demonstrating metastatic renal carcinoma to L-5. Center and Right: Anteroposterior and lateral

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Daryl R. Fourney, Dima Abi-Said, Frederick F. Lang, Ian E. McCutcheon, and Ziya L. Gokaslan

– 2462 , 1995 Hosono N, Yonenobu K, Fuji T, et al: Vertebral body replacement with a ceramic prosthesis for metastatic spinal tumors. Spine 20: 2454–2462, 1995 25. Jackson RJ , Gokaslan ZL : Spinal-pelvic fixation in patients with lumbosacral neoplasms. J Neurosurg (Spine 1) 92 : 61 – 70 , 2000 Jackson RJ, Gokaslan ZL: Spinal-pelvic fixation in patients with lumbosacral neoplasms. J Neurosurg (Spine 1) 92: 61–70, 2000 26. Jonsson B , Sjostrom L , Olerud C , et al : Outcome after limited

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Mohamad Bydon, Vance Fredrickson, Rafael De la Garza-Ramos, Yiping Li, Ronald A. Lehman Jr., Gregory R. Trost, and Ziya L. Gokaslan

indications for sacral fractures include: 1) unstable fractures, 2) neurological deficit, and 3) severe axial or sagittal spinal misalignment. 14 Most surgical interventions are based on 1) resection of the distal sacrum, 2) posterior or posterolateral neural decompression, 3) direct reduction and fixation, and 4) reduction and fixation of the lumbosacral spine with lumbopelvic fixation. 14 Unstable sacral fractures associated with anterior pelvic fractures are usually treated with anterior pelvic fixation or plating. Vertical shear patterns of injury coupled with

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Gary L. Gallia, Raqeeb Haque, Ira Garonzik, Timothy F. Witham, Yevgeniy A. Khavkin, Jean Paul Wolinsky, Ian Suk, and Ziya L. Gokaslan

titanium wires ( Figs. 2 and 3 ). Cancellous allograft bone chips, autologous bone, and demineralized bone matrix were placed after decortication of the L-3, L-4, and L-5 transverse processes and the medial aspect of the ilia. The previously mobilized rectus abdominis myocutaneous pedicle flap was advanced through the pelvis and used to reconstruct the sacral defect. Fig. 2. Intraoperative photograph showing lumbar pelvic fixation and fusion system following total sacrectomy. Fig. 3. Artist's illustration depicting the spinopelvic reconstruction

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Michelle J. Clarke, Patricia L. Zadnik, Mari L. Groves, Hormuzdiyar H. Dasenbrock, Daniel M. Sciubba, Wesley Hsu, Timothy F. Witham, Ali Bydon, Ziya L. Gokaslan, and Jean-Paul Wolinsky

anticipated nerve root sacrifice. F ig . 2. Case 1. Preoperative coronal (A) , axial (B and C) , and sagittal (D) MR images of the sarcoma centered in the left hemisacrum and the SI joint. White arrow indicates invasion of the ilium. Lateral (E) and anteroposterior (F) views of the lumbopelvic reconstruction on scout CT scans. Since the left hemipelvis was resected, it is notable how far lateral the pelvic fixation is relative to the right side (black arrow). Coronal CT (G) demonstrates the location of the femoral strut. Operation Initially a 2

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Daryl R. Fourney, Laurence D. Rhines, Stephen J. Hentschel, John M. Skibber, Jean-Paul Wolinsky, Kristin L. Weber, Dima Suki, Gary L. Gallia, Ira Garonzik, and Ziya L. Gokaslan

: Spinal-pelvic fixation in patients with lumbosacral neoplasms. J Neurosurg (Spine 1) 92 : 61 – 70 , 2000 Jackson RJ, Gokaslan ZL: Spinal-pelvic fixation in patients with lumbosacral neoplasms. J Neurosurg (Spine 1) 92: 61–70, 2000 26. Kaiser TE , Pritchard DJ , Unni KK : Clinicopathologic study of sacrococcygeal chordoma. Cancer 53 : 2574 – 2578 , 1984 Kaiser TE, Pritchard DJ, Unni KK: Clinicopathologic study of sacrococcygeal chordoma. Cancer 53: 2574–2578, 1984 27. Karakousis CP

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Iman Feiz-Erfan, Benjamin D. Fox, Remi Nader, Dima Suki, Indro Chakrabarti, Ehud Mendel, Ziya L. Gokaslan, Ganesh Rao, and Laurence D. Rhines

metastatic carcinomas of the kidney or melanomas: an analysis using palliative end points . Int J Radiat Oncol Biol Phys 41 : 401 – 405 , 1998 15 Huland E , Heinzer H : Renal cell carcinoma: novel treatments for advanced disease . Curr Opin Urol 13 : 451 – 456 , 2003 16 Jackson RJ , Gokaslan ZL : Spinal-pelvic fixation in patients with lumbosacral neoplasms . J Neurosurg 92 : 1 Suppl 61 – 70 , 2000 17 Laskin JJ , Sandler AB : State of the art in therapy for non-small cell lung cancer . Cancer Invest 23 : 427 – 442 , 2005 18 Lee

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Daniel M. Sciubba, Rory J. Petteys, Giannina L. Garces-Ambrossi, Joseph C. Noggle, Matthew J. McGirt, Jean-Paul Wolinsky, Timothy F. Witham, and Ziya L. Gokaslan

, 1998 53 Herman TS , Hammond N , Jones SE , Butler JJ , Byrne GE Jr , McKelvey EM : Involvement of the central nervous system by non-Hodgkin's lymphoma: the Southwest Oncology Group experience . Cancer 43 : 390 – 397 , 1979 54 Imai R , Kamada T , Tsuji H , Yanagi T , Baba M , Miyamoto T , : Carbon ion radiotherapy for unresectable sacral chordomas . Clin Cancer Res 10 : 5741 – 5746 , 2004 55 Jackson RJ , Gokaslan ZL : Spinal-pelvic fixation in patients with lumbosacral neoplasms . J Neurosurg 92 : 61 – 70

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Benjamin D. Elder, Wataru Ishida, C. Rory Goodwin, Ali Bydon, Ziya L. Gokaslan, Daniel M. Sciubba, Jean-Paul Wolinsky, and Timothy F. Witham

, 2010 35 Jackson RJ , Gokaslan ZL : Spinal-pelvic fixation in patients with lumbosacral neoplasms . J Neurosurg 92 : 1 Suppl 61 – 70 , 2000 36 Jandali S , Diluna ML , Storm PB , Low DW : Use of the vascularized free fibula graft with an arteriovenous loop for fusion of cervical and thoracic spinal defects in previously irradiated pediatric patients . Plast Reconstr Surg 127 : 1932 – 1938 , 2011 37 Joaquim AF , Powers A , Laufer I , Bilsky MH : An update in the management of spinal metastases . Arq Neuropsiquiatr 73 : 795