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Joseph S. Cheng and John K. Song

One of the basic tenets of performing surgery is knowledge of the relevant anatomy. Surgeons incorporate this knowledge along with factors, such as biomechanics and physiology, to develop their operative approaches and procedures. In the diagnosis and management of sacral tumors, the need to be familiar with the anatomy of the sacrum is no less important than knowledge of the pathological entity involved. This article will provide an overview of the embryology and anatomy of the sacrum, along with concepts as applied to surgical intervention.

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Pierre-Jacques Finiels, Hélène Finiels, Denise Strubel, and Jean-Marc Jacquot

S ince their initial description by Lourie in 1982, 14 spontaneous osteoporotic fractures of the sacrum seem to have become a well-known entity, predominantly occurring in elderly women with postmenopausal osteoporosis. The general clinical features are not specific, and diagnosis is made based on evaluation of imaging studies. 4 In a recent literature review the authors found more than 500 reported cases. 7 These authors focused primarily on the diagnostic problems raised by the absence of a traumatic episode, the lack of specificity of the symptoms and

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Daryl R. Fourney, Gregory N. Fuller, and Ziya L. Gokaslan

segment. 8 Only six cases have been reported in the English-language literature in which the tumor was thought to have arisen from within the sacrum, because there was minimal extension into the presacral space or regions dorsal to the sacrum. 10, 13–15, 18, 19 We report the only intraspinal extradural myxopapillary ependymoma known conclusively to arise from the filum terminale externa. Case Report History This 63-year-old man was previously in good health except for a history of hypothyroidism. He had presented at another institution 10 months earlier

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Dermot P. Byrnes, G. Lee Russo, Thomas B. Ducker, and R Adams Cowley

was normal, apart from a partial spinal bifida occulta of L-5. After several days the patient awoke and became cooperative. When the urinary catheter was removed, she was unable to micturate, and a lateral pelvic x-ray film revealed a fractured sacrum at the S1–2 level ( Fig. 1 ). In 5 days she was awake enough to cooperate with a full neurological examination. It became obvious that she had a perianal anesthesia from S-2 down and a lax anal sphincter, and that she was unable to micturate. A cystometrogram supported diagnosis of fractured sacrum with complete

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Nerve sheath tumors involving the sacrum

Case report and classification scheme

Paul Klimo Jr., Ganesh Rao, Richard H. Schmidt, and Meic H. Schmidt

Nerve sheath tumors that involve the sacrum are rare. Delayed presentation is common because of their slow-growing nature, the permissive surrounding anatomical environment, and nonspecific symptoms. Consequently, these tumors are usually of considerable size at the time of diagnosis.

The authors discuss a case of a sacral nerve sheath tumor. They also propose a classification scheme for these tumors based on their location with respect to the sacrum into three types (Types I–III). Type I tumors are confined to the sacrum; Type II originate within the sacrum but then locally metastasize through the anterior and posterior sacral walls into the presacral and subcutaneous spaces, respectively; and Type III are located primarily in the presacral/retroperitoneal area. The overwhelming majority of sacral nerve sheath tumors are schwannomas. Neurofibromas and malignant nerve sheath tumors are exceedingly rare. Regardless of their histological features, the goal of treatment is complete excision. Adjuvant radiotherapy may be used in patients in whom resection was subtotal. Approaches to the sacrum can generally be classified as anterior or posterior. Type I tumors may be resected via a posterior approach alone, Type III may require an anterior approach, and Type II tumors usually require combined anterior–posterior surgery.

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R. Lor Randall

Giant cell tumor (GCT) is a locally highly aggressive tumor of bone comprising 5 to 10% of all benign bone tumors. The sacrum is the third most common site of involvement. Patients with sacral GCTs present with localized pain in the lower back that may radiate to one or both lower limbs. Vague abdominal complaints and bowel and bladder symptoms may also be present. Neuroimaging workup should include advanced modalities, preferably magnetic resonance imaging, prior to obtaining a biopsy specimen. Giant cell tumor has a 1 to 5% rate of metastasizing to the lung and may convert to a fulminate malignant variant, which has a very poor prognosis. The standard treatment for GCT is curettage combined with adjuvant bone grafting or cement-augmented stabilization. In appropriately selected cases, sacral resection is a valuable procedure to effect local tumor control and overall survival. Embolization may also prove palliative and/or curative in cases in which the tumor is unresectable or refractory to treatment.

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Chunzi Jenny Jin, John Berry-Candelario, Anne S. Reiner, Ilya Laufer, Daniel S. Higginson, Adam M. Schmitt, Eric Lis, Ori Barzilai, Patrick Boland, Yoshiya Yamada, and Mark H. Bilsky

C hordomas are rare high-grade malignant tumors with poor rates of local control (LC) and a propensity for delayed metastatic spread. Arising in notochordal remnants in the sacrum, skull base, and mobile spine, they often involve critical neurological and skeletal structures, resulting in significant symptom burden. To date, no effective systemic therapies are available. Traditionally, surgery has been considered the first-line therapy for providing a definitive cure. 4 En bloc resection providing wide margins is superior to en bloc intralesional resection or

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Nicolas Dea, Charles G. Fisher, Jeremy J. Reynolds, Joseph H. Schwab, Laurence D. Rhines, Ziya L. Gokaslan, Chetan Bettegowda, Arjun Sahgal, Áron Lazáry, Alessandro Luzzati, Stefano Boriani, Alessandro Gasbarrini, Ilya Laufer, Raphaële Charest-Morin, Feng Wei, William Teixeira, Niccole M. Germscheid, Francis J. Hornicek, Thomas F. DeLaney, John H. Shin, and the AOSpine Knowledge Forum Tumor

C urrent evidence supports en bloc resection with wide margins as the best method to achieve disease-free survival for mobile spine and sacral chordomas. 1 , 9 Because of the unique anatomical and functional characteristics of the spine, achieving wide or marginal margins is often difficult, even in the most experienced hands. 1 , 21 , 26 Moreover, for chordomas located in the upper cervical spine and sacrum, the cost of achieving these margins from an adverse event and health-related quality-of-life (HRQOL) perspective is substantial. 5 , 22 , 24 , 25

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Andrea Winter, Alan Siu, Aria Jamshidi, Martin Malawer, and Jonathan H. Sherman

–16 , 19 , 27 , 28 spindle cell hemangioendothelioma exhibits an acral predisposition, 11 , 12 , 14 with sporadic reports of these tumors in the oral cavity, 24 brain, 7 and thoracic spine. 1 , 22 We present the first known case of a spindle cell hemangioendothelioma involving the sacrum. Case Report History and Examination This 31-year-old woman presented with low-back and left lower-extremity pain in the S-1 distribution without weakness or bowel or bladder dysfunction. Admission CT and MRI studies identified a large osteolytic sacral lesion

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William E. Humphries III, Krishna B. Satyan, Katherine Relyea, Eugene S. Kim, Adekunle M. Adesina, Murali Chintagumpala, and Andrew Jea

criteria for diagnosis. Myofibroblastic sarcoma of the bone seems to be extremely rare, and to the best of our knowledge, only 8 cases have been previously reported. We report a ninth case of myofibroblastic sarcoma involving the sacrum and ilium of a 15-year-old girl. Case Report History and Examination This 15-year-old girl had a history of a sacral mass that was diagnosed by CT-guided needle biopsy 2 years ago as benign fibrohistiocytoma. After being lost to follow-up and without undergoing further treatment, she presented again with worsening back and leg