Spinal—pelvic fixation in patients with lumbosacral neoplasms

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Object. Primary and metastatic neoplasms of the lumbosacral junction frequently pose a complex problem for the surgical management and stabilization of the spine because of the anatomical and biomechanical factors of this transition zone between spine and pelvis. The authors have used a modification of the Galveston technique, originally described by Allen and Ferguson in the treatment of scoliosis, to achieve rigid spinal—pelvic fixation in patients with lumbosacral neoplasms. The authors retrospectively reviewed their experience, with particular attention to method, pain relief, and neurological status.

Methods. From July 1994 through December 1998, 13 patients at the authors' institution have required spinal—pelvic fixation secondary to instability caused by primary (eight cases) or metastatic (five cases) neoplasms. Previous treatment included spinal surgery in 10 (77%), radiation therapy in seven (54%), and/or chemotherapy in six (46%). Following tumor resection, fixation was achieved by intraoperative placement of contoured titanium rods bilaterally into the ilium. These rods were attached to the lumbar spine with pedicle screws and subsequently crosslinked. Arthrodesis was performed.

In the follow-up period of 3 to 50 months (average 20 months), nine (69%) of 13 patients were still alive. There were no cases of surgery-related death. Seven weeks postoperatively instrumentation failure occurred in one patient and was corrected by performing double L-rod spinal—pelvic fixation. Two patients experienced neurological dysfunction (ankle weakness and neurogenic bladder) that was thought to be related to tumor resection rather than the fixation procedure. Neurological status improved in four patients and remained unchanged in seven patients. Ambulatory status improved in 62% (eight patients), remained unchanged in 23% (three patients), and worsened in 15% (two patients). Spinal pain, as measured by a visual analog pain scale and determined by medication consumption was significantly reduced in 85% (11 cases).

Conclusions. In selected patients with primary or metastatic lumbosacral tumors, resection followed by modified Galveston L-rod spinal—pelvic fixation is an effective means of achieving stabilization that can provide significant pain relief and preserve ambulatory capacity.

Article Information

Address reprint requests to: Ziya L. Gokaslan M.D., Department of Neurosurgery, Box 64, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030.

© AANS, except where prohibited by US copyright law.

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Figures

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    Artist's illustration depicting the posterior exposure of the sacrum, medial ilium, and lumbar spine. The lumbosacral fascia/muscular flap is lifted off of the sacrum and retracted cephalad and laterally. Inset: The dashed line represents the posterior incision.

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    Case 9. Upper Left and Right: Preoperative axial computerized tomography scan (upper left) magnetic resonance image (upper right) revealing a sacral chordoma. Lower Left: Hemisection of gross pathological specimen demonstrating complete en bloc resection of the sacrum. Lower Center and Right: Postoperative anteroposterior and lateral radiographs.

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    Artist's illustrations. Upper Left: A 6-mm titanium pilot rod is tapped into the cancellous portion of the ilium to create a path for the contoured rod. This temporary rod is directed 1.5 cm above the sciatic notch and between the two cortices of the ilium. It is tapped into place with a mallet to a depth of 6 to 9 cm. Upper Right: A 6-mm titanium rod is then contoured to match the template rod (wire) by using tube benders and a table vice. The final shape of spinal-pelvic rod matches template rod (A); tube benders are used to create the sacroiliac bend of approximately 60° (B); and the table vice is used to stabilize the sacral and iliac segments of the rod while an approximately 110° bend is created between the lumbar and sacral segments (C). Lower Left: Illustration of the spinal—pelvic fixation.

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    Bar graph showing the median VAS pain scores at preoperative evaluation and at postoperative follow-up examinations. A VAS score of 10 indicates severe pain and a score of 0 indicates no pain. n = number of patients examined at the follow-up interval.

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    Case 7. Anteroposterior radiographs demonstrating fractured rods (left) and revision in which dual rods were used for spinal—pelvic fixation (right).

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