Departments of1Neurosurgery and.
2Plastic & Reconstructive Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Neurosurg Focus. 2024 May;56(5):E7. doi: 10.3171/2024.2.FOCUS23926.
Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors' institutional case series.
The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed.
The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision.
The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.
为了最大限度地提高无复发生存率和总体生存率，同时降低治疗的发病率，当前对骶骨脊索瘤的治疗需要采用综合方法。整块切除术可在骶骨的不同水平进行，肿瘤的位置和体积最终决定了所需的切除范围和随后的组织重建。由于涉及上骶骨的肿瘤切除术可能会非常不稳定，因此其他相关的考虑因素与器械和随后的组织重建有关。本研究的主要目的是根据腰骶脊柱受累的位置，调查用于治疗原发性骶骨脊索瘤的手术方法，包括对文献的叙述性回顾和对作者机构病例系列的检查。
作者对涉及原发性骶骨肿瘤整块切除后重建和避免并发症的相关文献进行了叙述性综述，同时补充了作者所在队列的 11 例当代病例系列。还讨论了相关的手术解剖学、器械和重建技术的进步、术中成像和导航、软组织重建以及避免伤口并发症。
文献综述确定了几种用于治疗原发性骶骨脊索瘤的手术方法，这些方法适用于定位在低骶骨水平（中 S2 及以下）、高骶骨水平（涉及 S2 以上）和高骶骨水平伴腰椎受累的肿瘤。在当代病例系列中，大多数病例（8/11）为低骶骨肿瘤，无需使用器械。少数病例需要更广泛的器械和重建，其中 2 例肿瘤累及 S2 和/或 S1 水平，1 例肿瘤延伸至下腰椎。在 11 例病例中，有 10 例成功实现了整块切除术，由于直肠受累，有 2 例需要行结肠造口术。所有 11 例均由整形外科进行了肌皮瓣伤口闭合，无一例出现需要修复的伤口并发症。
骶骨脊索瘤的现代治疗方法涉及多学科手术团队和术中技术，通过整块切除术最大限度地降低手术发病率，同时优化肿瘤学结果。大多数病例表现为无需使用器械的低位骶骨肿瘤，但在上位骶骨和腰骶部病例中，稳定的器械和腰骶部重建通常是必要的。在努力减少与伤口相关的并发症方面，肌皮瓣闭合作为一种循证措施，可能会降低风险。
