Xia Yuanxuan, Papali Pritika, Al-Mistarehi Abdel-Hameed, Ahmed A Karim, Hansen Landon J, Meyer Christian, Gross John, Khan Majid, Winkle Malcolm, Bettegowda Chetan, Witham Timothy, Bydon Ali, Theodore Nicholas, Wolinsky Jean-Paul, Gokaslan Ziya, Lo Sheng-Fu Larry, Sciubba Daniel M, Colakoglu Salih, Lee Sang H, Redmond Kristin J, Lubelski Daniel
1Department of Neurosurgery.
2Division of Medical Oncology, and Departments of.
J Neurosurg Spine. 2025 Jul 11:1-12. doi: 10.3171/2025.3.SPINE241408.
Wide en bloc excision of sacrococcygeal chordomas often requires sacral nerve root sacrifice because of their large size and involvement of surrounding structures. In this study, the authors characterize the long-term functional outcomes of patients following definitive resection, investigate the relationship between sacrificed nerve roots and deficits, and examine predictors of postoperative neurological deficits.
A retrospective study was conducted on all patients followed for sacral chordoma management at a quaternary spinal oncology center from 2003 to 2023. Data on patient demographics, clinical characteristics, pre- and perioperative treatment, and symptoms at last follow-up were collected. Nerve root sacrifices were documented and, where unilateral ligations were performed, the highest level of bilateral sacrifice was noted. The primary outcomes were pain, weakness, bowel or bladder dysfunction (BBD), and sensory deficits.
Sixty-six patients were included, with a median follow-up of 5.8 (interquartile range [IQR] 3.0-8.5) years. The proportion of pain-free patients increased from 22.7% preoperatively to 54.5% after surgery, and a majority experienced improvement in pain (88.2%) and sensory deficits (83.3%). All patients who had bilateral sacrifices up to the S1-2 nerve roots and 92.9% with up to S3 bilateral nerve root sacrifice had BBD. However, motor deficits were observed in only 60.0% of those with S1 nerve root sacrifice. Additionally, 13.6% of patients had unexpected BBD and motor weakness at last follow-up. Multivariable analysis demonstrated surgical duration (odds ratio [OR] 1.003, 95% confidence interval [CI] 1.001-1.006; p = 0.020), tumor volume (OR 1.002, 95% CI 1.000-1.004; p = 0.017), and preoperative weakness (OR 37.0, 95% CI 1.3-1072.9; p = 0.036) were related to postoperative weakness. Only expected BBD due to nerve root sacrifice (OR 28.5, 95% CI 3.0-267.9; p = 0.002) was associated with postoperative BBD. Finally, preoperative sensory deficits (OR 6.6, 95% CI 1.2-36.4; p = 0.031) and surgical duration (OR 1.004, 95% CI 1.001-1.007; p = 0.003) were predictive of postoperative sensory deficits.
En bloc excisions of sacrococcygeal chordomas require complex approaches in which surgeons must consider the long-term functional effects of nerve root sacrifice. These results provide insight into residual function following these extensive operations and suggest that preserving the S3 nerve roots is critical in minimizing BBD. Cases in which the S3 is preserved but patients continue exhibiting postoperative BBD may be related to larger tumor size and intraoperative manipulation of distal S1-3 nerves or pudendal nerves. When S1 roots are preserved, larger tumor size may predict motor weakness.
由于骶尾部脊索瘤体积较大且累及周围结构，广泛整块切除往往需要牺牲骶神经根。在本研究中，作者描述了患者在根治性切除后的长期功能结果，研究了牺牲神经根与功能缺陷之间的关系，并探讨了术后神经功能缺陷的预测因素。
对2003年至2023年在一家四级脊柱肿瘤中心接受骶骨脊索瘤治疗随访的所有患者进行回顾性研究。收集了患者人口统计学、临床特征、术前和围手术期治疗以及最后随访时症状的数据。记录神经根牺牲情况，对于单侧结扎的患者，记录双侧牺牲的最高水平。主要结局指标为疼痛、无力、肠道或膀胱功能障碍（BBD）和感觉缺陷。
纳入66例患者，中位随访时间为5.8（四分位间距[IQR]3.0 - 8.5）年。无痛患者比例从术前的22.7%增加到术后的54.5%，大多数患者的疼痛（88.2%）和感觉缺陷（83.3%）有所改善。所有双侧牺牲至S₁ - ₂神经根的患者以及92.9%双侧牺牲至S₃神经根的患者均有BBD。然而，仅60.0%牺牲S₁神经根的患者出现运动功能缺陷。此外，13.6%的患者在最后随访时出现意外的BBD和运动无力。多变量分析显示手术时间（比值比[OR]1.003，95%置信区间[CI]1.001 - 1.006；p = 0.020）、肿瘤体积（OR 1.002，95% CI 1.000 - 1.004；p = 0.017）和术前无力（OR 37.0，95% CI 1.3 - 1072.9；p = 0.036）与术后无力相关。仅因神经根牺牲导致的预期BBD（OR 28.5，95% CI 3.0 - 267.9；p = 0.002）与术后BBD相关。最后，术前感觉缺陷（OR 6.6，95% CI 1.2 - 36.4；p = 0.031）和手术时间（OR 1.004，95% CI 1.001 - 1.007；p = 0.003）可预测术后感觉缺陷。
骶尾部脊索瘤的整块切除需要复杂的手术方法，外科医生必须考虑神经根牺牲的长期功能影响。这些结果为这些广泛手术后的残余功能提供了见解，并表明保留S₃神经根对于将BBD降至最低至关重要。S₃神经根保留但患者术后仍持续出现BBD的情况可能与肿瘤体积较大以及术中对S₁ - ₃远端神经或阴部神经的操作有关。当保留S₁神经根时，较大的肿瘤体积可能预示运动无力。
