TOTAL SACRECTOMY AND GALVESTON L-ROD RECONSTRUCTION FOR MALIGNANT NEOPLASMS - TECHNICAL NOTE

Although radical resection is the best treatment for malignant sacral tumors, total sacrectomy for such tumors has been performed in only a few instances. Total sacral resection requires reconstruction of the p elvic ring plus establishment of a bilateral union between the lumbar spine and iliac bone. This technique is illustrated in two patients ha rboring large, painful, sacral giant-cell tumors that were unresponsiv e to prior treatment. These patients were treated with complete en blo c resection of the sacrum and complex iliolumbar reconstruction/stabil ization and fusion. Surgery was performed in two stages, the first con sisting of a midline celiotomy, dissection of visceral/neural structur es, and ligation of internal iliac vessels, followed by an anterior L5 -S1 discectomy. The second stage consisted of mobilization of an infer iorly based myocutaneous rectus abdominis pedicle nap for wound closur e, followed by an L-5 laminectomy, bilateral L-5 foraminotomy, ligatio n of the thecal sac, division of sacral nerve roots, and transection o f the ilia lateral to the tumor and sacroiliac joints. Placement of th e instrumentation required segmental fixation of the lumbar spine from L-3 down by means of pedicle screws and the establishment of a bilate ral liaison between the lumbar spine and the ilia by using the Galvest on L-rod technique. The pelvic ring was then reestablished by means of a threaded rod connecting left and right ilia. Both autologous (poste rior iliac crest) and allograft bone were used for fusion, and a tibia l allograft strut was placed between the remaining ilia. The patients were immobilized for 8 weeks postoperatively and underwent progressive rehabilitation. At the 1-year follow-up review, one patient could wal k unassisted, and the other ambulated independently using a cane. Both patients controlled bowel function satisfactorily with laxatives and diet and could maintain continence but required self-catheterization f or bladder emptying. The authors conclude that in selected patients, t otal sacrectomy represents an acceptable surgical procedure that can o ffer not only effective local pain control, but also a potential cure, while preserving satisfactory ambulatory capacity and neurological fu nction.