Surgical techniques for spinopelvic reconstruction following total sacrectomy: a systematic review

Abstract

Purpose: To identify all available reconstruction methods for a total sacrectomy. Secondarily, we aimed to evaluate outcomes based on different interventions.

Methods: We searched PubMed to identify sacral resections for tumors requiring internal fixation for stabilization. Demographic information, fixation techniques and postoperative outcomes were abstracted.

Results: Twenty-three publications (43 patients) met inclusion criteria from an initial search of 856 (κ 0.93). Mean age was 37 years and follow-up was 33 months. Fixation methods included a combination of spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and/or anterior spinal column fixation (ASCF). For the purposes of analysis, patients were segregated based on whether they received ASCF. Postoperative complications including wound/instrument infections, GI or vascular complications were reported at a higher rate in the non-ASCF group (1.63 complications/patient vs. 0.7 complications/patient). Instrument failure was seen in 5 (16.1 %) out of the 31 patients with reported outcomes. Specifically, 1 out of 8 patients (12.5 %) with ASCF compared with 4 out of 23 patients (17.4 %) without ASCF had hardware failure. At final follow-up, 35 of 39 patients were ambulating.

Conclusion: While surgical treatment of primary sacral tumors remains a challenge, there have been advances in reconstruction techniques following total sacrectomy. SPF has shifted from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems for improved rigidity. PPRF and ASCF have adapted for deficiencies in the posterior ring and anterior column. A trend toward a lower rate of hardware failure emerged in the group utilizing anterior spinal column support. Despite a more involved reconstruction with ASCF, surgical complications such as infection rates and blood loss were lower compared to the group without ASCF. While we cannot definitively say one system is superior to the other, based on the data gleaned from this systematic review, it is our opinion that incorporation of ASCF in reconstructing the spinopelvic junction may lead to improved outcomes. However, most importantly, we recommend that the treating surgeon operate on patients requiring a total sacrectomy based on his or her level of comfort, as these cases can be extremely challenging even among experts.

Fig. 1

Outline of the review process

Fig. 2

Tumor diagnoses for patients included in this review

Fig. 3

“Older” SPF methods—pedicle screws connected to ilium via Harrington rods [26]

Fig. 4

SPF with ACSF—pedicle screws connected to iliac screws by two lumbar rods on each side; two titanium mesh cages [18]

Fig. 5

SPF and PPRF—pedicle screws connected to transiliac bar via lumbar rods and cross connectors; femoral bone graft. a Photograph of the final construct, b radiograph of the final construct [21]

Fig. 6

SPF with PPRF and ASCF—pedicle screws connected to iliac screws via lumbar rods; two transiliac bars (not shown); two oblique fibular grafts from L5 to the anterior ilium [20]