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Sacral tumors are rare and can be benign or malignant. Their management is multifactorial and is based on the pathology, extent, and local and distant spread. Managing sacral tumors is challenging due to their proximity to visceral and neural structures. Surgical wide excision has been the standard of care for aggressive benign and malignant tumors. Our purpose was to evaluate the outcomes of a multimodal approach to managing primary sacral tumors in Sakra World Hospital, a tertiary spine care center in Bengaluru, India and perform a literature review to determine a workflow pathway. Our study was a retrospective review of patient records and included 15 patients with primary sacral tumors. Eleven surgically treated patients were evaluated clinically and radiologically and underwent biopsy before surgical excision by an all-posterior approach. A multidisciplinary approach that included intraoperative neural monitoring, plastic reconstruction, adjuvant chemotherapy, and radiotherapy was implemented whenever necessary. Sacral root preservation was attempted whenever feasible. Functional outcomes (based on the Visual Analog Scale [VAS] and Biagini scoring system) were analyzed along with disease control, with a minimum of 2 years of follow-up. The mean follow-up was 29±9.8 months. The mean VAS score significantly improved from 7.8±2.6 to 3.7±3.8 (p=0.026). Bowel function showed statistically significant improvement, from a mean score of 0.81±0.47 to 0.63±0.52 (p=0.026) at 2 years of follow-up. The mean pretreatment motor and bladder function scores were 0.53±0.31 and 0.74±0.44, respectively, improving to 0.48±0.33 and 0.68±0.56 at follow-up but without statistical significance. There was no significant loss of function, which is expected in radical sacral resections. In conclusion, primary sacral tumors require a multidisciplinary approach and management for optimal outcomes. A stand-alone posterior approach can be employed to treat most sacral lesions. En-bloc wide resection is the optimal treatment for primary malignant and aggressive benign tumors. Preservation of at least one functional S2 nerve root is imperative to preserve bowel and bladder function.

Background Data: Adult spinal deformity (ASD) needing surgical treatment is often seen in the aging population. Radiological goals for ASD surgery have been standardized to achieve a good functional outcome. Lesser complication rates and blood loss have made MIS surgeries more popular in the current day. Trans-psoas / Pre-psoas Lateral Lumbar Interbody Fusion (LIF) has been the cornerstone of MIS surgeries for ASD. The corrective potential of conventional MIS surgeries was limited, owing to which various modifications have been described. Despite the demonstration of good clinical outcomes by various studies employing different surgical techniques, cumulative analysis of the radiological outcome of the various modifications of LIF is poorly discussed in the literature. A recommendation of an ideal MIS technique based on the type and magnitude of ASD is also lacking. Purpose: We aim to perform a qualitative systematic review of the radiological outcomes of various modifications of LIF surgeries for ASD and to decipher a treatment algorithm based on the type and severity of ASD with existing literature. Study design: Systematic review. Patients and Methods: A systematic search of two electronic databases (PubMed & Google Scholar) from its inception till December 2020 was done independently by 3 different authors. Relevant keywords and MeSH terms were used to identify articles and further filtered by applying appropriate selection criteria. Results: A total of 171 articles were selected for abstract screening, followed by full-text screening. After applying the selection criteria, 28 articles were selected for the systematic review. The methodology and radiological parameters of each study were analyzed qualitatively, and the inferences in regards to the radiological outcomes were validated. Conclusion: Circumferential MIS (cMIS) seems to be adequate in milder forms of ASD, while hybrid surgeries may be needed in higher magnitude deformities. Addressing the L5-S1 junction using LIF and anterior column realignment (ACR) are useful tools to correct more severe deformities. (2020ESJ223)

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