Biomechanical evaluation of reconstructed lumbosacral spine after total sacrectomy

Murakami, Hideki; Kawahara, Norio; Tomita, Katsuro; Sakamoto, Jiro; Oda, Juhachi

doi:10.1007/s007760200117

Cited by 35 publications

(21 citation statements)

References 16 publications

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“…The sacrum is a unique structure that connects the lumbar spine and pelvis, and although challenging, reconstruction after a sacrectomy is mandatory in some cases [20,21]. Once postoperative SSI occurs, the decision whether to remove the instrumentation is a dilemma.…”

Section: Discussionmentioning

confidence: 99%

Experience with wound complications after surgery for sacral tumors

Guo

et al. 2013

Eur Spine J

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Purpose The aim of this article is to summarize our experience in treating sacral wound complications after sacrectomy. We focus, in particular, on factors associated with wound complications, including surgical site infection (SSI) and wound dehiscence. Methods The definition of SSI devised by Horgan et al. was applied. Wound dehiscence was defined as a wound showing breakdown in the absence of clinical signs meeting the diagnostic standard for SSI. Between September 1997 and August 2009, 387 patients with a sacral tumor underwent sacrectomy performed by the same team of surgeons and were followed up for C12 months. Potential risk factors were evaluated for univariate associations with SSI and wound complications. Multivariable conditional logistic regression was used to identify the combined effects of several risk factors. Results Of the 387 wounds studied, 274 healed uneventfully, and 113 (29.2 %) broke down because of infection or dehiscence. Fifty-one (13.2 %) patients developed a postoperative SSI, and 62 (16.0 %) patients developed wound dehiscence. Gram-negative bacteria grew in 45 cultures (91.8 %) and included 38 cases of Escherichia coli. Previous radiation, rectum rupture, longer duration of surgery, and cerebrospinal fluid leakage were significantly associated with increased likelihood of developing an SSI. Previous radiation, rectum rupture, age \40 years, history of diabetes mellitus, maximum tumor diameter C10 cm, and instrumentation used were risk factors for wound complications. Conclusions The incidence of wound complications is not so high at a musculoskeletal tumor center with surgeons experienced in treating sacral tumors. Controlling for these risk factors when possible may improve clinical outcomes.

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Section: Discussionmentioning

confidence: 99%

Experience with wound complications after surgery for sacral tumors

Guo

et al. 2013

Eur Spine J

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“…Several studies have demonstrated that a negative surgical margin is the most important predictor of the local recurrence rate and survival [3,12,13,44]; however, wide resection is not achieved in 35% to 75% of patients undergoing surgery for this diagnosis [42]. Surgery in this anatomic site is challenging as a result of the complexity of the pelvic anatomy, adjacent visceral and vascular structures, and frequent compromise of spinopelvic continuity [12,17,32]. Surgeons often face a difficult choice between maximizing the preservation of function and achieving an adequate surgical margin.…”

Section: Introductionmentioning

confidence: 99%

What Are the Conditional Survival and Functional Outcomes After Surgical Treatment of 115 Patients With Sacral Chordoma?

Guo

Yang

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background Conditional survival is a measure of prognosis for patients who have already survived for a specific period of time; however, data on conditional survival after sacrectomy in patients with sacral chordoma are lacking. In addition, because sacral tumors are rare and heterogeneous, classifying them in a way that allows physicians to predict functional outcomes after sacrectomy remains a challenge. Questions/purposes (1) What is the overall survival and disease-free survival in patients treated by sacrectomy for chordoma? (2) What is the conditional survival probability and how do prognostic factors change over time in patients undergoing surgical resection for sacral chordoma? (3) What is the local recurrence rate after surgery, how was it treated, and what factors impact on local recurrence? (4) What is the postoperative motor, sensory, bowel, and bladder function by level of resection as determined by using a newly designed scoring method?Methods Between 2003 and 2012, our center treated 122 patients surgically for sacral chordoma. Of those, two died and five were lost before a minimum followup of 1 year was achieved, leaving 115 patients available for analysis in this retrospective study at a mean of 4.9 years (range, 1.3-10.8 years). Basically, single posterior or combined approaches were chosen based on the most cephalad extent of the tumor and resection level was normally at half or one sacral vertebrae above the tumor. The 5-year conditional survival rate was calculated based on Kaplan-Meier survival analysis. The effect of prognostic factors on conditional survival was also explored. A newly designed score method was proposed and adopted in the current study to critically evaluate the functional outcome after resection of the sacrum. Inter-and intraobserver reliability was tested by a preliminary study using kappa statistics and Spearman rank correlation coefficients. Significant interobserver (p\0.01) and intraobserver agreement (j[0.75) were found in nine items between each observer. Results The estimated 5-year overall survival rate was 81% (95% confidence interval [CI], 72%-90%) at diagnosis. The 5-year disease-free survival rate was 52% (95% CI, 43%-63%). The 5-year conditional overall survival decreased with each additional year in the first 4 years (81% at diagnosis versus 60% at the fourth year, p \ 0.0001) and increased slightly in the fifth year. Patients with adequate surgical margins displayed a higher 5-year survival than those with an inadequate margin (86% [95% CI, 76%-95%] versus 67% [95% CI, 48%-85%], p = 0.01) at diagnosis. Conditional survival estimates for patients who received operations elsewhere were lower than that of newly diagnosed patients treated by us at diagnosis (64% [95% CI, 46%-83%] versus 90% [95% CI, 82%-99%], p = 0.012), but with the numbers we had, we could not detect a difference in conditional survival between those treated elsewhere first compared with those initially treated by us at 5 years. The proposed score system for function evaluation was a...

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“…Murakami et al 15 reported a technique based on dual sacral rods that they called the triangular frame technique, which decreased the stress on the spinal rod but appeared to demonstrate increased stress at the sacral rods. Kawahara et al 13 biomechanically compared 3 techniques.…”

Section: Discussionmentioning

confidence: 99%

Gait-simulating fatigue loading analysis and sagittal alignment failure of spinal pelvic reconstruction after total sacrectomy: comparison of 3 techniques

Clark

Tang

Leasure

et al. 2014

SPI

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T oTal sacrectomy remains central to the treatment of certain aggressive malignant sacral tumors with S-1 involvement. However, the sacrum functions as an important load transfer interface between the lower extremity (via the pelvis) and the spinal column. Extent of resection is significantly associated with spinopelvic postoperative stability, as demonstrated in biomechanical testing of cadaveric specimens. With partial sacrectomy, resection between S-1 and S-2 decreases stability by 30% Object. Reconstruction after total sacrectomy is a critical component of malignant sacral tumor resection, permitting early mobilization and maintenance of spinal pelvic alignment. However, implant loosening, graft migration, and instrumentation breakage remain major problems. Traditional techniques have used interiliac femoral allograft, but more modern methods have used fibular or cage struts from the ilium to the L-5 endplate or sacral body replacement with transiliac bars anchored to cages to the L-5 endplate. This study compares the biomechanical stability under gait-simulating fatigue loading of the 3 current methods.Methods. Total sacrectomy was performed and reconstruction was completed using 3 different constructs in conjunction with posterior spinal screw rod instrumentation from L-3 to pelvis: interiliac femur strut allograft (FSA); L5-iliac cage struts (CSs); and S-1 body replacement expandable cage (EC). Intact lumbar specimens (L3-sacrum) were tested for flexion-extension range of motion (FE-ROM), axial rotation ROM (AX-ROM), and lateral bending ROM (LB-ROM). Each instrumented specimen was compared with its matched intact specimen to generate an ROM ratio. Fatigue testing in compression and flexion was performed using a custom-designed long fusion gait model.Results. Compared with intact specimen, the FSA FE-ROM ratio was 1.22 ± 0.60, the CS FE-ROM ratio was significantly lower (0.37 ± 0.12, p < 0.001), and EC was lower still (0.29 ± 0.14, p < 0.001; values are expressed as the mean ± SD). The difference between CS and EC in FE-ROM ratio was not significant (p = 0.83). There were no differences in AX-ROM or LB-ROM ratios (p = 0.77 and 0.44, respectively). No failures were noted on fatigue testing of any EC construct (250,000 cycles). This was significantly improved compared with FSA (856 cycles, p < 0.001) and CS (794 cycles, p < 0.001).Conclusions. The CS and EC appear to be significantly more stable constructs compared with FSA with FE-ROM. The 3 constructs appear to be equal with AX-ROM and LB-ROM. Most importantly, EC appears to be significantly more resistant to fatigue compared with FSA and CS. Reconstruction of the load transfer mechanism to the pelvis via the L-5 endplate appears to be important in maintenance of alignment after total sacrectomy reconstruction.

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Biomechanical evaluation of reconstructed lumbosacral spine after total sacrectomy

Cited by 35 publications

References 16 publications

Experience with wound complications after surgery for sacral tumors

Experience with wound complications after surgery for sacral tumors

What Are the Conditional Survival and Functional Outcomes After Surgical Treatment of 115 Patients With Sacral Chordoma?

Gait-simulating fatigue loading analysis and sagittal alignment failure of spinal pelvic reconstruction after total sacrectomy: comparison of 3 techniques

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