Sacral Nerves Reconstruction After Surgical Resection of a Large Sacral Chordoma Restores the Urinary and Sexual Function and the Anal Continence

Abstract

Objective: Chordomas are slow-growing tumors, with a high tendency to local relapse. En bloc resection is related to the most favorable outcome in terms of survival but is frequently associated with permanent neurological deficits involving sphincters and sexual functions. In the present article, we describe an innovative technique of en bloc resection followed by reconstruction of the sacral nerves with nerve grafts. Methods:The chordoma was excised through a posterior approach after dividing the proximal and distal sacral nerves using the established technique. After that, a microsurgical S2-S3-S4 nerve reconstruction was performed connecting the proximal and distal stumps with sural nerve grafts withdrawn from both lower limbs.Results: Immediately after surgery, the patient experienced complete impairment of sexual function and sphincters with urinary and fecal incontinence. After six months, there was a progressive recovery of sexual function and sphincter control. One year after the operation, the patient achieved an adequate sexual life (erection and ejaculation) and complete control of the bladder and anal sphincter. Conclusion:Reconstruction of nerves sacrificed during sacral tumor removal has been shown to be effective in restoring sphincter and sexual function and is a promising technique that may significantly improve patients' quality of life.

Cordoma sacrococcígeo: revisión del tema

“…14 The rectum is not involved anteriorly through the presacral fascia. 13,23 The most common presenting symptom is local pain 10 and tenderness resulting from periosteal stretching from cortical expansion, mass effect, and compression of neighboring structures. Increasing compression of nerve roots can impair reflex arcs and provokes multiradicular sensory deficits to the uni or bilateral buttocks, posterior thigh, leg, external genitalia, and perineum depending on the level of tumor extension.…”

“…Conventional chordoma, dedifferentiated chordoma and poorly differentiated chordoma. [3][4][5] Chordoma represents only 1-4% of all primary malignant bone neoplasms, [6][7][8][9][10][11] is the most common primary malignant tumor within the spine, 6 is the most common tumor of any type involving the sacrum, 6,[12][13][14][15] and approximately 50% of all chordomas are sacrococcygeal in origin. 6,13,16,17 Chordoma treatment is eminently surgical through wide or radical Cirugía de Columna | 2024; 2 (2): 104-111 resection (partial sacrectomy, total sacrectomy or extended sacrectomy), and is usually associated with important sequelae mainly related to sphincter control.…”

Reply to Commentary on “Sacral Nerves Reconstruction After Surgical Resection of a Large Sacral Chordoma Restores the Urinary and Sexual Function and the Anal Continence”

“…Dear Editor, We appreciate the interest in our article "Sacral nerves reconstruction after surgical resection of a large sacral chordoma restores the urinary and sexual function and the anal continence. " 1 The sacrifice of sacral nerves is often a necessary step if a benefit is to be given to the progression free survival rate, which results in a severe burden and deterioration of quality of life for patients with sacral chordoma.…”

Commentary on “Sacral Nerves Reconstruction After Surgical Resection of a Large Sacral Chordoma Restores the Urinary and Sexual Function and the Anal Continence”

“…In the paper, the authors described a new technique, which is used for the first time in the field of sacral chordoma resection, that is, bulk resection of sacral chordoma, and then sacral nerve reconstruction with peripheral nerve transplantation. 4 The 54-year-old patient diagnosed with sacral chordoma, the authors marked the nerve roots in the proximal and distal part of the lesion with sutures, separated the proximal and distal sacral nerves, and resected the chordoma involving bilateral lower S1 sacral nerves (14 cm× 8 cm× 7 cm) through the posterior approach. After operation, the sural nerve of the bilateral leg was grafted, and the epineurial microsuture technique was used to connect the stump and the distal end of S2-S3-S4.…”

“…Zheng et al [ 11 ] reported that 5 cases of sacral nerve root anastomosis were performed after block resection of sacral tumor, and only 2 cases showed improvement in limb, bladder and intestinal function. However, in the author’s article [ 4 ], only one case of functional improvement after nerve transplantation after tumor resection was described, which may be related to the surgeon’s experience, body healing ability etc. It does not have extensive maneuverability and outstanding representativeness.…”