Complex Lumbosacral Resection and Reconstruction Procedure

  • Daryl R. Fourney
  • Ziya L. Gokaslan
Part of the Current Clinical Oncology book series (CCO)


Surgical resection, reconstruction, and internal fixation of the spine are often indicated in the management of patients with lumbosacral neoplasms. Because of the complex anatomy of this region, aggressive resections are technically demanding and often involve long operative times and significant blood loss. Some wide resections may require the purposeful sacrifice of nerve roots, with inherent functional consequences for the patient. In addition, the unique biomechanical features of the lumbosacral junction, combined with the destructive nature of neoplastic processes and the resection of such disease, present a challenging problem in terms of spinal reconstruction and stabilization. The purpose of this chapter is to review the important anatomic, biomechanical, and functional considerations of this region; to provide a step-by-step description of techniques for the resection of lumbosacral tumors; and to describe current methods of spinopelvic reconstruction and stabilization. Although the differential diagnosis of lumbosacral lesions is broad and includes inflammatory conditions as well as a variety of developmental abnormalities and cysts, the discussion here is limited to the management of neoplastic disease.


Pedicle Screw Sacroiliac Joint Giant Cell Tumor Lumbosacral Junction Iliac Screw 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Biagini R, Ruggieri P, Mercuri M, et al. Neurologic deficit after resection of the sacrum. Chir Organi Mov 1997; 82:357–372.PubMedGoogle Scholar
  2. 2.
    Stener B, Gunterberg B. High amputation of the sacrum for extirpation of tumors. Principles and technique. Spine 1978; 3:351–366.PubMedCrossRefGoogle Scholar
  3. 3.
    Gunterberg B, Norlen L, Stener B, Sundin T. Neurological evaluation after resection of the sacrum. Invest Urol 1975; 13:183–188.PubMedGoogle Scholar
  4. 4.
    Turcotte RE, Sim FH, Unni KK. Giant cell tumor of the sacrum. Clin Orthop Relat Res 1993; 291:215–221.PubMedGoogle Scholar
  5. 5.
    York J, Kaczaraj A, Abi-Said D, et al. Sacral chordoma: 40-year experience at a major cancer center. Neurosurgery 1999; 44:74–80.PubMedCrossRefGoogle Scholar
  6. 6.
    Camins M, Oppenheim J, Perrin R. Tumors of the vertebral axis: Benign, primary malignant, and metastatic tumors. In: Youmans J, ed. Neurological Surgery. Vol. 2. Philadelphia, PA: W. B. Saunders; 1996:3134–3167.Google Scholar
  7. 7.
    Weber KL, Nelson H, Gunderson LL, Sim FH. Sacropelvic resection for recurrent anorectal cancer. A multidisciplinary approach. Clin Orthop Relat Res 2000; 372:231–240.PubMedCrossRefGoogle Scholar
  8. 8.
    Moffat F, Falk R. Radical surgery for extensive rectal cancer: is it worthwhile? Recent Results Cancer Res 1998; 146:71–83.PubMedGoogle Scholar
  9. 9.
    Broaddus WC, Grady MS, Delashaw JB, Ferguson RD, Jane JA. Pre-operative superselective arteriolar embolization: a new approach to enhance resectability of spinal tumors. Neurosurgery 1990; 27:755–759.PubMedCrossRefGoogle Scholar
  10. 10.
    Akeyson E, McCutcheon I. Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis. J Neurosurg 1996; 85:211–220.PubMedGoogle Scholar
  11. 11.
    Jackson R, Gokaslan Z. Spinal-pelvic fixation in patients with lumbosacral neoplasms. J Neurosurg (Spine 1) 2000; 92:61–70.Google Scholar
  12. 12.
    McCormick P, Post K. Surgical approaches to the sacrum. In: Doty J, Rengachary S, eds. Surgical Disorders of the Sacrum. New York, NY: Thieme, 1994:257–265.Google Scholar
  13. 13.
    Esses S, Botsford D. Surgical anatomy and operative approaches to the sacrum. In: Frymoyer J, ed. The Adult Spine: Principles and Practice. Vol. 2. Philadelphia, PA: Lippincott-Raven; 1997:2329–2341.Google Scholar
  14. 14.
    Localio S, Eng K, Ranson J. Abdominosacral approach for retrorectal tumors. Ann Surg 1980; 191:555–560.PubMedCrossRefGoogle Scholar
  15. 15.
    Huth JF, Dawson EG, Eilber FR. Abdominosacral resection for malignant tumors of the sacrum. Am J Surg 1984; 148:157–161.PubMedCrossRefGoogle Scholar
  16. 16.
    McDonald J, Lane J. Surgical approaches to the sacroiliac joint. In: Sundaresan N, Schidek H, Schiller A, Rosenthal D, eds. Tumors of the Spine: Diagnosis and Clinical Management. Philadelphia, PA: W. B. Saunders; 1996:426–431.Google Scholar
  17. 17.
    Camins M, Duncan A, Smith J, Marcove R. Chondrosarcoma of the spine. Spine 1978; 3:202–209.PubMedCrossRefGoogle Scholar
  18. 18.
    McCarty C, Waugh J, Mayo C, Coventry M. The surgical treatment of presacral tumors: a combined problem. Proc Staff Meet Mayo Clin 1952; 27:73–84.Google Scholar
  19. 19.
    Bowers R. Giant cell tumor of the sacrum. A case report. Ann Surg 1948; 1:1164–1172.CrossRefGoogle Scholar
  20. 20.
    Miles WK, Chang DW, Kroll SS, et al. Reconstruction of large sacral defects following total sacrectomy. Plas Reconstr Surg 2000; 105:2387–2394.CrossRefGoogle Scholar
  21. 21.
    Hung S, Chen H, Wei F. Free flaps for reconstruction of the lower back and sacral area. Microsurgery 2000; 20:72–76.PubMedCrossRefGoogle Scholar
  22. 22.
    Karakousis C, Emrich L, Driscoll D. Variants of hemipelvectomy and their complications. Am J Surg 1989; 158:404–408.PubMedCrossRefGoogle Scholar
  23. 23.
    Gokaslan Z, Romsdahl M, Kroll S, et al. Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms. J Neurosurg 1997; 87:781–787.PubMedGoogle Scholar
  24. 24.
    Spiegel DA, Richardson WJ, Scully SP, Harrelson JM. Long-term survival following total sacrectomy with reconstruction for the treatment of primary osteosarcoma of the sacrum. A case report. J Bone Joint Surg Am 1999; 81:848–855.PubMedGoogle Scholar
  25. 25.
    Gunterberg B, Romanus B, Stener B. Pelvic strength after major amputation of the sacrum. Acta Orthop Scand 1976; 47:635–642.PubMedGoogle Scholar
  26. 26.
    Hayes R. Resection of the sacrum for benign giant cell tumor: a case report. Ann Surg 1953; 138:115–120.CrossRefGoogle Scholar
  27. 27.
    Localio S, Francis K, Rossano P. Abdominosacral resection of sacrococcygeal chordoma. Ann Surg 1967; 166:394–402.PubMedCrossRefGoogle Scholar
  28. 28.
    Gennari L, Azzarelli A, Guagliuolo V. A posterior approach for the excision of sacral chordoma. J Bone Joint Surg Br 1987; 69:565–568.PubMedGoogle Scholar
  29. 29.
    Bridwell K. Management of tumors at the lumbosacral junction. In: Margulies J, Floman Y, Farcy J-P, Neuwirth M, eds. Lumbosacral and Spinopelvic Fixation. Philadelphia, PA: Lippincott-Raven; 1996:109–122.Google Scholar
  30. 30.
    Luque E. Segmental spinal instrumentation for correction of scoliosis. Clin Orthop 1982; 163:192–198.PubMedGoogle Scholar
  31. 31.
    Ogilvie J, Bradford D. Sublaminar fixation in lumbosacral fusions. Clin Orthop 1991; 269:157–161.PubMedGoogle Scholar
  32. 32.
    Ogilvie J, Transfedt E, Wood K. Overview of fixation to the sacrum and pelvis in spinal surgery. In: Margulies J, Floman Y, Farcy J-P, Neuwirth M, eds. Lumbosacral and Spinopelvic Fixation. Philadelphia, PA: Lippincott-Raven, 1996:191–198.Google Scholar
  33. 33.
    Fourney D, Abi-Said D, Lang F, McCutcheon I, Gokaslan Z. The use of pedicle screw fixation in the management of malignant spinal disease: experience in 100 consecutive procedures. J Neurosurg (Spine 1) 2001; 94:25–37.CrossRefGoogle Scholar
  34. 34.
    Carson W, Duffield R, Arendt M, Ridgely B, Gaines JR. Internal forces and moments in transpedicular spine instrumentation. The effect of pedicle screw angle and transfixation-the 4R-4bar linage concept. Spine 1990; 15:893–901.PubMedCrossRefGoogle Scholar
  35. 35.
    McCord D, Cunningham B, Shono Y, Myers J, McAfee P. Biomechanical analysis of lumbosacral fixation. Spine 1992; 17:235–243.CrossRefGoogle Scholar
  36. 36.
    Carlson G, Abitbol J, Anderson D, et al. Screw fixation in the human sacrum. An in vitro study of the biomechanics of fixation. Spine 1992; 17:196–203.CrossRefGoogle Scholar
  37. 37.
    Smith S, Abitbol J, Carlson G, Anderson D, Taggart K, Garfin S. The effects of depth of penetration, screw orientation, and bone density on sacral screw fixation. Spine 1993; 18:1006–1010.PubMedCrossRefGoogle Scholar
  38. 38.
    Krag M, Beynnon B, Pope M, DeCoster T. Depth of insertion of transpedicular vertebral screws into human vertebrae: effect on screw-vertebra interface strength. J Spinal Disord 1988; 1:287–294.PubMedCrossRefGoogle Scholar
  39. 39.
    Jackson R. Jackson sacral fixation and contoured spinal correction techniques. In: Margulies J, Floman Y, Farcy J-P, Neuwirth M, eds. Lumbosacral and Spinopelvic Fixation. Philadelphia, PA: Lippincott-Raven; 1996:357–379.Google Scholar
  40. 40.
    Baldwin N, Benzel E. Sacral fixation using iliac instrumentation and a variable angle screw device. J Neurosurg 1994; 81:313–316.PubMedGoogle Scholar
  41. 41.
    Allen BJ, Ferguson R. The Galveston technique for L rod instrumentation of the scoliotic spine. Spine 1982; 7:276–284.PubMedCrossRefGoogle Scholar
  42. 42.
    Brooke R. The sacroiliac joint. J Anat 1924; 58:297–301.Google Scholar
  43. 43.
    Allen BJ, Ferguson RL. The Galveston technique of pelvic fixation with L-rod instrumentation of the spine. Spine 1984; 9:388–394.PubMedCrossRefGoogle Scholar
  44. 44.
    Allen BJ, Ferguson R. A 1988 perspective on the Galveston technique of pelivc fixation. Orthop Clin North Am 1988; 19:409–418.PubMedGoogle Scholar
  45. 45.
    Shikata J, Yamamuro T, Kotoura Y, Mikawa Y, Iida H, Maetani S. Total sacrectomy and reconstruction for primary tumors. J Bone Joint Surg 1988; 70-A:122–125.Google Scholar
  46. 46.
    Tomita K, Tsuchiya H. Total sacrectomy and reconstruction for huge sacral tumors. Spine 1990; 15:1223–1227.PubMedCrossRefGoogle Scholar
  47. 47.
    Thompson J, Doty J. Sacral biomechanics and reconstruction. In: Doty J, Rengachary S, eds. Surgical Disorders of the Sacrum. New York, NY: Thieme Medical; 1994:253–256.Google Scholar
  48. 48.
    Santi MD, Mitsunaga MM, Lockett JL. Total sacrectomy for a giant sacral schwannoma. A case report. Clin Orthop 1993:285–259.Google Scholar
  49. 49.
    Wuisman P, Lieshout O, Sugihara S, Dijk Mv. Total sacrectomy and reconstruction: oncologic and functional outcome. Clin Orthop 2000; 381:192–203.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press, Inc., Totowa, NJ 2006

Authors and Affiliations

  • Daryl R. Fourney
    • 1
  • Ziya L. Gokaslan
    • 2
  1. 1.Department of NeurosurgeryThe University of Texas M.D. Anderson Cancer CenterHouston
  2. 2.Department of NeurosurgeryThe Spine Program, The University of Texas M.D. Anderson Cancer CenterHouston

Personalised recommendations