What Are the Functional Outcomes After Total Sacrectomy Without Spinopelvic Reconstruction?

Piya Kiatisevi, Chaiwat Piyaskulkaew, Sombat Kunakornsawat, Bhasanan Sukunthanak

After total sacrectomy, many types of spinopelvic reconstruction have been described with good functional results. However, complications associated with reconstruction are not uncommon and usually result in further surgical interventions. Moreover, less is known about patient function after total sacrectomy without spinopelvic reconstruction, which may be indicated when malignant or aggressive benign bone and soft tissue tumors involved the entire sacrum. (1) What is the functional outcome and ambulatory status of patients after total sacrectomy without spinopelvic reconstruction? (2) What is the walking ability and ambulatory status of patients when categorized by the location of the iliosacral resection relative to the sacroiliac joint? (3) What complications and reoperations occur after this procedure? Between 2008 and 2014, we performed 16 total sacrectomies without spinopelvic reconstructions for nonmetastatic oncologic indications. All surviving patients had followup of at least 12 months, although two were lost to followup after that point (mean, 43 months; range, 12-66 months, among surviving patients). During this time period, we performed total sacrectomy without reconstruction for all patients with primary bone and soft tissue tumors (benign and malignant) involving the entire sacrum with no initial metastasis. The level of resection was the L5-S1 disc in 14 patients and L4-L5 disc in two patients. We classified the resection into two types based on the location of the iliosacral resection. Type I resections went medial to or through or lateral but close to the sacroiliac joint. Type II resections were far lateral (more than 3 cm from the posterior iliac spine) to the sacroiliac joint. Musculoskeletal Tumor Society (MSTS) scores, physical function assessments, and complications were gleaned from chart review performed by the treating surgeons (PK, BS). Video documentation of patients walking was obtained at followup in eight patients. The mean overall MSTS scores was 17 (range, 5-27). Thirteen patients were able to walk, five without walking aids, two with a cane and sometimes without a walking aid, three with a cane, and three with a walker. Thirteen of 14 patients who had bilateral Type I resections or a Type I resection on one side and Type II on the contralateral side were able to walk, five without a walking aid, and had a mean MSTS score of 19 (range, 13-27). Two patients with bilateral Type II resection were only able to sit. Complications included wound dehiscences in 13 patients (which were treated with reoperation for drainage), sciatic nerve injury in seven patients, a torn ureter in one patient, and a rectal tear in one patient. Without spinopelvic reconstruction, most patients in this series who underwent total sacrectomy were able to walk. Good MSTS scores could be expected in patients with bilateral Type I resections and patients with a Type I on one side and a Type II on the contralateral side. Total sacrectomy without spinopelvic reconstruction should be considered as a useful alternative to reconstructive surgery in patients who undergo Type I iliosacral resection on one or both sides. Level IV, therapeutic study.