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Decancellation Sacral Osteotomy in Iliosacral Tumor Resection: A Technique for Precise Sacral Margins
Clinical Orthopedics and Related Research, 08/28/09

Farid YR – The authors performed a decancellation osteotomy in five patients with sarcomas requiring difficult oblique or sagittal sacral osteotomies and selective root sacrifice. Through laminectomy and without anterior exposure, a precise full–thickness osteotomy of the sacrum was performed without major technique–related morbidities or complications. This was followed by formal pelvic resection and reconstruction. Surgical margins were adequate in all patients and all tumor–free nerve roots were preserved.

Exclusive Author Commentary
Yasser R. Farid, 08/29/09

-The procedure is indicated in a fraction of tumors of the pelvis when sacral tumor infiltrate approximates or involves the sacral root or central neural canal. Otherwise, traditional osteotomies can be applied. -Although the report includes limb salvage patients, the procedure has been performed to ensure sacral margins in some hindquarter amputations in which the tumor extended across the midline in an effort to protect the contralateral sacral roots. -Proper selection of candidate patients should consider tumor types in which surgical resection with wide margins is necessary while considering feasibility of resection, and surgical experience of the operating team. Although indications are limited, they are more likely encountered in major referral centers dealing with sarcomas on regular basis. -The importance of minimizing sacral bleeding can not be overemphasized. The highly vascular sacrum is rendered even more vascular by the presence of malignancy. Adequate blood, blood products, and cryoprecipitate replacement along with adequate perioperative supportive care are mandatory. During surgery, proper positioning of the patient ensures free abdominal movement with respiration to avoid splanchnic, epidural, and osseous venous congestion. This is the most important caveat to minimize blood loss. -An efficient assistant with constant suction irrigation along the decancellation tunnel and the use of optical magnification should enhance surgical performance and minimize overall blood loss. -Most decancellation procedures in orthopedics including transpedicle decancellation of the spine and cuboid decancellation of the foot aim at generous excavation of bone in preparation for collapse of its cortical confines. The goal is deformity correction that is directly proportional to the magnitude of decancellation. In sacral decancellation osteotomy, the procedure has to be done in a linear fashion and decancellation should be limited to a narrow linear trough throughout the procedure to avoid neural injury, tumor violation, or unnecessary violation of the lumbosacral joint. Remember that the goal is to divide not to excavate the sacrum. This minimizes blood loss. -Following such massive resections, I currently prefer simple biological skeletal reconstructions as psuedoarthroses of the femur against the remaining sacrum. I do not hesitate to perform resection in a second stage if necessary and I believe (apart from lumbosacral fusion) that additional operative time and surgical exposure should be limited to soft tissue rather than skeletal reconstruction.

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