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Background Resection of pelvic and sacral tumors can cause severe blood loss, complications, and even postoperative death. Hypotensive epidural anesthesia has been used to mitigate blood loss after elective arthroplasty, but to our knowledge, it has not been studied as an approach that might make resection of pelvic and sacral tumors safer. Questions/purposes The purposes of this study were (1) to compare the blood loss and blood product use for patients undergoing pelvic and sacral tumor surgery under standard anesthesia or hypotensive epidural anesthesia; (2) to assess the frequency of end-organ damage with the two techniques; and (3) to compare 90-day mortality between the two techniques. Methods Between 2000 and 2014, 285 major pelvic and sacral resections were performed at one center. A total of 174 (61%) had complete data sets for analysis of blood loss, transfusion use, complications, and mortality at 90 days. Of those, 102 (59%) underwent hypotensive epidural anesthesia, whereas the remainder received standard anesthetic care. The anesthetic approach was determined by the anesthetists in charge of the case with hypotensive epidural anesthesia exclusively performed by one of two subspecialty trained anesthetists as their routine for major pelvic or sacral surgery. The groups were comparable in terms of potential confounding variables such as age, gender, tumor volume, and operation performed. Hypotensive epidural anesthesia was defined as a technique using an extensive epidural block up to T2-3 dermatome, peripherally administered low-concentration intravenous adrenaline infusion, and using unimpeded spontaneous respiration to achieve controlled hypotension, precise rate control of the heart, and enhanced velocity of venous return, all aggregated thus to minimize blood loss during pelvic surgery while preserving vital perfusion. The groups were assessed for perioperative blood loss calculated from pre- and postsurgery hemoglobin and transfusion use as well as postoperative complications, morbidity, and mortality at 90 days. Results There was less mean blood loss in the hypotensive epidural anesthesia group (1457 mL, SD 1721, 95% confidence interval [CI], 1114–1801 versus 2421 mL, SD 2297, 95% CI, 1877–2965; p = 0.003). Patients in the hypotensive epidural anesthesia group on average received fewer packed red cell transfusions (2.7 units, SD 2.9, 95% CI, 2.1–3.2 versus 3.9 units, SD 4.4, 95% CI, 2.9–5.0; p = 0.03). There were no differences in the proportions of patients experiencing end-organ injury (7%, n = seven of 102 versus 6%, n = four of 72; p = 0.72). With the numbers available, there was no difference in 90-day mortality rate between groups (1.9%, n = two of 102 versus 1.3%, n = one of 72; p = 0.77). Conclusions We found that hypotensive epidural anesthesia resulted in less blood loss, fewer transfusions, and no apparent increase in serious complications in pelvic and sacral tumor surgery performed in the setting of a high-volume tertiary sarcoma referral hospital. We recommend that further collaborative studies be undertaken to confirm our results with hypotensive epidural anesthesia in surgery for pelvic tumors. Level of Evidence Level III, therapeutic study.

Pressure ulcers represent a major current health problem and produce an important economic impact on the healthcare system. Most of studies to prevent pressure ulcers have been carried out in hospital contexts, with respect to the use of hyperoxygenated fatty acids and to date, no studies have specifically examined the use of olive oil-based substances. Main objective: To assess the effectiveness of the use of olive oil, comparing it with hyperoxygenated fatty acids, for immobilised home-care patients at risk of suffering pressure ulcers. Design: Non-inferiority, triple-blind, parallel, multicentre, randomised clinical trial. Scope: Population attending Primary Healthcare Centres in Andalusia (Spain). Sample: 831 immobilised patients at risk of suffering pressure ulcers. The follow-up period was 16 weeks. Groups were similar after randomization. In the per protocol analysis, none of the body areas evaluated presented risk differences for pressure ulcers incidence that exceeded the 10% delta value established. Sacrum: Olive Oil 8 (2.55%) vs HOFA 8 (3.08%), ARR 0.53 (-2.2 to 3.26) Right heel: Olive Oil 4 (1.27%) vs HOFA 5 (1.92)%, ARR0.65 (-1.43 to 2.73). Left heel: Olive Oil 3 (0.96%) vs HOFA 3 (1.15%), ARR0.2 (-1.49 to 1.88). Right trochanter: Olive Oil 0 (0%) vs HOFA 4 (1.54%), ARR1.54 (0.04 to 3.03). Left trochanter: Olive Oil 1 (0.32%) vs HOFA 1 (0.38%), ARR0.07 (-0.91 to 1.04). In the intention to treat analysis the lower limit of the established confidence interval was never exceeded. The results obtained confirmed that the use of topical extra-virgin olive oil to prevent PU in the home environment, for immobilised patients at high risk, is not inferior to the use of HOFA. Further studies are needed to investigate the mechanism by which olive oil achieves this outcome. Clinicaltrials.gov NCT01595347.

Purpose Several risk factors and causes of adjacent segment disease have been debated; however, no quantitative relationship to spino-pelvic parameters has been established so far. A retrospective case–control study was carried out to investigate spino-pelvic alignment in patients with adjacent segment disease compared to a control group. Methods 45 patients (ASDis) were identified that underwent revision surgery for adjacent segment disease after on average 49 months (7–125), 39 patients were selected as control group (CTRL) similar in the distribution of the matching variables, such as age, gender, preoperative degenerative changes, and numbers of segments fused with a mean follow-up of 84 months (61–142) (total n  = 84). Several radiographic parameters were measured on pre- and postoperative radiographs, including lumbar lordosis measured (LL), sacral slope, pelvic incidence (PI), and tilt. Results Significant differences between ASDis and CTRL groups on preoperative radiographs were seen for PI (60.9 ± 10.0° vs. 51.7 ± 10.4°, p  = 0.001) and LL (48.1 ± 12.5° vs. 53.8 ± 10.8°, p  = 0.012). Pelvic incidence was put into relation to lumbar lordosis by calculating the difference between pelvic incidence and lumbar lordosis (∆PILL = PI−LL, ASDis 12.5 ± 16.7° vs. CTRL 3.4 ± 12.1°, p  = 0.001). A cutoff value of 9.8° was determined by logistic regression and ROC analysis and patients classified into a type A (∆PILL <10°) and a type B (∆PILL ≥10°) alignment according to pelvic incidence-lumbar lordosis mismatch. In type A spino-pelvic alignment, 25.5 % of patients underwent revision surgery for adjacent segment disease, whereas 78.3 % of patients classified as type B alignment had revision surgery. Classification of patients into type A and B alignments yields a sensitivity for predicting adjacent segment disease of 71 %, a specificity of 81 % and an odds ratio of 10.6. Conclusion In degenerative disease of the lumbar spine a high pelvic incidence with diminished lumbar lordosis seems to predispose to adjacent segment disease. Patients with such pelvic incidence-lumbar lordosis mismatch exhibit a 10-times higher risk for undergoing revision surgery than controls if sagittal malalignment is maintained after lumbar fusion surgery.

Background Giant sacral and presacral schwannomas are very rare conditions and their prevalence is estimated to account for only 0.3 to 3.3% of overall schwannomas. Current published literature about these tumors is limited to case reports and small case series. In this paper we systematically reviewed and analyzed the available literature on giant sacral schwannomas focusing on identifying the presenting symptoms, Klimo type, surgical approach, recurrence rate and postoperative complications. Methods Following the PRISMA guidelines, we conducted a literature search on electronic databases to obtain the relevant studies until March 2024. We included reports of surgically managed giant sacral schwannomas; either involving tumor of at least 2 adjacent vertebra or had a maximum diameter of 5 cm or more. Presenting symptoms, tumor size, morphology, surgical approach and postoperative complications were reported. Results A total of 102 studies with 201 unique patients were included in our analysis (mean age 45.4 ± 9.8, 49.7% females). The most common presenting symptoms were lower extremity radicular pain (19.5%), lower back pain (14.1%), lower extremity numbness or paresthesia (9%), and constipation (7.6%). Most surgeries used an open posterior approach (40.1%) or open anterior approach (33.5%). Postoperative complications occurred in (29.3%) of patients and 10% had local recurrence or progression of their tumor. On linear regression the volume of the tumor could significantly predict the estimated amount of blood loss ( P =  0.03). We found that an anterior approach was far more likely to be used in patients with Klimo type III, ( P <  0.001). Similarly, posterior approach was mostly used for Klimo type I and type II ( P <  0.001). Conclusion The management approach of giant sacral and presacral schwannomas are mainly tailored according to the tumor size and location. Due to the benign nature and the overall recurrence rate of the tumor, frequent imaging follow-up is required after safe resection with adequate clean margins.

BackgroundRecent studies demonstrated that primary tumor resection (PTR) improves survival of patients with metastatic bone sarcomas. However, it remains quite unclear regarding the role of PTR in the treatment of sarcomas of pelvic bones with synchronous metastasis at diagnosis.MethodsUsing the Surveillance, Epidemiology, and End Results Program, we enrolled a total of 385 patients with sarcomas of pelvic bones, sacrum, and coccyx who have metastasis at initial diagnosis, including 139 patients with osteosarcoma, 176 with Ewing sarcoma, and 70 with chondrosarcoma. Association between PTR and disease-specific survival (DSS) were investigated using the univariable and multivariable Cox regression models. Hazard ratio (HR) and 95% confidence interval (CI) were reported. Representative institutional PTR strategies and clinical outcomes for patients with metastatic pelvic sarcomas from our cancer center were displayed.ResultsThe usage rate of PTR was 28.1% (39/139) in osteosarcoma, 13.6% (24/176) in Ewing sarcoma, and 41.4% (29/70) in chondrosarcoma with synchronous metastatic lesions. PTR was not associated with an improved DSS for metastatic pelvic osteosarcoma (HR = 0.686, 95% CI = 0.430 ~ 1.094, P = 0.113) and Ewing sarcoma (HR = 0.580, 95% CI = 0.291 ~ 1.154, P = 0.121). The use of PTR was associated with an improved DSS for metastatic pelvic chondrosarcoma (HR = 0.464, 95% CI = 0.225 ~ 0.954, P = 0.037).ConclusionPrimary lesion resection may provide a survival benefit for metastatic chondrosarcoma, but not for osteosarcoma and Ewing sarcoma of pelvic bones, sacrum, and coccyx. This population-based study recommends an active surgical intervention for metastatic chondrosarcoma while non-surgical treatment for metastatic osteosarcoma and Ewing sarcoma of the pelvis in terms of survival improvement.

Background Chordoma is a rare and aggressive primary bone sarcoma. En-block resection remains the primary treatment, but some patients are unable to undergo it due to the location and potential complications. Currently, there is no direct comparison of the effects of radiotherapy (RTH) and surgical treatment. However, retrospective analyses indicate the potential benefits of using RTH. Methods A retrospective analysis was conducted on 48 patients with sacral chordoma who were treated with surgery and/or radiotherapy between 2001-2020. Among those, 22 were initially treated with surgery, 19 with definitive radiotherapy, and 7 received combined treatment. The outcomes of the treatment of recurrence in 16 patients were considered. The resection margins were defined according to R classification, and the Kaplan-Meier method was employed to calculate disease-free survival (DFS) and overall survival (OS). Results The median (mOS) for the entire cohort was 80.6 months (95% CI: 62.3-NA), and the median (mDFS) was 40.4 months (95% CI: 35-69.5). Patients who underwent radical surgery of the primary tumor did not achieve the mOS (mean 68), while patients treated only with RTH for the primary tumor achieved an mOS of 62.3 months (95% CI: 52.1-NA). This resulted in a significant advantage of surgery over RTH in terms of OS (P = 0.01). This was not observed for DFS. The 3-year DFS rates were 65% in the surgical treatment group and 53.3% in the RTH group. The 3-year OS rates were 96% in the surgery group and 88.9% in the RTH group. In the treatment of recurrence, there were no statistically significant differences between RTH and surgery, for OS (P = 0.76). Conclusions Radical surgery remains the optimal treatment for sacral chordoma. For patients who are not candidates for surgical intervention, RTH offers excellent long-term outcomes. The treatment of recurrence remains a significant challenge. Comparing modern RTH techniques and surgical procedures could provide further insights.

Abstract Chordomas are rare tumors of the axial skeleton that are refractory to conventional therapy. Few studies have compared the morphological and molecular characteristics of chordomas according to the skull base and sacral locations. Histopathological data and changes revealed by array comparative genomic hybridization (CGH) and next-generation sequencing (NGS) of cell cycle regulation genes were analyzed for 28 skull base (SBCs) and 15 sacral (SC) chordomas. All cases were conventional chordomas. SBCs were significantly more frequent in patients aged <40 years and SCs predominated in patients aged >60 years. Mitotic indices ≥2 mitoses/10 high-power fields were correlated with high degrees of nuclear atypia and Ki67 labeling indices ≥6%. We identified 321 genomic positions, and copy number variation losses were more frequent than gain. Moreover, we report a panel of 85 genetic variants of cell cycle genes and the presence of molecular clusters for chordoma as well in CGH as in NGS. These new data strengthen the view that the chordoma should not be considered as a single molecular entity.

Background Treatment of impending pathologic fractures and insufficiency fractures of the sacrum due to metastatic disease and radiation is challenging. The use of traditional hardware is limited by poor bone quality and presence of non-contained defects. The role of minimally invasive photodynamic nails (PDN) for treatment of these fractures remains poorly understood. Methods Patients with symptomatic impending pathologic fractures of the sacrum due to metastatic bone disease, multiple myeloma, or insufficiency fractures from radiation osteitis who underwent PDN stabilization were identified. Primary outcomes included post-operative complications, pain relief, opioid consumption, and function. Pain was assessed using Visual Analog Scale (VAS), and function was measured using the Combined Pain and Ambulatory Function (CPAF) score. Outcomes were assessed preoperatively at 6 weeks, 3 months, 6 months, 1 year and 2 years. Results Fourteen patients (median age 70, 50% female) underwent sacral PDN stabilization between 2020 and 2023, with a median 1.4-year follow-up. Overall complication rate was 7% (1/14 patients), with one case of venous thromboembolism. Median pain VAS decreased from 7 preoperatively to 6 at 6 weeks ( p  = 0.02), and to 4 at 2 years ( p  = 0.002). Median CPAF score improved from 6 preoperatively to 7 at 3 months and remained at this level through the 2-year follow-up. Chronic opioid use decreased from 85.7% preoperatively to 60% at 2 years. Conclusion PDN stabilization sacral insufficiency fractures in oncologic patients is a safe surgical technique that effectively restores patient ambulatory function and provides rapid pain relief. Further research with larger cohorts is warranted to confirm these promising results. Level of evidence III. Clinical trial number Not applicable.

Sacral epidural cavernous hemangioma involving the intervertebral foramen is exceptionally rare and may closely mimic more common benign nerve sheath tumors on magnetic resonance imaging. We report the case of a woman in her mid-50s who presented with a 1-month history of nocturnal left lower-extremity pain and mild weakness. Contrast-enhanced lumbar magnetic resonance imaging revealed a strongly enhancing nodular lesion in the left S2 foraminal region, and schwannoma was considered preoperatively. The patient underwent microsurgical resection through a posterior midline approach. Intraoperatively, the lesion was dark red, soft, and hypervascular, raising suspicion for a vascular malformation rather than schwannoma. Frozen-section analysis suggested hemangioma, and postoperative histopathology confirmed cavernous hemangioma. The patient experienced marked postoperative relief of radicular pain, and follow-up analysis indicated complete symptom resolution without radiological evidence of residual lesion. This case emphasizes that cavernous hemangioma should be included in the differential diagnosis of sacral foraminal masses. Purely epidural cavernous hemangiomas centered in the sacral foramen are particularly rare and frequently misdiagnosed preoperatively as schwannoma; thus, careful preoperative planning, anticipation of intraoperative hypervascularity, and frozen-section histology may help guide safe resection.

Sacral insufficiency fracture (SIF) is an important late adverse event after pelvic irradiation for cervical cancer and may impair long-term quality of life. This retrospective study aimed to identify clinical and dosimetric factors associated with SIF after pelvic radiotherapy for cervical cancer. We analyzed 121 patients treated between 2014 and 2022, including 73 who received curative radiotherapy and 48 who underwent postoperative adjuvant radiotherapy. The sacrum was manually contoured on planning computed tomography (CT), and dose-volume histogram parameters, including mean sacral dose, V30, and V40, were evaluated. Sacral CT attenuation in Hounsfield units (HU) was also measured. SIF was diagnosed based on follow-up CT, and in patients with SIF, site-specific dose metrics were additionally assessed by fusing planning CT with follow-up CT. SIF occurred in 31 patients (25.6%). In univariate analyses, age ≥55 years, body mass index (BMI) ≤20.5, mean sacral dose ≥38 Gy, and sacral HU <142 were significantly associated with SIF. In multivariate analysis, low BMI and higher mean sacral dose remained independently associated with SIF. Receiver operating characteristic analysis identified 38 Gy as the optimal cut-off value for mean sacral dose in this cohort. Site-specific analysis suggested that fractures tended to occur in relatively high-dose regions within the sacrum. Low BMI and higher mean sacral dose were independently associated with SIF after pelvic irradiation for cervical cancer. The 38 Gy threshold and the site-specific dose findings should be considered exploratory and require further validation.