Neurosurg Focus 42 (1):E15, 2017 P rimary bone malignancy is relatively rare, accounting for 0.2% of all cancers and less than 5% of all osseous neoplasms. 15 Primary tumors of the spine are particularly rare, accounting for 2.8% 9 to 13% 6 of all primary bone tumors. Patients with spinal tumors typically present with variable and nonspecific signs and symptoms, but 85% of these patients present with pain. 16 Patients with sacral tumors typically complain of low-back pain that is insidious in

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... set and not related to activity. Other symptoms may include radicular pain, weakness, bowel or bladder dysfunction, and paresthesia. Point tenderness over the spine is a common physical finding, but patients only infrequently present with a palpable mass. Due to the low incidence of sacral tumors and the difficulty of identifying tumors on plain radiographs, a high clinical suspicion is required for a timely diagnosis; consequently, delayed diagnosis is common. Imaging features of various spinal tumors are often characteristic, but because of the overlying bowel gas, lytic, destructive lesions are difficult to identify on plain radiographs and require MRI or CT evaluation. Definitive diagnosis is based on histological evaluation of a specimen obtained through either core needle biopsy or open biopsy. Once the diagnosis has been determined, surgical therapy may be undertaken, but surgical treatment for sacral tumors can be quite challenging, with complications of neural compression, lumbopelvic instability, and suboptimal oncological resection. Complications resulting from sacrificing sacral nerves intraoperatively can be burdensome for the patient. Removing more than 50% of the S-1 vertebra/ AbbreviAtioNs ABC = aneurysmal bone cyst; GCT = giant cell tumor; IGS = image-guided surgery; WBB = Weinstein-Boriani-Biagini. objeCtive The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors. MethoDs The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type. resUlts Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type. CoNClUsioNs Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum. https://thejns.org/doi/abs/10.3171/2016.6.FOCUS16125