|Beitragstitel||Gluteal flap coverage for sacrectomy to compensate for biopsy induced soft tissue contamination|
Sacral chordomas are locally aggressive tumors that grow slowly causing subtle symptoms usually. Surgery of these tumor aims at complete en bloc resection, which because of its close relation to neural elements, may be associated with important functional consequences for bowel and bladder continence. The placement of the biopsy is therefore extremely important not to contaminate further tissues to be resected.
A 49 year-old patient presented with a history of 8 year long sacral pain. She did not note any reduced sensation and muscular weakness, no bowel or bladder incontinence. Preoperative MRI guided us in identifying a 52x55mm sacral chordoma of S3 and S4 body in close contact to S3 roots right. Staging studies with CT showed small two lung nodules. A biopsy was performed from laterally to reach the anterior portion of the tumor, potentially sparing the neural elements. Preoperative underwent the patient photon therapy.
A posterior midline skin incision with inclusion of the entire biopsy tract from laterally was performed necessitating on the left side the mobilization of the gluteus maximus muscle. Wound was exposed to the tip of the coccyx and pelvic ligament (sacrotuberous and sacrospinous) were found and sectioned, lower border of pyriformis muscle was identified and dissected. We identified the dural sac with exiting sacral roots, especially S2 and S3 bilaterally. The identified sacral nerve roots are traced laterally outside the sacral foramen and we resected the S3 root right which direct in relation with tumor was. The osteotomy level was decided based on the tumor extent and performed; the sacrum was gently lifted up with tumor and the removed bone with tumor was sent for histopathological examination. A left gluteus maximus advancement muscle flap was used to fill the defect. At 6 month-follow-up, the patient was pain free and no local or distal recurrence after 29 months follow-up.
Surgery is the mainstay for local control of sacral chordoma. Biopsies need to be performed strictly from posteriorly in the midline. If mistakenly it is carried out from laterally, additional soft tissue resection requires the usage of additional tissues to reconstruct the large posterior sacral defect. This may lead to increased morbidity, should be avoided and highlights the importance of defining the biopsy tract preoperatively in a multidisciplinary team.