Background: Sacral tumours are commonly diagnosed late and therefore are often large and at an advanced stage before treatment is instituted. The late presentation means that curative surgical excision is technically demanding¹. Total en-bloc sacrectomy is fraught with potential complications: deep infection, substantial blood loss, large bone and soft tissue defects, bladder, bowel and sexual dysfunction, spinal-pelvic non-union, and gait disturbance². The aim of the current study was two-fold: firstly to detail the technique used by the senior author and chronicle how this has evolved; and secondly to present the complications and outcome of nine total en bloc sacrectomies.

Methods: We retrospectively analysed of total en-bloc sacrectomies between 1991 and 2004. Nine patients (2M, 7F, mean age at surgery 39 years, range 21 – 64yrs) with a diagnosis of primary sacral tumour underwent total en-bloc sacrectomy under the care of the senior author. The mean follow-up was 50.2 months (range: 3.5 – 161 mths). Patients’ functional outcome was evaluated using the Functional Independence Measure (FIM) instrument and the SF-36. Intra-operative and postoperative complications (including disease progression) were documented.

Results: Surgical technique has evolved from single stage surgery without and with colostomy to two stage surgery with colostomy. Currently, the first stage includes an anterior lumbar interbody fusion at L4/L5 retaining the L5 nerve roots. In the second stage an L4 to pelvic fusion is performed posteriorally. The dura is tied and divided just below the L5 roots. The mean total operating time was 13.3 hrs (range: 8 – 20.1hrs); the mean total blood loss 14.1 ltrs (range: 4.2 – 33 ltrs). There were two revision L4 to pelvic fusions for pseudoarthroses. The mean length of hospital stay was 8.9mths (range: 2 – 36mths). One patient had a recurrence and died 2 years after her surgery. Of the surviving 8 patients the results from the functional outcome scores were variable. Three patients are able to walk independently; the remaining 5 are all mobile but require differing degrees of assistance to walk.

Conclusion: Total en bloc sacrectomy is a major surgical undertaking but our series has shown that it is probably justified in view of the fact that 8 out of 9 patients have had no tumour recurrence and all are able to walk.

Aim: Chordomas are relatively rare, malignant and strictly found in the midline. This study is to review our experience in the diagnosis, treatment and outcome of sacral chordomas. Method: A retrospective study reviewing 25 sacral chordoma patients treated at the Royal National Orthopaedic Hospital between August 1987 and April 2002, with a minimum follow-up of 6 months. Results: Of the 25 patients, 17 were male and 8 were female. The mean age at diagnosis was 61 years, and the mean duration of symptoms was 2 years. The commonest presenting symptom was lower back pain (20 cases). Three patients had inoperable tumours at the time of referral; the remaining 22 underwent surgical excision. A complete excision (based on microscopic examination) was achieved in11 cases, 2 of whom received adjuvant radiotherapy. Of the11 who had an incomplete excision 8 received adjuvant radiotherapy. Complete excision extended the mean disease free period to2.92 years, compared to 0.67 years following incomplete excision. The disease free period following an incomplete excision was extended from a mean of 0.67 years to 2.82 years with radiotherapy. 10 patients had postoperative neurological complications. Conclusion: We believe that the aim of surgical resection should be a microscopically complete excision margin, having documented an increased time to recurrence in patients in whom this has been achieved, compared to those treated with an incomplete excision. Radiation therapy should be given after an incomplete excision as we have shown that it lengthens the disease free interval in these cases.