A wider dissection will typically be performed for primary tumors compared to a trauma case.
3. Sacral laminectomy
Remove intact sacral lamina according to the preoperative planning using a high-speed burr or a Kerrison rongeur.
4. Tumor resection
Dissection of the tumor should progress from normal to abnormal tissues to protect normal neurological elements and facilitate dissection.
Use reverse-angle curettes and pituitary rongeurs to debulk the tumor.
Nerve root mobilization should be minimized to reduce the risk of neurological injury.
The goal is to achieve gross total resection.
Intraoperative navigation can be used as an adjunct to maximize resection accuracy.
Once the tumor is entirely resected, the goal of the surgery is met.
5. Intraoperative imaging
Before wound closure, intraoperative imaging is performed to check the adequacy of reduction, position, and length of screws, and the overall coronal and sagittal spinal alignment.
6. Posterior closure
Perform a multilayer closure as described in the approach.
Even a low sacrectomy has a high chance of deep wound infection.
To decrease the risk of wound infections, a gluteal advancement flap may be considered. This is typically performed by the plastic surgeon.
Intrawound vancomycin can be applied to decrease the risk of postoperative wound complications.
Patients are made to sit up in the bed on the first day after surgery, unless contraindicated because of a plastic flap closure. Patients with intact neurological status are made to stand and walk on the first day after surgery.
Patients can be discharged when medically stable or sent to a rehabilitation center if further care is necessary.
Throughout the hospital stay, adequate caloric intake of a high-quality diet should be monitored.
Patients are generally followed with periodical x-rays at 6 weeks, 3 months, 6 months, and 1 year to monitor for hardware failure and with an MRI every 6 months for tumor surveillance.
Some primary benign tumors of the spine can recur years after surgery, and long-term tumor surveillance is important.