SPINE Volume 38, Number 3, pp E185–E192
©2013, Lippincott Williams & Wilkins
SURGERY
A New Surgical Technique (Modified Osaka
Technique) of Sacral Resection by
Posterior-Only Approach
Description and Preliminary Results
Andrea Angelini, MD and Pietro Ruggieri, MD, PhD
Study Design. Operative technique.
Objective. To report a new technique for sacral resection, with
short-term preliminary results.
Summary of Background Data. Although various reports
analyzed en bloc excision of sacral tumors, there are still technical
problems to improve protection of nerve roots, preserve surrounding
structures, and reduce intraoperative bleeding, while maintaining
the oncological result.
Methods. Thirteen patients were resected for their sacrococcygeal
tumor by following the described technique. Two patients had
undergone previous surgery elsewhere. The sacrum was exposed
by a posterior midline incision and complete soft-tissue dissection.
Lateral osteotomies were performed through the sacral foramina
using a threadwire saw (devised by Tomita and Kawahara) and
Kerrison rongeurs, to avoid damage to the sacral roots. After
proximal osteotomy, the sacrum was laterally elevated and
mobilized to allow dissection of presacral structures. Mean surgical
time was 5.5 hours (range; 1.5–8). Mean blood loss was 2961 mL
(range; 1000–8000 mL).
Results. Level of resection was proximal in 9 patients and at S3 or
below in 4. Margins were wide in 10 patients, marginal in 1, and
intralesional in 2. At a mean follow-up of 35.5 months, 9 patients
were disease free, while the tumor recurred locally in 4 cases.
Complications requiring surgery were seen in 1 case.
Conclusion. The reported technique allows wide margins
with preservation of roots, and reduction in blood loss and
operative time. Indications for posterior-only approach can be
From the Department of Orthopedics, University of Bologna, Istituto
Ortopedico Rizzoli, Bologna, Italy.
Acknowledgment date: November 9, 2011. First revision date: September 17,
2012. Acceptance date: November 2, 2012.
The device(s)/drug(s) is/are FDA-approved or approved by corresponding
national agency for this indication.
No funds were received in support of this work.
No relevant financial activities outside the submitted work.
Address correspondence and reprints requests to Pietro Ruggieri, MD, PhD,
University of Bologna, Department of Orthopaedics, Istituto Ortopedico
Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy; E-mail: pietro.ruggieri@ior.it
DOI: 10.1097/BRS.0b013e31827db1ba
Spine
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BRS205378.indd E185
extended to resection proximal to S3, when there is minimal
pelvic invasion and none or partial involvement of sacroiliac
joints. However, the long-term benefits of this technique need
to be evaluated.
Key words: chordoma, sacral resection, sacral tumor, surgical
technique. Spine 2013;38:E185–E192
T
umors of the sacrum are rare1,2 and because of their
mild symptoms, are usually not diagnosed early.
Therefore, these tumors are often large by the time
they are diagnosed and offer challenging problems to ade-
quate surgery. In adults, chordomas are the most common
malignant primary tumors in the sacrum, while giant cell
tumors represent the most common primary benign lesions.
These tumors are invasive and without timely treatment
patients can develop metastasis and succumb to progression
of their disease.1,3,4 Because of low responsiveness to chemo-
therapy and radiotherapy,4–7 surgery is the primary modal-
ity of management. Partial or total resection of the sacrum
is considered the treatment of choice for malignant primary
lesions because it allows for a good local control and pro-
longed disease-free survival or healing.7–10 Recent articles
have reinforced the idea that achieving wide resection mar-
gins is the most important predictor of local recurrence and
survival in these tumors,6,8,11–17 even if the sacral concavity
below S1, the frequent ventral mass, the complex local anat-
omy and the surgeon’s desire to protect neural function may
increase the risk for inadvertent tumor contamination.18–19
Advances in surgical techniques have allowed surgeons to
perform en bloc tumor excision with greater success and
decreased morbidity. New surgical approaches, tools, and
techniques for sacral resection have been recently described,
with the aim of improving protection of nerve roots and
functional outcomes, preserving the surrounding structures
and reducing intraoperative bleeding, without compromis-
ing oncological adequacy and results. Here, we report a new
technique of sacral resection that uses a device similar to the
modified threadwire saw for sacral osteotomies developed
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 SURGERY
by Tomita and Kawahara20 and subsequently modified by
Osaka et al.13 We also report the short-term outcomes of
our first 13 patients, treated according to this technique.
MATERIALS AND METHODS
Patients Series
Between 2006 and 2010, we performed this technique in 13
patients with sacral tumors. Inclusion criteria for the current
study included (1) patients with diagnosis of sacral tumor,
(2) surgical treatment with posterior-only approach using
the new subsequently described technique, and (3) minimum
of 6 months clinical follow-up. Thirteen patients (9 males,
4 females), with a mean age at resection of 47 years (range,
22–71 yr) were included in the analysis.
The following data and variables were prospectively
collected and evaluated for their distributions and correlations
with patient outcomes: clinical and neurological symptoms,
type of biopsy, histological composition of the tumor, prior
surgical or nonsurgical treatments, surgical related complica-
tions, surgical margins, postoperative functional results, and
local recurrences or metastases. In addition, level of resection,
soft tissue involvement of the tumor and sacral roots killed at
surgery were recorded.
The margins were further defined on the basis of the worst
margin: wide if a continuous shell of healthy tissue could be
demonstrated around the tumor; marginal if the plane of
resection was along the pseudocapsule; intralesional when
pathological tissue was present in a margin.11–12
Patients were followed postoperatively at regular inter-
vals of 3 months for the first 2 years and every 6 months for
the next 3 years. Clinical examination and imaging studies
were performed at each check and were compared with the
previous ones to rule out signs of recurrence and for lung
metastases. Functional neurological outcomes were scored
using the method reported by Biagini et al.21 The follow-up
time was calculated from the date of surgical resection to the
most recent check or until time of death. Oncological results
were classified into 4 categories: no evidence of disease if the
patient was continuously disease free until last check; alive
with disease if the patient had local recurrence or metastasis
not treated; died with disease, and died of other disease if the
patient died of other causes. Oncological follow-up at recur-
rence or metastasis was calculated from the date of surgical
resection to the date of diagnosis of first recurrence or metas-
tasis. Complications were classified as intraoperative (during
procedure), early (within 30 d from surgery), or late (after
1 mo or more).
Planning and Surgical Technique
As with the traditional techniques of sacral resection, the
best way to define the surgical margins in the sacrum and the
soft tissue removal around the sacrum is to rely on a care-
ful preoperative planning based on a complete preoperative
imaging. Preoperative evaluation of the surgical stage by an
experienced musculoskeletal multidisciplinary team included
plain radiographs, bone scan, computed tomographic scans,
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BRS205378.indd E186
New Surgical Technique of Sacral Resection • Angelini and Ruggieri
and magnetic resonance images to assess the soft tissue
involvement, the degree of bony destruction and to allow an
accurate planning of level of resection and osteotomy sites. A
computed tomographic scan of the chest was taken to ensure
that no distant metastatic disease was present in the lungs.
In patients without previous treatment elsewhere, computed
tomography guided trocar biopsy was performed via a pos-
terior approach under strict aseptic conditions to assess the
histopatological aspects of the lesion. Criteria for sacral resec-
tion with only posterior approach according with the present
technique are presented in Table 1. Before surgery, informed
consent was obtained from each patient. Central venous
access with large bore catheters was placed the day before sur-
gery in the event that rapid transfusion of fluid was required
during resection.
Prophylactic intravenous antibiotic with cefazolin and
tobramycin was administered prior to the procedure and for
3 to 7 days postoperatively. A rectal tube was inserted in the
operating room preoperatively to aid in the identification of
the rectum during surgery. The patient was positioned prone
with care as represented in Figure 1. A posterior midline
incision and dissection through the subcutaneous tissue, the
fascia, and the posterior pelvic muscles were performed with
reference to the preoperative imaging studies (Figure 2A).
Although all the imaging tools are useful, the most important
is the magnetic resonance imaging with gadolinium. Namely
the sagittal plane studies are crucial to define the level of prox-
imal osteotomy and to identify the limit of the anterior mass
of the tumor, while the axial images are useful to define the
lateral delimitation of the tumor and exclude the involvement
of the sacroiliac joint or the ileum. Moreover, on T2-weighted
images and fat-sat sequences possible satellite tumor nodules
in the surrounding soft tissue are easily detectable and this is
again extremely useful for planning the surgical margins in the
perisacral soft tissues and muscles. Care was taken to excise
any skin area involved by tumor, previous biopsy sampling,
and radiation-induced change and scars of previous surgery
with the tumor, obtaining an en bloc resection (Figure 2A).
Then, the incision is continued proximally to expose 2 full
vertebral levels above the lowest involved vertebral level.
Paraspinal muscles were dissected laterally to expose facet
joints and transverse processes and the gluteus maximus
muscles were freed bilaterally from the sacrum (Figure 2A).
Violation of the tumor capsule was avoided; in fact muscles
TABLE 1. Criteria for Sacral Resection With
New Only-Posterior Technique
Level of Resection
Proximal to S1 Not indicated (anterior-posterior approach is
preferred)
S1 or S2 Central lesion with no or minor involvement of
sacroiliac joints
Minimal pelvic invasion
At S3 or below Always
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 SURGERY New Surgical Technique of Sacral Resection • Angelini and Ruggieri

dissection was performed as far away from the tumor mar-

gins as possible. Sometimes an intraoperative ultrasound
study was used to detach intramuscular tumor nodules. After
dissecting and retracting the gluteal muscles, the piriformis
muscles were cut at the musculotendinous junction and the
ligamentous attachments of the sacrum to the rest of the pel-
vis were dissected. The sciatic notch and any nerve roots were
identified and preserved if they were not involved by tumor.
When the soft-tissue dissection was completed, the field was
circumferentially prepared to osteotomize the sacrum in the
proximal and lateral portion.
The first lateral osteotomy is performed starting from the site
of lesser involvement from the tumor. Osteotomies of the lateral
portion of the sacrum were performed using the threadwire saw
Figure 1. The photograph shows the patient’s position during surgery as
well as the operating room distribution.
devised by Tomita and Kawahara20 because we do not have

Figure 2. Artist’s drawings showing opera-

tive field at the time of sacral resection.
(A) The figure shows a posterior midline
incision and dissection through subcuta-
neous tissue. Any skin areas potentially
involved by tumor must be included with
the specimen. The gluteal muscles are cut
with reference to the preoperative imaging
studies and sciatic notch is identified and
preserved. (B) Completion of the soft tissue
dissection. A drainage with 3 mm of di-
ameter is inserted into and passed through
the sacral foramina designed for resection.
Then, using it as a guide, the saw is intro-
duced and manually pushed into correct
position. (C) The figure shows how to per-
form the lateral osteotomy with the saw.
The first lateral osteotomy is performed
starting from the site of lesser involvement
from the tumor. Then with rongeurs, the os-
teotomy is completed from the chosen fora-
men to the level of laminectomy. Moreover
the figure shows the resection of anococcy-
geal and sacrotuberous ligaments. (D) The
figure shows the enlargement of the lateral
sacral osteotomies, with the protection of
the nerve roots. Laminectomies are carried
out at 1-level cephalad to the rostral extent
of the tumor. When necessary, the dural
sac must be isolated, legated, and cut as
shown. This is followed by a carefully cra-
nial osteotomy of the sacrum between the
2 sacral foramina.
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 SURGERY New Surgical Technique of Sacral Resection • Angelini and Ruggieri

the saw available as modified by Osaka.13 A drainage with 3
mm of diameters was then inserted into and passed through
the sacral foramina designed for resection, distally to protect
the sciatic nerves and superior gluteal arteries (Figure 2B). The
drainage was therefore inserted obliquely lateral to the root that
we wanted to spare. Then, using it as guide, the saw was intro-
duced and manually pushed into correct position (Figure 2C).
Keeping the saw adherent to the posterior part of the
foramina, complete lateral osteotomy was performed with a
prevalent vertically orientation to avoid damage in the course
of the corresponding ventral sacral nerve roots (Figure 2C).
An enlargement of the sacral osteotomy was performed
using a combination of Luer and Kerrison rongeurs and,
after protection of the nerve roots, the osteotomy was com-
pleted (Figure 2D). Laminectomies were carried out at one-
level cephalad to the rostral extent of the tumor to expose
the sacral nerve roots using a Luer and Kerrison rongeurs
(Figure 2D). During high sacral resection, the dural sac was
isolated, cut and legated at the planned level using a double
layer suture (Figure 2D). Then protecting the anterior sur-
face of the sacrum with multiple levers and/or the surgeons
fingers, the osteotomy of the median portion of the sacrum
is performed, mobilizing laterally or proximally the dural
sac previously ligated. This osteotomy is performed using
osteotomes and completing and enlarging the osteotomy of
the anterior cortex with Cobb elevators. With completion
of the proximal and inferolateral osteotomies, mobilization
of the distal part of the sacrum is more easily feasible. The
portion of the sacrum to be resected is progressively and
carefully mobilized and “opened” as a book laterally, start-
ing where the lateral involvement of the sacrum from the
tumor is less relevant. In such a way it is usually easier to
isolate the tumor mass anteriorly from the rectum and/or
vascular structures depending on the required level of oste-
otomy. The distal free-floating sacrum was laterally elevated
and mobilized to allow rectum preservation away from the
presacral fascia (which then was divided) and dissection
of sacral nerve roots and vascular structures. Sacral nerve
roots without gross tumor involvement were preserved. Inci-
sion of the sacrotuberous and sacrospinous ligaments were
performed (where was not possible before) to allow better
mobilization and complete the visceral and vascular dissec-
tion. At this moment, if it was not possible to make it before
and with the same technique used from the first site, the con-
tralateral osteotomy is performed and with rongeurs until it
reaches the laminectomy and median osteotomy. Then, the
tumor specimen was removed en bloc and careful hemosta-
sis accomplished. All osseous and soft tissue margins were
inspected. The entire specimen was sent for macroscopic and
histopathological examination of the tumor margins by the
surgical pathologist. Reconstruction was not performed in
any of these patients. Finally, adequate drains were placed,
the skin was closed and the wound was covered with a
dry sterile dressing. If any contamination was evident or
suspected, it was confirmed by frozen-section and eventu-
ally the margin was cleaned by further removal of possibly

TABLE 2. Patient Demographics and Surgical Data

Previous Age at Level of Operative Blood
Patient Sex Diagnosis Sacral Surgery Resection (yr) Resection Time (hr) Loss (mL) Complications
1 Female Chordoma No 51 S1 5.5 1500 Partial sciatic
nerve damage
2 Male Chordoma No 48 S2 8.0 8000 None
3 Female Chordoma No 64 S2 5.5 3500 None
4 Male Chordoma Yes 29 S3 4.0 1000 None
5 Female Chordoma Yes 62 S2* 6.0 4000 None
6 Male Chordoma No 57 S2 6.5 3500 Stress fracture
of S1
7 Male Chordoma No 71 S1 8.0 4000 Postoperative
hematoma
8 Male Chordoma No 46 S1 5.5 2000 None
9 Male Chordoma No 40 S3 4.5 1500 None
10 Male Mesenchimal No 45 S2 7 3500 None
chondrosarcoma†
11 Male Osteoblastoma No 33 S3 5 2500 None
12 Male Chordoma No 22 S2 5 3000 Wound deishence
13 Female Chordoma No 45 S4-S5 1.5 1000 None
*Resection was performed for the sacral recurrence, while general surgeons performed marginal excision for the 2 nodules near the rectum.

†Resection was performed for the sacral metastasis of D11 mesenchimal chondrosarcoma. Definitive histology showed dedifferentiated spindle cell sarcoma.

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 SURGERY New Surgical Technique of Sacral Resection • Angelini and Ruggieri

contaminated tissues. The resection was always done in 1
procedure and duration of surgery ranged between 1.5 and
8 hours (mean, 5.5 hr). The blood loss ranged between 1000
and 8000 mL (mean, 2961 mL).
RESULTS
Our experience with the use of this technique of sacral resec-
tion with posterior-only approach to date encounters 13 cases.
Patient demographics and summaries are listed in Tables 2
and 3. All patients presented with pain, constipation, fullness,
or a combination of these symptoms. The sacrococcygeal
neoplasm was chordoma in 11 cases, metastasis of mesenchy-
mal chondrosarcoma, and osteoblastoma in 1 case each. The
mean age at the time of surgery was 47 years (range, 22–71
yr). Two patients had been previously treated elsewhere with
intralesional partial excision in one and marginal resection
in the other. The remaining were observed primarily for their
sacral disease. No patient received preoperative chemother-
apy or radiation therapy. Level of resection was proximal to
S3 in 9 patients and at S3 or below in 4 patients. Wide sur-
gical margins were achieved in 10 patients, thus the overall
success rate of achieving our goal of wide resection with this
new technique was 77% in this study. One patient treated
with resection at S2 (number 6) had focal marginal resec-
tion in the anterior part of the specimen, while 1 patient with
chordoma (number 12) and the patient with mesenchymal
chondrosarcoma (number 10) had intralesional margin at
histopathological evaluation. The mean follow-up from time
of surgery until most recent clinic check was 35.5 months
(range, 6–50 mo); all patients were alive at last follow-up.
Three patients were alive with disease due to inoperable
local recurrences and started chemotherapy (Table 3). One
patient had local recurrence and was alive without evidence
of disease after surgical treatment of the relapse (number 1).
Multiple metastases were observed in the patient with mes-
enchymal chondrosarcoma. Patient 4 had wedge resection
for 2 lung nodules, but histopathology excluded metastatic
disease. Only one wound complication requiring surgery
were observed (number 12). A stress fracture of the body of
the S1 vertebra was observed in 1 patient (number 6) with
progressive improvement during follow-up; partial sciatic
nerve damage in 1 patient (number 1) with complete function
restoration and postoperative hematoma in 1 case (patient 7),
spontaneously resolved.
Functional results were correlated with intraoperative
nerve roots killed: we found that bladder and bowel functions
was maintained when bilateral S2 were preserved (patients 4,
9, 11, 13). On the other hand, 8 patients (patient 2, 3, 5, 6, 7,
8, 10, 12) with sacrifice of their bilateral S2 nerve roots had
sphincterial continence with constipation and postmiction
vescical residual (patient 2 needs permanent urinary catheter-
ization). Patient 1 (S1 resection) also needs one external sup-
port for walking because of partial right sciatic nerve impair-
ment. Hypoesthesia was present in all patients at different
dermatomeres. However, the size of our study cohort is too
small to allow for a statistical analysis.

TABLE 3. Surgical Margins and Oncological Results

Patient Margins Local Relapse Distant Relapse Disease Status Follow-up (mo)
1 Wide At 4 yr No NED1LR 50.6
2 Wide At 2.2 yr, 2.7 yr, and 3.1 yr* No AWD3LR 47.3
3 Wide No No NED 37.3
4 Wide No No NED 39.8
5 Wide At 0.8 yr† No AWD1LR 23.4
6 Marginal No No NED 16.7
7 Wide No No NED 16.3
8 Wide No No NED 12.1
9 Wide No No NED 10.8
10 Intralesional At 4 mo‡ Yes AWD LR + M 11.5
11 Wide No No NED 11.3
12 Intralesional No No NED 9.2
13 Wide No No NED 6.1
*The 1st and 2nd local recurrences were treated with marginal excision. The 3rd was considered inoperable and patient started palliative chemotherapy with
Imatinib Mesylate (Glivec/Gleevec, Novartis Pharmaceuticals Corp, East Hanover, NJ).

†Multiple local recurrences with small bowel involvement. Patient was considered inoperable and started palliative chemotherapy with Imatinib Mesylate
(Glivec/Gleevec, Novartis Pharmaceuticals Corp).

‡Because of multiple metastases and local recurrence, patient started chemotherapy with High Dose Ifosfamide (HDIFO) plus Zoledronic Acid (Zometa, Novar-
tis Pharmaceuticals Corp).

NED indicates no evidence of disease; AWD, alive with disease; LR, local recurrence; M, metastases.

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 SURGERY
DISCUSSION
Tumors of the sacrum are rare and commonly present at a
locally advanced stage because symptoms and signs are often
mild and nonspecific. Treatment depends on malignancy or
local aggressiveness: radical resection is indicated for malignan-
cies and aggressive benign sacral tumors that are resistant to
noninterventional therapies, while intralesional surgery is indi-
cated for the other benign lesions. Between malignant lesions,
chordomas are the most common primary bone tumors found
in the mobile spine22,23 and the sacrum22 and represent the most
frequent tumor in patient series about sacral resection.24,25
Although chordomas are low-grade tumors, recurrence rates
are high (range, 43%–85% of patients8,10–12,15–17,26,27) even
after resection. The quality of surgical margins has been
recently described as the main prognostic factor for local
failure11,12,23,28,29; in fact, achieving wide resection margins
is the most important predictor of local recurrence and sur-
vival in chordoma.8,11,15,23,30 Although some investigators have
recently reported good preliminary results using radiotheraphy
with hadrons (high-dose protons or charged particles, such as
carbon ions or helium),3,31 more sophisticated photon beam
techniques,32 or chemotherapy with new molecular-targeted
agents such as Imatinib mesylate (Glivec/Gleevec, Novartis
Pharmaceuticals Corp, East Hanover, NJ),33 resection of the
sacrum remain the mainstay of treatment. Patient selection is
important because, if adequate margins cannot be achieved, the
patient may not profit from such an extensive and devastating
surgery. Given the difficulties in surgical approach (frequently
accompanied by complications such as massive blood loss,
nerve injury, and infection) and in achieving adequate margins,
treatment of malignant sacral tumors is challenging and differ-
ent surgical strategies and techniques have been described in
literature.6,13,14,20,22,24,25
According to the tumor extension into the sacrum and
the proximity of important anatomic structures, sacral resec-
tion could be categorized in the following 2 groups: “proxi-
mal” resection with tumor extension above S3 and “distal”
resection when tumor involves the S3 vertebra and/or below.
Proximal resections are significantly more complex proce-
dures, typically requiring a combined anterior (transperi-
toneal) and posterior approach, whereas a posterior-only
approach is generally preferred for distal resections.6,8,10–17,26,27
Total sacrectomy is rarely required and should be performed
in selected cases, because about two-thirds of sacral tumors
arise at or below the level of S2 and may be generally resected
with transverse partial sacrectomy. Fuchs et al12 performed
sacral resection with a combined anteroposterior approach
in 30 chordomas: 10 patients in whom the lesion extended
above S2 and 17 patients with a lesion extending to S2 or S3.
They preferred this approach because it allows (1) exposure
of the entire sacrum with mobilization of the rectum, ureter,
and major vessels, (2) ligation of internal iliac arteries, and (3)
the harvest of a pedicled rectus abdominis flap for posterior
wound closure. A posterior-only approach was performed in
8 patients with involvement of S4 and S5 and in other 17
patients with a lesion extending to S2 or S3. More recently,
Hanna et al27 reported their series where only patients with S3
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New Surgical Technique of Sacral Resection • Angelini and Ruggieri
involvement or below were posteriorly resected. Hulen et al15
described a series of 16 patients treated with resection for
their sacral chordoma. All patients had involvement of levels
cephalad to or including at least a portion of S2 and a com-
bined sequential anterior and posterior approach was used
for every patient, avoiding when possible ligation of internal
iliac vessels. In other centers, such as the Massachusetts Gen-
eral Hospital34 and the National Cancer Institute of Milan,26
the posterior approach is preferred for lesions affecting up
to the body of S1 (when a combined approach is necessary
because of the proximity of vascular and other vital struc-
tures) because it is feasible, satisfactory, and safe. In our expe-
rience, a combined anterior and posterior approach was the
preferred approach for proximal sacral resection. One study
recently reported our results on 56 sacral resections for chor-
doma: all patients with bone resection level at or below at S3
vertebras were treated with posterior-only approach whereas
proximal resection required a combined anterior and poste-
rior approach (in 3 cases during 2-stage surgery).11
The choice of surgical approach is also discussed accord-
ingly to the possibility of preserving the nerve roots during
resection. In fact, preservation of the nerve roots is impor-
tant because it contributes to the postoperative quality of
life, and combined approach allow easier identification of
the nerve roots and possible preservation for retained bowel
and bladder function.35,36 At the Department of Orthopaedic
Surgery, in Nihon University School of Medicine (Tokyo) it
has been recently introduced as a new technique for greater
precision in osteotomies, preserving nerve roots during sacral
resections13,29,37 on the basis of the use of as a new device for
cutting bone. Tomita and Kawahara20 devised a threadwire
saw (T-saw: diameter 0.5 mm) subsequently modified by
Osaka et al (MT-saw)13,29 with a flexible silver guide probe for
osteotomies of the lateral portion of the sacrum, facilitating
preservation of nerve roots, and blood vessels.
In consideration of the good preliminary results reported
by Osaka et al in 2006,13,29 we decided to use this technique,
that we partially modified. Our technique for partial sacral
resection with the use of T-saw for lateral osteotomies of the
sacrum was introduced in our practice from 2006, with the
aim of improving functional results of our patients and allow-
ing safer excision with a wider margin. Inner advantages of
this technique are (1) the choice of the lower foramen as land-
mark for performing the resection; (2) the possibility of spear-
ing 1 more root and sensibly diminish the risk of undesired
damage of the roots; and (3) the precision in performing oste-
otomy for the lateral exposure and progressive mobilization
that allow both a safer osteotomy of the sacral vertebra on the
median line and an easier detachment of the rectum, anterior
roots that can be expired and median neural structures of the
parasympathetic from the anterior surface of tumor mass.
Differences with the original technique are simple and con-
sist of the following: (1) The use of the classical Tomita saw
because we could not have the Osaka modified saw in Europe.
The Osaka saw has probes that protect the tissue and roots
during the introduction of the saw. Because we do not have
this and, moreover, because we prefer to feel the saw at the
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 SURGERY
extremity, we decided to use a small drainage to insert the saw.
When performing the lateral osteotomy the small plastic tube
is introduced obliquely through the chosen foramen lateral to
the root that we want to spare. Then the saw is introduced
into the tube and the tube removed, keeping the saw adher-
ent to the “roof” of the foramen distal to the one crossed by
the saw and the sacrum lateral to the foramen involved and
distal to it, so that the bone can be cut without risk of damag-
ing the corresponding nerve root and the next distal root. (2)
The start of the lateral osteotomy from an identified foramen.
We do not perform a long lateral osteotomy with the thread-
wire saw because we think that this increases the risks of roots
damage, but we rather prefer to do a short oblique osteotomy
from the chosen foramen down with the saw. The osteotomy-
line (performed with great precision considering the diam-
eter of the saw) and laminectomy are always enlarged using
a Luer and/or Kerrison rongeurs because it allows safe and
more accurate protection of the nerve roots both during sacral
mobilization and during en bloc excision. (3) The osteotomy
of the sacral vertebra is performed with osteotomes and Cobb
elevators, protecting the abdominal content with fingers or
moldable levers. In fact, care must be taken to protect the ret-
roperitoneal visceral structures, including the rectum, ureters,
iliac vessels, nerves, and intestines, because they are generally
displaced by the anterior protrusion of the tumor. After the lat-
eral osteotomy is performed, the surgeons’ finger or a flexible
metallic lever can be progressively introduced anterior to the
sacrum to perform the median osteotomy using small osteo-
tomes or the same rongeurs. (4) In our experience, the mobili-
zation of the sacrum performed laterally allows a better view
of the pelvic structures than starting from caudal to rostral
part of the specimen, and also reduces the risk of nerve roots
damage. Moreover, in cases where the sacroiliac joint is unilat-
erally involved, this modified technique can still be used (and it
has been used) performing the lateral osteotomy from the side
of lesser involvement, mobilizing laterally the sacrum after the
median osteotomy, and completing the osteotomy in the ilium
on the other site (laterally to the sacroiliac joint involved) with
rongeurs and osteotomes. (5) In cases with the tumor mass
raising proximally, even to the second sacral metamer, but not
presenting with a huge mass from side-to-side, this modified
technique can be used, and it has been used. (6) Eventually a
further advantage is represented by the possibility of spearing
some more anatomical structures, for example, gluteal muscles
and/or nerve roots and the presacral parasympathetic nerve
structures, when compared with the traditional techniques.
In addiction, at neurological dysfunction, sacral resections
are associated with a high level of complications including
visceral damage, vascular injury and surgical site infections;
an important intraoperative complication is excessive bleed-
ing, which may be a life-threatening problem in total or par-
tial sacral surgery, usually with a massive blood loss.8,10–12,24–26
Through an anterior approach, intraoperative blood loss can
be reduced by bilateral ligation of internal iliac arteries and
veins as reported by several authors.8,11,12,15,27,38 Although
operative time and blood loss vary according to tumor
location, Osaka et al37 recently analyzed bleeding with the
Spine
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
BRS205378.indd E191
New Surgical Technique of Sacral Resection • Angelini and Ruggieri
MT-saw procedure, that was significantly less with conven-
tional methods (P < 0.05) (Student t test) because the blood
in epidural vessels coagulated within the sacral canal. In
our preliminary experience, mean blood loss was 2961 mL
(min 1000, max 8000), and even if higher than reported by
Osaka et al (1370 mL for the posterior approach)29 it is better
than the mean value reported in literature for sacral resec-
tions (5000 mL).15,39,40 Similar results were recently obtained
performing the sacral resection within 24 hours of selective
arterial embolization of tumor feeding vessels.41 Recently, the
use of the Ultracision Harmonic Scalpel (Ethicon, Cincin-
nati, OH), an ultrasound scissor and blade, has made the soft
tissue resection easier and faster and contributed to reduce
blood loss. Using ultrasound, this instrument allows the sec-
tion of the soft tissue and, in the same time, the coagulation
of blood vessels.
About functional results, the posterior-only approach offers
the advantage of a single procedure with shorter operative
time. In the present series, it ranged between 1.5 and 8 hours
(mean, 5.5 hr), comparable with operative time described
in literature for posterior-only approach.29,35,37 Comparing 5
patients who underwent posterior excision of tumors distal
to S2 using a modified threadwire saw (MT-saw) with 5 simi-
lar patients who underwent tumor excision using chisels and
airtomes, the operative time in the first group was shorter by
2 hours 24 minutes than that for conventional methods, but
without statistical significance.37 The functional advantages
of the use of this Osaka modified technique in our series are
essentially due to the posterior-only approach, that allows for
a very early mobilization of the patient and faster functional
recovery and walking capability.
The surgical margins obtained at initial surgery and previ-
ous intralesional surgery are the primary prognostic factors
for local recurrence in patients with sacral chordoma.8,10–12,17
We do not think that this surgical technique is directly related
with improved surgical outcome, but we do think that the use
of the threadwire Tomita saw, the Osaka technique, and our
modifications allow the surgeons to benefit from the advan-
tages of performing the posterior-only approach without
increasing the risk of oncological inadequacy of the surgical
margins. In fact, the reported technique seems to provide a
significant improvement in the width of the surgical margin
of tumors with preservation of roots and significant reduction
in blood loss and operative time compared with the conven-
tional technique. Analyzing sacral chordomas, the incidence
of local recurrence in primarily treated patients was 22% (2
of the 9 patients), better than the incidence of 32% in a previ-
ously reported series of resected sacral chordoma.11 Indica-
tions for posterior-only approach could be extended to sacral
resection proximal than S3, when there is no involvement of
sacroiliac joints by the tumor and minimal pelvic invasion.
However, although it is not correct to compare our prelimi-
nary results based on a small series with long-term results of
the conventional procedures reported in literature, the good
oncological and functional outcomes encourage us to use this
technique as preferred surgical procedure for sacral resection,
when criteria described in Table 1 are confirmed.
www.spinejournal.com E191
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 SURGERY
➢ Key Points
‰ Sacral resection with posterior-only approach is
always indicated for lesions distal to S3 and could
be extended proximally than S3 when there is no or
minor involvement of sacroiliac joints by the tumor
and minimal pelvic invasion.
‰ The reported technique provides preservation of
roots and significant reduction in blood loss and
operative time compared with the conventional
technique.
‰ Preliminary results encourage us to use this
technique as preferred surgical procedure for sacral
resection.
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