JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
5). The posterior incisionwas closed using bilateral advancement flaps to decrease tension on the abdominal wound. The patient remained intubated and was admitted to the ICU overnight. The following day the patient returned to the operating room with the surgical oncology team for planned exploratory laparotomy of the abdominal cavity in order to inspect the resection bed, achieve hemostasis, and final close the abdomen. The patient was extubated on post-operative day two and discharged to home on post-operative day 13. Postoperatively the patient was able to ambulate with a rolling walker but experienced persistent urinary incontinence and erectile dysfunction with perineal numbness. At one year follow-up, the patient continued to have urinary incontinence and radicular leg pain. His ambulation had improved and he was able to walk without assistive device with only a small limp. His surgical scar was well-healed (Figure 6).
CASE PRESENTATION
We present the case of a 46-year-old African American man who was referred to the surgical oncology clinic for findings of a large, rapidly expanding sacral mass on magnetic resonance imaging (MRI) of the lumbar spine obtained for lumbar radiculopathy and urinary retention (Figure 1). A biopsy of the lesion by interventional radiology was positive for chordoma. The patient elected for surgery and underwent resection of the mass with a combined surgical oncology and neurosurgery approach carried out over two days. The surgical oncologist started the resection with an abdominal laparotomy and dissection of the pelvis to free the pelvic viscera, iliac vessels, and ureters off the lateral pelvic walls and sacrum. Once these structures were mobilized, the abdomen was closed and the patient flipped into the prone position. The neurosurgeon then opened a midline lumbosacral incision and placed pedicle screws along L3-L5. The dissection exposed the sacral mass as well as the sacroiliac joints. The thecal sac and nerve roots were tied off at the level of S1 with sacrifice of the right S1 nerve root. An osteotome was then used to cut through the S1 vertebral body and the SI joints and the tumor was removed en bloc (Figures 2 and 3). Bilateral iliac screws were placed, three in each iliac crest. Vertical rods were run from L3- L5 and extended to attach to the last pair of iliac screws. Two horizontal rods were used to connect the top two pairs of iliac screws with a fibula strut wired between the rods (Figures 4 and
DISCUSSION
While sacral chordomas are rare, they present a unique challenge to the treating physician. Their insidious presentation requires careful attention to the patient’s symptoms, with the diagnosis often being made based on imaging workup for lumbar radiculopathy, incontinence, or erectile dysfunction. Often the symptoms are non-specific and the diagnosis is made after the tumor has grown to a large size, rendering the resection of such tumors more difficult. In contrast to osteosarcomas or
Figure 2 : Posterior view of the pelvis after removal of sacral chordoma and ligation of thecal sac and nerve roots. The abdominal packing placed during the anterior part of the procedure is visible.
Figure 3 : Gross pathology specimen resected en bloc.
J La State Med Soc VOL 170 JANUARY/FEBRUARY 2018 7
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