The sacrum is the bottom of the spine. It has a structure that surrounds the pelvis from behind and is a follow-up of the pelvis. Sometimes it is called as tail end. It is one of the most important bones that make up the pelvis.
Sacrum tumors are special tumors due to their different anatomic locations, nerve roots they contain, their relations with pelvic organs and large vessels, and the delicacies in their treatment. Some of the sacrum tumors may be tumors originating from the sacrum itself, as well as tumors from other sites to the sacrum (metastatic) is often seen. Benign tumors include giant cell tumors, aneurysmal bone cysts, osteoid osteoma, and nerve sheath tumors. Malignant tumors include chordomas and sarcomas.
Sometimes there may be only low back or leg pain, sometimes there may be a pain in the tail end. Sometimes there may be numbness or loss of strength in the legs. Urinary, digestive system and defecation problems may occur. Constipation and fullness are sometimes the first symptoms. Sexual dysfunctions may occur. Symptoms may present very different clinical pictures depending on the location and type of spread of the tumor. In malignant tumors, fever, weight loss and general symptoms of malignant tumors can also be seen. The patient’s complaints, history of the disease and examination are very important in terms of diagnosis.
Magnetic resonance imaging (MRI) is usually the first requested test. It gives detailed information about the tumor. The relationship of the tumor with the organs in the pelvis is also evaluated. Sacrum tomography can give detailed information about the structures of the spine bones, calcifications in the tumor. Angiography can show the blood supply to the tumor tissue and its relationship to the surrounding large vessels. X-rays may show distortions and melts in the sacrum bones.
The most important criterion that determines the treatment in sacrum tumors is the genus of the tumor. For this, patients are usually biopsied. Treatment is decided according to the pathology result.
Since radiotherapy or chemotherapy does not have much effect in the treatment of malignant tumors such as chordoma or sarcoma, the main treatment is the removal of the tumor. The most important point here is the removal of the tumor together with the intact, tumor-free tissues around it. The nerves that control legs and feet, and the nerves that control urine and feces, pass through the sacrum bone. In sacrum tumors, these nerve structures are usually surrounded by the tumor tissue and cannot be separated. These neural structures may need to be cut while the tumor is being removed.
Benign tumors are usually removed by entering into the tumor, fragmentation. In this way, it may be possible to protect the nerve structures. Lumbopelvic stabilization (fixation of the spine and pelvis with screws) may be necessary after the removal of the entire sacrum bone called total sacrectomy.
Surgical procedures applied to sacrum tumors carry a high risk in many ways. Total removal of the tumor is the basis of surgical treatment. However, total sacrectomy is a very special operation due to the characteristics of the site and its relationship with the abdominal and pelvic organs. Therefore, it is important that the operations for sacrum tumors be performed by teams experienced in sacrum surgery.
Preoperative angiography and occlusion can increase intraoperative comfort and minimize blood loss. Sometimes it is possible to give effective drugs to the tumor with this method. Although radiotherapy is used to shrink the remaining tumor and prevent a recurrence, it is not effective for most malignant tumors.
Approximately half of all chordomas are seen in the sacrum. In addition, chordomas are the most common tumors arising from the sacrum. These tumors originate from notochord remnants in the prenatal period and are malignant and grow slowly. They are more common in middle age and older. They are twice as common in men as in women. Chordomas are among the first tumors that should be considered in patients with low back pain and constipation after 40 years of age. The biopsy taken before the surgical intervention and confirming the diagnosis helps planning operational plan. The treatment is to remove the tumor with tumor-free and intact tissues around it without entering inside the tumor. Operative risks and complications are much lower if early diagnosis can be made.
Tumors such as osteosarcoma, chondrosarcoma, Ewing’s sarcoma can be seen with progressive local pain and, later on, with loss of strength and sense, dysfunctions. Chondrosarcomas may occur directly in the sacrum or develop as a result of malignancy of benign tumors such as enchondroma, osteochondroma. These are more common in males at an average age of 45 years, and osteosarcomas are more common in older ages. Only Ewing’s sarcoma can occur in children or young adults and they are worse than those seen outside the sacrum. This is due to delayed clinical findings and large size. In sarcomas located in the sacrum, it is important to perform CT before surgery and to confirm the diagnosis by biopsy. The treatment is to remove the tumor with tumor-free and intact tissues around it without entering inside the tumor.
Giant Cell Tumor
Giant cell tumors are the second most common tumors of the sacrum. Although they are generally benign, partial malignancy rates are not very low. It also has the ability to spread to the lungs. They grow by expanding bone and often reach large sizes when diagnosed. In many patients, a mass may be noticed during the rectal examination. The incidence is common between the ages of 20-40. They often occur with pain spreading behind the hip. The treatment is surgical. It is important that the mass is completely removed and cleaned as much as possible to avoid recurrence. It is also possible to clean the inside of the tumor by curettage in tumors that cannot be removed completely by turning around it. In the operations of these tumors, it may be necessary to fix the spine and pelvic bones by placing screws as in all sacrum tumors.