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Update on the Management of Sacral Metastases

Aleksander Mika, BS Abstract Addisu Mesfin, MD » Sacral metastases have increased over the past decades as chemotherapy improves and more patients survive common cancers.

» Sacral metastases can present with cauda equina syndrome, Investigation performed at the , and instability. Department of Orthopaedic Surgery, University of Rochester School of » Sacral metastases are often treated with radiation therapy, a surgical Medicine and Dentistry, Rochester, procedure, or sacroplasty. New York » Patient-reported outcomes are of increasing importance when evaluating patients for the management of sacral metastasis.

n the United States, there were to bowel or bladder incontinence8. nearly 1.6 million cases of cancer in Decreased ambulation associated with 2016. In the last several decades, radicular symptoms and/or pathological 5-year survival rates have increased fractures can increase the risk of thrombo- fromI 49.1% in 1980 to 57.7% in 1990, embolism that is already increased because 9 66% in 2000, and 68.9% in 20081. of the history of malignancy . Metastatic sacral disease is rare, represent- ing 1% to 7% of metastatic spine disease2. Anatomy of the Although rectal carcinoma can metastasize Thesacrum iscomposed ofa concave surface and directly invade the sacrum, most sacral (facing the ) and convex outer surface, metastatic tumors are the result of hema- which articulates superiorly with L5 via the L5-S1 facet, inferiorly with the , and togenously spread tumor cells3. The spread bilaterally with the iliac via the sacro- of metastasis often occurs via the Batson iliac joint. The sacrum projects posteriorly venous plexus, especially in the thoracic and forms the lumbosacral angle. Because of spine4. In recent years, metastases this projection, the articulation at this angle have been attributed to the increased is subject to shearing forces. Sacral nerve number of chemotherapy drugs used in roots help to control the sphincters of the metastatic colorectal cancer5. Additionally, , bladder, and sexual organs, as well as because of the effectiveness of systemic the motor and sensory contributions to the therapy, patients are living longer, and lower extremities10. more symptomatic spinal metastases are 6 being identified . Sacral metastases are Clinical Presentation often diagnosed late when they have already Metastatic tumors are the most common extended beyond the osseous margins malignancy of the sacrum and can signify around the sacral nerves and other sur- advanced disease. These are often charac- rounding organs7. Patients commonly terized by radicular pain due to nerve root present with pain due to sacral nerve root compression or even tumor infiltration7,11. compression and pathological fractures. Pain may radiate into the buttocks, poste- Also, sacral nerve root compression can lead rior aspect of the leg, and perineal region12.

Disclosure: There was no source of external funding for this study. On the Disclosure of Potential which are provided with the online version of the article COPYRIGHT © 2018 BY THE Conflicts of Interest forms, , one or more of the JOURNAL OF BONE AND JOINT authors checked “yes” to indicate that the author had a relevant financial relationship in the SURGERY, INCORPORATED biomedical arena outside the submitted work (http://links.lww.com/JBJSREV/A348).

JBJS REVIEWS 2018;6(7):e8 · http://dx.doi.org/10.2106/JBJS.RVW.17.00130 1 | Update on the Management of Sacral Metastases

Clinical findings include changes in enough tissue is not obtained, then an metastases to major organs, primary sensation, radiculopathy, motor deficits, open biopsy can be performed. How- cancer site, and extent of neurological bladder and bowel incontinence, and ever, in cases of localized extension of deficits25. A score of 0 to 8 points pre- sexual dysfunction13. Cauda equina tumor into the sacrum such as in the dicts ,6 months to live, a score of 9 to syndrome can be the initial presentation setting of colon cancer or endometrial 11 points predicts $6 months to live, of sacral metastases. The clinical pre- cancer, a biopsy may not be needed. and a score of 12 to 15 points predicts a sentation can include severe pain, Also, in the setting of acute neurological life expectancy of $1 year. urinary retention, constipation, and, at deterioration or cauda equina syndrome, A palliative surgical procedure or later stages of presentation, bowel and surgical intervention should not be de- nonsurgical options may be considered bladder incontinence. Bowel and blad- layed and intraoperative biopsy would for patients with a low score. The To- der incontinence is a surgical emergency suffice. mita score is another validated scoring and prompt decompression should be system for prognosis in spine tumors. performed14. Management It has 3 components that evaluate the Conventional radiation therapy remains type of tumor, the presence of visceral Imaging the first-line intervention for sacral metastases, and the presence of bone Radiographs are often the first imaging metastasis, and doses for conventional metastases. Scores of 2 to 10 points can modality performed. However, these radiation therapy include 30 to 40 Gy be generated, with a higher score indi- may remain inadequate because of the over multiple fractions19. Stereotactic cating worse prognosis and a lower score difficulty in evaluating the sacrum on radiosurgery for the spine and sacrum is indicating consideration for excisional radiographs11. Additionally, radio- being increasingly used in the United surgical procedures26. Tumors can be graphic evaluation has proven unreliable States20. Recurrent sacral lesions fol- divided into 3 categories based on the even in patients with confirmed sacral lowing conventional radiation therapy Tomita scoring system: slow, moderate, pathology. Instead, clinicians should can also be addressed with stereotactic and fast-growth tumors27. There is a focus their attention on the loss of sacral radiosurgery21. Gerszten et al. demon- minimal role for an excisional surgical arcuate lines, which more strongly cor- strated in 103 cases of sacral metastasis procedure in the setting of metastatic relates with the presence of metastatic that spinal stereotactic radiosurgery is sacral lesions; however, a palliative sur- disease15. In the case of sacral insuffi- effective in decreasing pain and with gical procedure can be considered, ciency fractures, these are often not fewer complications22. Additionally, especially if neurological deficits such as displaced and can be challenging to be precise control and treatment volume cauda equina syndrome are present. visualized in radiographs16.Thegold increase success and decrease the risk of Spinal stability serves as a critical deci- standard for evaluating a metastatic neural element injury. Radiosurgery is sion criterion when evaluating patients lesion to the sacrum is magnetic reso- not indicated in cases of neurological for a sacral surgical procedure. The Spi- nance imaging (MRI) with and with- deficit caused by osseous compression nal Instability Neoplastic Score (SINS) out contrast17. Computed tomography to neural structures. Also, it may not is a validated instrument that provides (CT) helps to evaluate the degree of be indicated as the only treatment mo- an objective means of grading spinal lytic or blastic involvement by the dality when spinal instability is present. stability. A score of 0 to 6 points is a lesion. Lastly, when treating larger lesions, stable spine, a score of 7 to 12 points radiosurgery may not deliver enough suggests impending instability, and a Diagnosis radiation22,23. score of 13 to 18 points is an unstable A tissue diagnosis is always fundamen- Indications for a surgical procedure spine28. The SINS can help to guide tally critical to establish prior to treat- include neurological deficits, failed treatment for symptomatic upper sacral ment and must distinguish among radiation therapy, and spinal instabil- lesions. infection, , and other metastatic ity24. Surgical intervention relies heavily With some minor exceptions, a histologies. Histological examination on the individual pathology of each surgical procedure for sacral metastases will differentiate metastases from un- patient. Several scoring systems are is performed via laminectomy with or common infectious conditions17,18. available to help to guide the type of without instrumentation and/or fusion. However, culture specimens should also surgical intervention and to determine if A decompression surgical procedure be sent along with the biopsy specimen a patient’s prognosis precludes surgical generally involves laminectomy for the to rule out any concurrent infections. intervention. The modified Tokuhashi evacuation of a tumor causing nerve root Biopsies can be performed as open in- score is composed of 6 sections, includ- compression or cauda equina syndrome, cisional procedures, percutaneously or ing general condition of the patient and instrumentation (lumbopelvic fixa- with CT guidance. CT-guided biopsy (performance status), number of tion) and fusion are employed for im- is the most frequently used biopsy extraspinal bone metastases, number pending instability with concurrent modality and carries a minimal risk18.If of metastases in the vertebral body, nerve root compression.

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For the majority of sacral metastases, months, reinforcing the perception that balloon occlusion. In a series of 215 conventional radiation therapy and stere- a surgical procedure is mainly a palliative patients with sacral lesions, 57 (26.5%) otactic radiosurgery are adequate treat- intervention. In the senior author’s underwent surgical debulking of sacral ment modalities. Surgical intervention practice, sacral metastases with no evi- metastatic lesions31. The 30 metastatic should be reserved for when neurological dence of instability but symptomatic patients without aortic balloon occlu- deficits are present and/or spinal instability nerve root compression are managed via sion had 4.12 L of blood loss, and the 27 is present. There is also no role for radia- laminectomy alone (Fig. 1). In the set- metastatic patients with aortic balloon tion treatment in the setting of cauda ting of nerve root compression and im- occlusion had 2.78 L of blood loss31. equina syndrome associated with sacral pending instability as measured on the In the entire cohort of patients, there metastases, and this should be considered a SINS, lumbopelvic instrumentation was significantly decreased blood loss surgical emergency and prompt decom- ( pedicle screws and iliac screws) with aortic balloon occlusion (4,337 pression should be performed. along with a laminectomy is performed compared with 2,963 mL; p , 0.001). In one of the largest series on sacral (Fig. 2). For concurrent unilateral Complications included femoral metastases, Du et al. found that a sur- involvement of the along with the artery embolism and puncture-site gical procedure for sacral metastases was sacral metastases and instability, the hematomas. an effective palliative technique to senior author would perform unilateral improve bowel function and quality of lumbopelvic instrumentation in the Sacroplasty life27. Patients who underwent a surgi- unaffected side (Fig. 3). Sacroplasty, a minimally invasive pro- cal procedure without preoperative cedure, can be useful in sacral metastases radiation therapy had a significantly Selective Arterial Embolization without instability or epidural disease32. decreased risk (p 5 0.003) of postoper- Selective arterial embolization can Polymethylmethacrylate (PMMA) is ative complications compared with be used for pain control in the setting injected into the involved region of the patients who underwent a surgical pro- of metastatic spine and sacral disease29. sacrum. Indications for sacroplasty cedure after preoperative radiation A reduction in tumor size can occur, include unrelenting pain in the setting of therapy27. Du et al. also reported that with associated improvement in previously irradiated sacral metastatic better local control was associated with pain; however, in 1 series, post- lesions. Sacroplasty is contraindicated in tumors with rapid growth and the use of embolization complications were com- the presence of epidural disease. Sacro- aortic balloon occlusions27. Feiz-Erfan mon (56.7%)29. Preoperative emboli- plasty provides pain relief and stability in et al. had previously demonstrated sim- zation is also useful when treating the setting of diseased sacral segments33. ilar success on a much smaller cohort of vascular lesions (renal cell, hepatocellu- Interventional radiologists and inter- 25 patients. In that study, 24 of 25 lar, thyroid cancers)30 and can decrease ventional neuroradiologists often per- patients underwent a surgical procedure intraoperative blood loss. An intra- form sacroplasty. for pain relief, with instrumentation and operative means of decreasing blood loss Hirsch et al. suggested that the fusion used in 12 of the 25 patients24. during a sacral metastatic surgical pro- development of percutaneous sacro- The median overall survival time was 11 cedure is the use of abdominal aortic plasty lagged behind vertebroplasty

Fig. 1 Figs. 1-A, 1-B, and 1-C A 23-year-old man who presented with cauda equina syndrome associated with metastatic melanoma to the sacrum. Fig. 1-A Sagittal T2-weighted MRI of the sacrum demonstrating epidural compression causing severe stenosis (arrow). Fig. 1-B Sagittal MRI, with contrast, of the sacrum demonstrating sacral canal enhancement associated with the metastatic compression. Fig. 1-C Sagittal CT of the sacrum demonstrating no fracture or lytic lesion. The patient was managed with sacral laminectomy without instrumentation.

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Fig. 2 Figs. 2-A through 2-F A 78-year-old man who presented with severe pain and radicular symptoms associated with a lytic lesion of S1 from colon cancer. The patient had a SINS of 9 points, or impending instability. Sagittal T2-weighted MRI of the sacrum (Fig. 2-A) and sagittal MRI of the sacrum with contrast (Fig. 2-B) demonstrate involvement of S1 and S2. Sagittal CT (Fig. 2-C) and axial CT (Fig. 2-D) of the sacrum demonstrate a lytic lesion of S1 with associated S1 fracture. The patient was managed with L4-to-pelvis lumbopelvic fixation and sacral laminectomy followed by radiation therapy. An anteroposterior radiograph (Fig. 2-E) and lateral radiograph (Fig. 2-F) of the lumbar spine demonstrate the L4-pelvis instrumentation. The patient was still alive at 15 months following the procedure and continued to have minimal pain.

because of the likelihood of misdiagnosis and radiation therapy does not alleviate et al. demonstrated a mean reduction in as well as the inherent difficulties of underlying mechanical pain caused by visual analog scale (VAS) pain from 9.0 sacral anatomy34. Several other reports associated pathological fractures39. to 2.6 in a series of 39 patients (of a total have experienced difficulty in defining With the exception of 1 multicenter 243 cases), with complete resolution of good landmarks for needle placement, report on 204 cases of sacral insuffi- pain in 18%, pain reduction in 72%, including difficulty visualizing the ven- ciency fractures9, 24 due to sacral and no pain relief in 10% of patients9. tral cortical margin of the sacrum35,36. metastasis, the literature comprises These data are largely representative of Safe sacroplasty can be performed with case reports and single-center studies. the subsequent studies at other single- meticulous preoperative planning and Madaelil et al. demonstrated that sac- center cohorts and in case reports. In the use of MRI or CT for delivery of the roplasty can be successfully paired with cohort examined by Moussazadeh et al., PMMA37. Although radiation therapy is radiofrequency ablation for pain relief 84% of patients experienced severe pain an important component of decreasing and local tumor control40. before treatment (scores of 7 to 10 on a pain and local disease burden, up to two- In a large cohort undergoing sac- 10-point scale) and 80% experienced thirds of patients with radiation therapy roplasty for symptomatic lesions and pain reduction at a median follow-up of do not experience complete pain relief38 sacral insufficiency fractures, Kortman 6.5 months, with 56% of patients

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Fig. 3 Figs. 3-A through 3-E A63-year-old woman with pain and radicular symptoms associated with metastatic endometrial cancer affecting the right ilium and sacrum. Radiation therapy was administered to the region, but disease progression ensued. Because of the patient’s S3-S4 fracture and mechanical pain with ambulation associated with the metastatic lesion of the right ilium and , we performed left lumbopelvic instrumentation to provide stability and pain control. Fig. 3-A Sagittal T2 short tau inversion recovery (STIR) MRI of the sacrum demonstrating multilevel sacral canal stenosis. Fig. 3-B Axial STIR MRI of the sacrum demonstrating the predominant involvement of the right sacrum and ilium along with canal compromise. Fig. 3-C Sagittal CT demonstrating the fracture of the sacrum at the S3-S4 level. The patient was managed with left-sided L4- to-pelvis instrumentation and multilevel sacral laminectomy. An anteroposterior radiograph (Fig. 3-D) and lateral radiograph (Fig. 3-E) demonstrate the L4-pelvis instrumentation. having mild pain (scores of 1 to 4 points have also been reported by Gupta et al. may be the most important criterion on a 10-point scale) at the time of the but without improvements in scores on as they allow for some further thera- latest follow-up. Additionally, of the 17 the functional mobility scale. Instead, peutic measures to be tolerated by patients needing ambulatory aid, 6 patients with osteoporotic insufficiency patients42. Although the results are required less aid and 3 returned to or traumatic fractures experienced promising, it is important to remem- ambulation41. Similar improvements in greater improvement in the pain VAS ber that sacroplasty is effective only in the pain VAS, from a median of 8.0 than patients with cancer-related frac- a select group of patients having sacral preoperatively to 4.0 postoperatively, tures16. Improvements in the pain VAS pain and reinforces the fact that sacral

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metastasis requires a multidisciplinary treatmentanddonothaveneuralelement reported self-assessment. A systematic approach. involvement. review of the literature found that few Complications associated with studies on metastatic spine disease used sacroplasty include hemorrhage, infec- Surgical Complications patient self-assessment instruments to tion, leakage, and Surgical intervention in the sacrum assess health status51. Established out- nerve root or lumbosacral plexus represents a complex problem, which, come instruments for oncology and injury41,43. Misplacement of the injec- dependent on the selected surgical spinal disorders are not designed for tion needle can lead to direct sacral nerve approach, can lead to either minor or patients with metastatic spine disease damage or imprecise cement deposition. major complications. Complications and a disease-specific instrument is These cases can lead to bowel and blad- include poor wound-healing, wound necessary to increase specificity and der incontinence and motor weakness infections, neurological damage, sensitivity to detect change51. The Spine (foot drop, plantar flexion weakness)37. cerebrospinal fluid leakage, deep Oncology Study Group Outcomes Cement leakage may also lead to ra- vein thrombosis, loosening of instru- Questionnaire (SOSGOQ) was devel- diculopathy, which can be treated by mentation, blood vessel damage, oped as a quality-of-life instrument surgical decompression of the encased wound seroma, and urinary tract specific to patients with metastatic nerve root via sacral laminectomy to ;infections24,27. A surgical procedure is lesions of the spine52. The SOSGOQ remove the PMMA43. It has been not usually indicated for S1/S2 lesions may provide a better measure of disease suggested that balloon insertion can without epidural extension because of burden compared with other patient prevent leakage by compaction of the the risk of associated surgical complica- self-assessment instruments previously peripheral tissues leading to closure of tions such as surgical-site infection. The identified52. Most recent recommenda- possible fissures42. exception would be the presence of tions involve use of the SOSGOQ for instability46. En bloc resection with measuring quality of life, the Patient- Radiofrequency Ablation reconstruction is also associated with Reported Outcomes Measurement Radiofrequency ablation uses thermal high rates of complications47 and should Information System (PROMIS) Physi- energy to cause tumor necrosis and to only be reserved for an isolated meta- cal Function for measuring physical destroy pain-generating pain fibers44. static lesion in a patient with a prognosis function, and the PROMIS Pain Radiofrequency ablation is used to of longer than a few years of life expec- Intensity for measuring pain53. Alter- manage symptomatic metastatic spine tancy. Additionally, patients who natively, recommendations have also disease in the absence of epidural meta- undergo preoperative radiation therapy been made to use questionnaires that static disease. Spinal instability is also a have a significantly increased risk of best address 7 domains governing relative contraindication for radiofre- postoperative complications compared patient outcomes: mental health, phys- quency ablation. In a series of 11 of with patients who underwent a sacral ical health, pain, gastrointestinal symp- radiofrequency ablation procedures to surgical procedure prior to radiation ther- toms, urinary incontinence, sexual treat 16 sacral metastases, Madaelil et al. apy (p , 0.003)24. Some strategies to function, and social health54. The study reported no complications and a decrease decrease wound complications and infec- of patient-reported outcomes in meta- in pain score from 8 to 3 (p 5 0.004). tions include collaborating with plastic static spine and sacral disease is still in an They also did cement augmentation in 7 surgeons on the closure of the wound, early stage, with the potential for further of the 11 procedures40. Goetz et al. re- administration of intrawound vancomy- research and improvement. ported on 43 patients with osseous cin powder, and, if performing lumbo- metastases undergoing radiofrequency pelvic instrumentation, considering Conclusions ablation, 12 (28%) of whom underwent placing minimally invasive screws with Sacral metastasis is approached in a mul- radiofrequency ablation treatment of concurrent open decompression48-50. tidisciplinary manner. Sacral metastases, sacral metastases45. A reduction in pain although historically uncommon, have scores compared with baseline was Patient-Reported Outcomes been increasing in frequency. Manage- noted, although 1 of the patients un- There is growing recognition that eval- ment can be a combination of conven- dergoing radiofrequency ablation in uation of the success of surgical inter- tional radiation therapy, radiosurgery, the sacrum developed bowel and blad- ventions should ideally incorporate the sacroplasty, radiofrequency ablation, sur- der incontinence following the pro- patient’s self-assessment of functional gical decompression, and stabilization. cedure. Although, to our knowledge, outcomes48. In general, the literature on Complications include poor wound- there have been no large series or ran- clinical outcomes of metastatic tumors healing, wound infections, neurological domized trials on the efficacy of radio- has been limited to survival, local damage, cerebrospinal fluid leakage, deep frequency ablation for sacral metastases, recurrence, complications, and gross vein thrombosis, loosening of instrumen- it is an option forpainful sacralmetastases measures of function (ambulatory sta- tation, and blood vessel damage. Having a that have not responded to radiation tus, Frankel score) and lacks patient- plastic surgeon assist with wound closure

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Total en bloc spondylectomy for palliation of sacral metastases: preliminary

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