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En Bloc Resection of Sacral Chordomas Aided by Frameless Stereotactic Image Guidance: A Technical Note

Dasenbrock, Hormuzdiyar H. BA; Clarke, Michelle J. MD§; Bydon, Ali MD*; McGirt, Matthew J. MD; Witham, Timothy F. MD*; Sciubba, Daniel M. MD*; Gokaslan, Ziya L. MD*; Wolinsky, Jean-Paul MD*

doi: 10.1227/NEU.0b013e31822dd958
Operative Technique

BACKGROUND: The most important predictor of survival for patients with sacral chordomas is an initial en bloc resection with negative margins. However, obtaining negative margins can be technically challenging. Intraoperative navigation may be helpful in attempting an excision with negative margins.

OBJECTIVE: This is the first report of partial sacrectomy guided by frameless stereotactic navigation.

METHODS: Three patients with a mean age of 58.7 years underwent en bloc resection of sacral chordomas aided by image guidance. Intraoperatively, the reference arc was clamped to the spinous process of L5 and the bony landmarks of S1 were used for registration. Subsequently, the drill was registered, allowing the osteotomy trajectory to be visualized in real time with reference to the patients' anatomy and tumor location.

RESULTS: None of the patients had any intraoperative or postoperative complications. Two patients with smaller tumors (5 cm) had negative margins, whereas the third patient with an 11.5 cm tumor had marginal margins. With an average follow-up of 44 months, none of the patients have had a recurrence of the tumor.

CONCLUSION: The use of frameless stereotaxy during the en bloc resection of sacral tumors is safe and feasible. Frameless stereotactic navigation was a useful adjunct to preoperative imaging and to the surgeon's anatomic knowledge. Image guidance was used during the osteotomies to decrease the likelihood of injury to vital adjacent structures or violation of the tumor capsule and to increase the likelihood that the appropriate surrounding tissue was resected to attempt a wide or marginal resection.

*Department of Neurosurgery

School of Medicine, The Johns Hopkins University, Baltimore, Maryland

§Department of Neurosurgery, Mayo Clinic Medical Center, Rochester, Minnesota

Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee

Correspondence: Jean-Paul Wolinsky, MD, Department of Neurosurgery, The Johns Hopkins University, 600 North Wolfe Street, Meyer 5-109, Baltimore, MD 21287. E-mail:

Received June 29, 2010

Accepted May 11, 2011

Copyright © by the Congress of Neurological Surgeons