History & Physical: This 75-year-old female patient had a long history of mixed mullerian tumor of the uterus (Stage IIIC) that was initially resected in July of 2000. Subsequently, she underwent pelvic radiation along with cisplatin chemotherapy. In July of 2001, it was noted that she had evidence of a right sacroiliac metastases, and further radiation treatments provided resolution of her pain in this region. On a routine follow-up, radiological studies from January of 2003 show bony resorption of the S2 region with angulation and deformity that is significantly changed from prior studies one year ago. However, she is still ambulating quite well and going "shopping" frequently with her daughters. She also denies any current pain, but has been on a Duragesic patch for quite some time. Otherwise, she denies any other motor, sensory, bowel, or bladder changes.
Imaging: MRI shows resorption of S2 with angulation, along with bilateral sacral alar marrow signal changes that continue to exhibit enhancement. The caudal end of the thecal sac at S1 is compromised due to the degree of canal stenosis. This deformity and canal stenosis is progressive as compared to the prior study.
1. The diagnosis of this sacral injury is most likely:
2. The treatment option of choice in this patient is:
3. The optimal surgical option offered to this patient would be:
4. The optimal surgical approach to a bony decompression of this lesion would be:
5. The optimal bone placement for spinal fusion to be offered to this patient would be:
6. The optimal spinal instrumentation option offered to this patient would be:
7. Please provide any comments or suggestions regarding management of this case:
the risk of failure to achieve sagittal balance in a 75 y.o. s/p XRT and the risk of plexus injury sacrificing bladder / bowel far outweigh the benefits to this woman with high functional ADL status
In situ fixation is the right management in view of the lack of symptoms, to prevent the development of radicular deficit
The patient is 72 y.o. and there is evidence of general spinal and pelvic osteopenia. Also the patient still ambulant. This is a case of osteoporotic fracture. Probably this is an old fracture and is currently cured. I suggest a pelvic bone scan to verify if there is osteocytic activity at site. This will rule out if the fracture is recent or chronic. No surgery needed. I suggest Fosamax or Evista therapy.
I would manage conservatively without intervention if she is asymptomatic. If she becomes symptomatic decompression with Lumbar to Iliac fusion warranted
Taking into consideration the age of the patient and also the fact that she is presently doing great, I will just not think of surgery. JUST OBSERVATION AND ONLY REPEAT RADIOLOGICAL STUDIES IF BECOMES SINTOMATIC.
Histological diagnosis (CT guided biopsy) would help guide treatment. In the patients current state, observation is probably the best option. If there is clinical and radiographic progression, decompression and spinopelvic fixation is a consideration.
Treat the patient not the radiographs. Patient is asymptomatic and her activities of daily living are not effected. No surgery indicated. Observed her with surveillance imaging and bracing if needed.
A biopsy would potentially provide some useful information, as would a CT scan
Sacropelvic stability is evident thru the alae to S1 and the relative lack of pain with weight bearing. Posterior decompression might be considered if the patient developed bladder sx or refractory sacral segment radicular pain. Bracing would be unlikely to be of benefit. Lumbosacral/pelvic stabilization with a Galveston technique would be extensive but required if the area became grossly unstable via sacroiliac destruction.