Abstract» Sacral metastases have increased over the past decades aschemotherapy improves and more patients survive common cancers.
» Sacral metastases can present with cauda equina syndrome,radiculopathy, and instability.
» Sacral metastases are often treated with radiation therapy, a surgicalprocedure, or sacroplasty.
» Patient-reported outcomes are of increasing importance whenevaluating patients for the management of sacral metastasis.
Inthe United States, there werenearly 1.6 million cases of cancer in2016. In the last several decades,5-year survival rates have increased
from 49.1% in 1980 to 57.7% in 1990,66% in 2000, and 68.9% in 20081.Metastatic sacral disease is rare, represent-ing 1% to 7% of metastatic spine disease2.Although rectal carcinoma can metastasizeand directly invade the sacrum, most sacralmetastatic tumors are the result of hema-togenously spread tumor cells3. The spreadof metastasis often occurs via the Batsonvenous plexus, especially in the thoracicspine4. In recent years, bone metastaseshave been attributed to the increasednumber of chemotherapy drugs used inmetastatic colorectal cancer5. Additionally,because of the effectiveness of systemictherapy, patients are living longer, andmore symptomatic spinal metastases arebeing identified6. Sacral metastases areoften diagnosed latewhen they have alreadyextended beyond the osseous marginsaround the sacral nerves and other sur-rounding organs7. Patients commonlypresent with pain due to sacral nerve rootcompression and pathological fractures.Also, sacral nerve root compression can lead
to bowel or bladder incontinence8.Decreased ambulation associated withradicular symptoms and/or pathologicalfractures can increase the risk of thrombo-embolism that is already increased becauseof the history of malignancy9.
Anatomy of the SacrumThe sacrum is composedof a concave surface(facing the pelvis) and convex outer surface,which articulates superiorly with L5 via theL5-S1 facet, inferiorly with the coccyx, andbilaterally with the iliac bones via the sacro-iliac joint. The sacrum projects posteriorlyand forms the lumbosacral angle. Because ofthis projection, the articulation at this angleis subject to shearing forces. Sacral nerveroots help to control the sphincters of therectum, bladder, and sexual organs, aswell asthe motor and sensory contributions to thelower extremities10.
Clinical PresentationMetastatic tumors are the most commonmalignancy of the sacrum and can signifyadvanced disease. These are often charac-terized by radicular pain due to nerve rootcompression or even tumor infiltration7,11.Pain may radiate into the buttocks, poste-rior aspect of the leg, and perineal region12.
Disclosure: There was no source of external funding for this study. On the Disclosure of Potential
Conflicts of Interest forms, which are provided with the online version of the article, one or more of the
authors checked “yes” to indicate that the author had a relevant financial relationship in the
biomedical arena outside the submitted work (http://links.lww.com/JBJSREV/A348).
Clinical findings include changes insensation, radiculopathy,motor deficits,bladder and bowel incontinence, andsexual dysfunction13. Cauda equinasyndrome can be the initial presentationof sacral metastases. The clinical pre-sentation can include severe back pain,urinary retention, constipation, and, atlater stages of presentation, bowel andbladder incontinence. Bowel and blad-der incontinence is a surgical emergencyand prompt decompression should beperformed14.
ImagingRadiographs are often the first imagingmodality performed. However, thesemay remain inadequate because of thedifficulty in evaluating the sacrum onradiographs11. Additionally, radio-graphic evaluation has proven unreliableeven in patients with confirmed sacralpathology. Instead, clinicians shouldfocus their attention on the loss of sacralarcuate lines, which more strongly cor-relates with the presence of metastaticdisease15. In the case of sacral insuffi-ciency fractures, these are often notdisplaced and can be challenging to bevisualized in radiographs16. The goldstandard for evaluating a metastaticlesion to the sacrum is magnetic reso-nance imaging (MRI) with and with-out contrast17. Computed tomography(CT) helps to evaluate the degree oflytic or blastic involvement by thelesion.
DiagnosisA tissue diagnosis is always fundamen-tally critical to establish prior to treat-ment and must distinguish amonginfection, sarcoma, and other metastatichistologies. Histological examinationwill differentiate metastases from un-common infectious conditions17,18.However, culture specimens should alsobe sent along with the biopsy specimento rule out any concurrent infections.Biopsies can be performed as open in-cisional procedures, percutaneously orwith CT guidance. CT-guided biopsyis the most frequently used biopsymodality and carries a minimal risk18. If
enough tissue is not obtained, then anopen biopsy can be performed. How-ever, in cases of localized extension oftumor into the sacrum such as in thesetting of colon cancer or endometrialcancer, a biopsy may not be needed.Also, in the setting of acute neurologicaldeterioration or cauda equina syndrome,surgical intervention should not be de-layed and intraoperative biopsy wouldsuffice.
ManagementConventional radiation therapy remainsthe first-line intervention for sacralmetastasis, and doses for conventionalradiation therapy include 30 to 40 Gyover multiple fractions19. Stereotacticradiosurgery for the spine and sacrum isbeing increasingly used in the UnitedStates20. Recurrent sacral lesions fol-lowing conventional radiation therapycan also be addressed with stereotacticradiosurgery21. Gerszten et al. demon-strated in 103 cases of sacral metastasisthat spinal stereotactic radiosurgery iseffective in decreasing pain and withfewer complications22. Additionally,precise control and treatment volumeincrease success and decrease the risk ofneural element injury. Radiosurgery isnot indicated in cases of neurologicaldeficit caused by osseous compressionto neural structures. Also, it may notbe indicated as the only treatment mo-dality when spinal instability is present.Lastly, when treating larger lesions,radiosurgery may not deliver enoughradiation22,23.
Indications for a surgical procedureinclude neurological deficits, failedradiation therapy, and spinal instabil-ity24. Surgical intervention relies heavilyon the individual pathology of eachpatient. Several scoring systems areavailable to help to guide the type ofsurgical intervention and to determine ifa patient’s prognosis precludes surgicalintervention. The modified Tokuhashiscore is composed of 6 sections, includ-ing general condition of the patient(performance status), number ofextraspinal bone metastases, numberof metastases in the vertebral body,
metastases to major organs, primarycancer site, and extent of neurologicaldeficits25. A score of 0 to 8 points pre-dicts,6 months to live, a score of 9 to11 points predicts$6 months to live,and a score of 12 to 15 points predicts alife expectancy of$1 year.
A palliative surgical procedure ornonsurgical options may be consideredfor patients with a low score. The To-mita score is another validated scoringsystem for prognosis in spine tumors.It has 3 components that evaluate thetype of tumor, the presence of visceralmetastases, and the presence of bonemetastases. Scores of 2 to 10 points canbe generated, with a higher score indi-cating worse prognosis and a lower scoreindicating consideration for excisionalsurgical procedures26. Tumors can bedivided into 3 categories based on theTomita scoring system: slow, moderate,and fast-growth tumors27. There is aminimal role for an excisional surgicalprocedure in the setting of metastaticsacral lesions; however, a palliative sur-gical procedure can be considered,especially if neurological deficits such ascauda equina syndrome are present.Spinal stability serves as a critical deci-sion criterion when evaluating patientsfor a sacral surgical procedure. The Spi-nal Instability Neoplastic Score (SINS)is a validated instrument that providesan objective means of grading spinalstability. A score of 0 to 6 points is astable spine, a score of 7 to 12 pointssuggests impending instability, and ascore of 13 to 18 points is an unstablespine28. The SINS can help to guidetreatment for symptomatic upper sacrallesions.
With some minor exceptions, asurgical procedure for sacral metastasesis performed via laminectomy with orwithout instrumentation and/or fusion.A decompression surgical proceduregenerally involves laminectomy for theevacuation of a tumor causing nerve rootcompression or cauda equina syndrome,and instrumentation (lumbopelvic fixa-tion) and fusion are employed for im-pending instability with concurrentnerve root compression.
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For themajority of sacral metastases,conventional radiation therapy and stere-otactic radiosurgery are adequate treat-ment modalities. Surgical interventionshould be reserved for when neurologicaldeficits are present and/or spinal instabilityis present. There is also no role for radia-tion treatment in the setting of caudaequina syndrome associated with sacralmetastases, and this shouldbe consideredasurgical emergency and prompt decom-pression should be performed.
In one of the largest series on sacralmetastases, Du et al. found that a sur-gical procedure for sacral metastases wasan effective palliative technique toimprove bowel function and quality oflife27. Patients who underwent a surgi-cal procedure without preoperativeradiation therapy had a significantlydecreased risk (p5 0.003) of postoper-ative complications compared withpatients who underwent a surgical pro-cedure after preoperative radiationtherapy27. Du et al. also reported thatbetter local control was associated withtumors with rapid growth and the use ofaortic balloon occlusions27. Feiz-Erfanet al. had previously demonstrated sim-ilar success on a much smaller cohort of25 patients. In that study, 24 of 25patients underwent a surgical procedurefor pain relief, with instrumentation andfusion used in 12 of the 25 patients24.The median overall survival time was 11
months, reinforcing the perception thata surgical procedure ismainly a palliativeintervention. In the senior author’spractice, sacral metastases with no evi-dence of instability but symptomaticnerve root compression are managed vialaminectomy alone (Fig. 1). In the set-ting of nerve root compression and im-pending instability as measured on theSINS, lumbopelvic instrumentation(lumbar pedicle screws and iliac screws)along with a laminectomy is performed(Fig. 2). For concurrent unilateralinvolvement of the ilium along with thesacral metastases and instability, thesenior author would perform unilaterallumbopelvic instrumentation in theunaffected side (Fig. 3).
Selective Arterial EmbolizationSelective arterial embolization canbe used for pain control in the settingof metastatic spine and sacral disease29.A reduction in tumor size can occur,with associated improvement inpain; however, in 1 series, post-embolization complications were com-mon (56.7%)29. Preoperative emboli-zation is also useful when treatingvascular lesions (renal cell, hepatocellu-lar, thyroid cancers)30 and can decreaseintraoperative blood loss. An intra-operativemeans of decreasing blood lossduring a sacral metastatic surgical pro-cedure is the use of abdominal aortic
balloon occlusion. In a series of 215patients with sacral lesions, 57 (26.5%)underwent surgical debulking of sacralmetastatic lesions31. The 30 metastaticpatients without aortic balloon occlu-sion had 4.12 L of blood loss, and the 27metastatic patients with aortic balloonocclusion had 2.78 L of blood loss31.In the entire cohort of patients, therewas significantly decreased blood losswith aortic balloon occlusion (4,337compared with 2,963mL; p, 0.001).Complications included femoralartery embolism and puncture-sitehematomas.
SacroplastySacroplasty, a minimally invasive pro-cedure, can be useful in sacral metastaseswithout instability or epidural disease32.Polymethylmethacrylate (PMMA) isinjected into the involved region of thesacrum. Indications for sacroplastyinclude unrelenting pain in the setting ofpreviously irradiated sacral metastaticlesions. Sacroplasty is contraindicated inthe presence of epidural disease. Sacro-plasty provides pain relief and stability inthe setting of diseased sacral segments33.Interventional radiologists and inter-ventional neuroradiologists often per-form sacroplasty.
Hirsch et al. suggested that thedevelopment of percutaneous sacro-plasty lagged behind vertebroplasty
Fig. 1
Figs. 1-A, 1-B, and1-CA23-year-oldmanwhopresentedwith cauda equina syndrome associatedwithmetastaticmelanoma to the sacrum. Fig. 1-ASagittal T2-weighted MRI of the sacrum demonstrating epidural compression causing severe stenosis (arrow). Fig. 1-B Sagittal MRI, with contrast, ofthe sacrum demonstrating sacral canal enhancement associated with themetastatic compression. Fig. 1-C Sagittal CT of the sacrum demonstratingno fracture or lytic lesion. The patient was managed with sacral laminectomy without instrumentation.
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because of the likelihood ofmisdiagnosisas well as the inherent difficulties ofsacral anatomy34. Several other reportshave experienced difficulty in defininggood landmarks for needle placement,including difficulty visualizing the ven-tral cortical margin of the sacrum35,36.Safe sacroplasty can be performed withmeticulous preoperative planning anduse of MRI or CT for delivery of thePMMA37.Although radiation therapy isan important component of decreasingpain and local disease burden, up to two-thirds of patients with radiation therapydo not experience complete pain relief38
and radiation therapy does not alleviateunderlying mechanical pain caused byassociated pathological fractures39.With the exception of 1 multicenterreport on 204 cases of sacral insuffi-ciency fractures9, 24 due to sacralmetastasis, the literature comprisescase reports and single-center studies.Madaelil et al. demonstrated that sac-roplasty can be successfully paired withradiofrequency ablation for pain reliefand local tumor control40.
In a large cohort undergoing sac-roplasty for symptomatic lesions andsacral insufficiency fractures, Kortman
et al. demonstrated a mean reduction invisual analog scale (VAS) pain from 9.0to 2.6 in a series of 39 patients (of a total243 cases), with complete resolution ofpain in 18%, pain reduction in 72%,and no pain relief in 10% of patients9.These data are largely representative ofthe subsequent studies at other single-center cohorts and in case reports. In thecohort examined byMoussazadeh et al.,84% of patients experienced severe painbefore treatment (scores of 7 to 10 on a10-point scale) and 80% experiencedpain reduction at a median follow-up of6.5 months, with 56% of patients
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 coloncancer. The patient had a SINS of 9 points, or impending instability. Sagittal T2-weightedMRI of the sacrum (Fig. 2-A) and sagittal MRI of the sacrumwith contrast (Fig. 2-B) demonstrate involvement of S1 and S2. Sagittal CT (Fig. 2-C) and axial CT (Fig. 2-D) of the sacrumdemonstrate a lytic lesion ofS1withassociatedS1 fracture. ThepatientwasmanagedwithL4-to-pelvis lumbopelvic fixationandsacral laminectomy followedby radiation therapy.An anteroposterior radiograph (Fig. 2-E) and lateral radiograph (Fig. 2-F) of the lumbar spine demonstrate the L4-pelvis instrumentation. Thepatientwas still alive at 15 months following the procedure and continued to have minimal pain.
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having mild pain (scores of 1 to 4 pointson a 10-point scale) at the time of thelatest follow-up. Additionally, of the 17patients needing ambulatory aid, 6required less aid and 3 returned toambulation41. Similar improvements inthe pain VAS, from a median of 8.0preoperatively to 4.0 postoperatively,
have also been reported by Gupta et al.but without improvements in scores onthe functional mobility scale. Instead,patients with osteoporotic insufficiencyor traumatic fractures experiencedgreater improvement in the pain VASthan patients with cancer-related frac-tures16. Improvements in the pain VAS
may be the most important criterionas they allow for some further thera-peutic measures to be tolerated bypatients42. Although the results arepromising, it is important to remem-ber that sacroplasty is effective only ina select group of patients having sacralpain and reinforces the fact that sacral
Fig. 3
Figs. 3-A through3-EA63-year-oldwomanwithpainand radicular symptomsassociatedwithmetastaticendometrial cancer affecting the right iliumand sacrum. Radiation therapy was administered to the region, but disease progression ensued. Because of the patient’s S3-S4 fracture andmechanical pain with ambulation associated with the metastatic lesion of the right ilium and sacroiliac joint, we performed left lumbopelvicinstrumentation to provide stability and pain control. Fig. 3-A Sagittal T2 short tau inversion recovery (STIR) MRI of the sacrum demonstratingmultilevel sacral canal stenosis.Fig. 3-BAxial STIRMRI of the sacrumdemonstrating thepredominant involvementof the right sacrumand iliumalongwith canal compromise. Fig. 3-C Sagittal CT demonstrating the fracture of the sacrum at the S3-S4 level. The patient wasmanagedwith left-sided L4-to-pelvis instrumentation andmultilevel sacral laminectomy. An anteroposterior radiograph (Fig. 3-D) and lateral radiograph (Fig. 3-E) demonstratethe L4-pelvis instrumentation.
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metastasis requires a multidisciplinaryapproach.
Complications associated withsacroplasty include hemorrhage, infec-tion, cerebrospinal fluid leakage, andnerve root or lumbosacral plexusinjury41,43. Misplacement of the injec-tion needle can lead to direct sacral nervedamage or imprecise cement deposition.These cases can lead to bowel and blad-der incontinence and motor weakness(foot drop, plantar flexion weakness)37.Cement leakage may also lead to ra-diculopathy, which can be treated bysurgical decompression of the encasednerve root via sacral laminectomy toremove the PMMA43. It has beensuggested that balloon insertion canprevent leakage by compaction of theperipheral tissues leading to closure ofpossible fissures42.
Radiofrequency AblationRadiofrequency ablation uses thermalenergy to cause tumor necrosis and todestroy pain-generating pain fibers44.Radiofrequency ablation is used tomanage symptomatic metastatic spinedisease in the absence of epidural meta-static disease. Spinal instability is also arelative contraindication for radiofre-quency ablation. In a series of 11 ofradiofrequency ablation procedures totreat 16 sacral metastases, Madaelil et al.reported no complications and a decreasein pain score from 8 to 3 (p5 0.004).They also did cement augmentation in 7of the 11 procedures40. Goetz et al. re-ported on 43 patients with osseousmetastases undergoing radiofrequencyablation, 12 (28%) of whom underwentradiofrequency ablation treatment ofsacral metastases45. A reduction in painscores compared with baseline wasnoted, although 1 of the patients un-dergoing radiofrequency ablation inthe sacrum developed bowel and blad-der incontinence following the pro-cedure. Although, to our knowledge,there have been no large series or ran-domized trials on the efficacy of radio-frequency ablation for sacral metastases,it is an option forpainful sacralmetastasesthat have not responded to radiation
treatment anddonothaveneural elementinvolvement.
Surgical ComplicationsSurgical intervention in the sacrumrepresents a complex problem, which,dependent on the selected surgicalapproach, can lead to either minor ormajor complications. Complicationsinclude poor wound-healing, woundinfections, neurological damage,cerebrospinal fluid leakage, deepvein thrombosis, loosening of instru-mentation, blood vessel damage,wound seroma, and urinary tract;infections24,27. A surgical procedure isnot usually indicated for S1/S2 lesionswithout epidural extension because ofthe risk of associated surgical complica-tions such as surgical-site infection. Theexception would be the presence ofinstability46. En bloc resection withreconstruction is also associated withhigh rates of complications47 and shouldonly be reserved for an isolated meta-static lesion in a patient with a prognosisof longer than a few years of life expec-tancy. Additionally, patients whoundergo preoperative radiation therapyhave a significantly increased risk ofpostoperative complications comparedwith patients who underwent a sacralsurgical procedure prior to radiation ther-apy (p, 0.003)24. Some strategies todecrease wound complications and infec-tions include collaborating with plasticsurgeons on the closure of the wound,administration of intrawound vancomy-cin powder, and, if performing lumbo-pelvic instrumentation, consideringplacing minimally invasive screws withconcurrent open decompression48-50.
Patient-Reported OutcomesThere is growing recognition that eval-uation of the success of surgical inter-ventions should ideally incorporate thepatient’s self-assessment of functionaloutcomes48. In general, the literature onclinical outcomes of metastatic tumorshas been limited to survival, localrecurrence, complications, and grossmeasures of function (ambulatory sta-tus, Frankel score) and lacks patient-
reported self-assessment. A systematicreview of the literature found that fewstudies on metastatic spine disease usedpatient self-assessment instruments toassess health status51. Established out-come instruments for oncology andspinal disorders are not designed forpatients with metastatic spine diseaseand a disease-specific instrument isnecessary to increase specificity andsensitivity to detect change51. The SpineOncology Study Group OutcomesQuestionnaire (SOSGOQ) was devel-oped as a quality-of-life instrumentspecific to patients with metastaticlesions of the spine52. The SOSGOQmay provide a better measure of diseaseburden compared with other patientself-assessment instruments previouslyidentified52. Most recent recommenda-tions involve use of the SOSGOQ formeasuring quality of life, the Patient-Reported Outcomes MeasurementInformation System (PROMIS) Physi-cal Function for measuring physicalfunction, and the PROMIS PainIntensity for measuring pain53. Alter-natively, recommendations have alsobeen made to use questionnaires thatbest address 7 domains governingpatient outcomes: mental health, phys-ical health, pain, gastrointestinal symp-toms, urinary incontinence, sexualfunction, and social health54. The studyof patient-reported outcomes in meta-static spine and sacral disease is still in anearly stage, with the potential for furtherresearch and improvement.
ConclusionsSacral metastasis is approached in a mul-tidisciplinary manner. Sacral metastases,although historically uncommon, havebeen increasing in frequency. Manage-ment can be a combination of conven-tional radiation therapy, radiosurgery,sacroplasty, radiofrequency ablation, sur-gical decompression, and stabilization.Complications include poor wound-healing, wound infections, neurologicaldamage, cerebrospinal fluid leakage, deepvein thrombosis, loosening of instrumen-tation, and blood vessel damage.Having aplastic surgeon assist with wound closure
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in the setting of prior radiation can de-crease the rate of wound complications.Patient-reported outcomes for sacralmetastases are mostly still being definedand studied, including the PROMIS andSOSGOQ questionnaire.
Aleksander Mika, BS1,Addisu Mesfin, MD1
1Department of Orthopaedic Surgery,University ofRochester School ofMedicineand Dentistry, Rochester, New York
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