UNASSIGNED: Erector spinae plane block (ESPB) has been found to be simple, safe, and effective at thoracic and lumbar levels. There is no randomized controlled trial evaluating its effectiveness at sacral level. The present study was conducted to evaluate its effectiveness at sacral level for postoperative analgesia in pediatric patients undergoing hypospadias repair.
UNASSIGNED: Forty children of 2-7 years with ASA grade I or II were included. They were randomly allocated to one of the two groups of 20 patients each. After induction of general anesthesia, patients of group I were given ultrasound-guided sacral ESPB with 1 ml/kg of 0.25% bupivacaine, and patients of group II were not given block. Postoperatively, pain was assessed using face, legs, activity, cry, consolability (FLACC) scale at 0 hour, every 15 min up to 1 hour, every half an hour up to 2 hours, 2 hourly up to 12 hours, and at 18th hour and 24th hour postoperatively. At FLACC score ≥4, rescue analgesia was given using 15 mg/kg paracetamol infusion. Primary objective was to compare postoperative analgesic (paracetamol) consumption, and secondary objective was time to first rescue analgesia.
UNASSIGNED: Mean postoperative paracetamol consumption was 360 ± 156.60 mg in group I and 997.50 ± 310.87 mg in group II (P = 0.001). Time to first rescue analgesia was 906 ± 224.51 min in group I and 205.00 ± 254.92 min in group II (P = 0.001).
UNASSIGNED: Sacral ESPB has been found to be effective in reducing postoperative analgesic consumption in pediatric patients undergoing hypospadias repair.

OBJECTIVE: Spinal chordoma treatment guidelines recommend resection. However, in patients in whom gross-total resection (GTR) is achieved, the benefits of radiation therapy (RT) are unclear. Therefore, the authors performed a systematic review to determine if RT is associated with postoperative progression-free survival (PFS) or overall survival (OS) after achieving GTR of spinal chordoma.
METHODS: The PubMed database was searched for studies including individualized data of patients undergoing GTR with or without RT for spinal chordoma. Patients < 18 years of age or those who underwent stereotactic body RT were excluded. Qualitative assessment was performed using Newcastle-Ottawa Scale guidelines. Log-rank tests for time-to-event data and a Cox proportional-hazards model were generated for a multivariable statistical model.
RESULTS: Complete data of 132 patients were retrieved, with 37 (28%) patients receiving adjuvant RT and 95 (72%) not receiving adjuvant RT. The mean follow-up was not statistically significantly different between those undergoing RT and not undergoing RT (54.02 months and 65.43 months, respectively). Patients were more likely not to undergo RT if their disease was located in the sacrum versus the mobile spine (p < 0.001). When controlling for age ≥ 65 years, male sex, disease location, and treatment year ≥ 2010, patients undergoing RT had similar PFS and OS when compared with those not undergoing RT on multivariable survival analysis (HR 0.935 [95% CI 0.703-2.340], p = 0.844 and HR 2.078 [95% CI 0.848-5.090], p = 0.110, respectively). However, age ≥ 65 years was associated with poorer OS in adjusted analyses (HR 2.761 [95% CI 1.185-6.432], p = 0.018) relative to patients < 65 years of age.
CONCLUSIONS: After achieving GTR of spinal chordoma, the utility of RT on PFS and OS remains unclear. Age ≥ 65 years appears to be associated with OS in spinal chordoma patients. Additional multicenter prospective studies are needed to determine the utility of RT in this patient population.

Ewing\'s sarcoma is a rare and highly aggressive bone tumor primarily affecting children and adolescents. It commonly presents in the pelvic and axial skeleton, with sacral involvement posing unique challenges due to its intricate anatomical location. This report details the case of an 18-year-old male with sacral Ewing\'s sarcoma, emphasizing the diagnostic, surgical, and reconstructive aspects of management. The patient presented with lower back pain, lower limb weakness, and urinary incontinence, which prompted an extensive diagnostic evaluation. Magnetic resonance imaging and computed tomography scans revealed a large lytic mass extending from the S2 vertebra to the coccyx invading the presacral space. Biopsy confirmed the diagnosis of Ewing\'s sarcoma, characterized by the EWS-FLI1 type 1 translocation. A multidisciplinary team comprising neurosurgeons, colorectal surgeons, and plastic surgeons was formulated. En bloc resection of the tumor, lumbopelvic fixation, and soft-tissue reconstruction using bilateral gluteus maximus advancement flaps were successfully performed. The procedure aimed to address both the oncological and functional aspects of the patient\'s condition. Chemotherapy and radiotherapy were administered as adjuvant therapies. At 2-year follow-up, the patient was ambulating independently with no residual tumor on imaging. This case highlights the complex nature of sacral Ewing\'s sarcoma and underscores the importance of a multidisciplinary approach. The described surgical technique, including the innovative use of gluteus maximus advancement flaps for soft-tissue reconstruction, contributes to reducing wound complications and promoting successful patient outcomes. The presented approach serves as a valuable addition to the armamentarium of treatment options for this challenging malignancy.

OBJECTIVE: Tethered cord syndrome (TCS) comprises three symptom categories: back/leg pain, bowel/bladder, and neurological complaints. MRI typically reveals a low-lying conus medullaris, filum terminale (FT) pathology, or lumbosacral abnormalities. FT resection is established in TCS but not in radiologically occult TCS (OTCS). This study aims to identify patients with OTCS who are likely to benefit from FT resection.
METHODS: The authors recruited 149 patients with OTCS (31 pediatric, 118 adult) treated with FT resection-including only cases with progressive TCS, negative spine MRI, and no concurrent neurological/urological conditions. A comprehensive questionnaire collected patient self-reported symptoms and clinical findings at the preoperative and at 3- and 12-month follow-up examinations. Based on questionnaire data, the authors extracted a 15-item symptoms and findings scale to represent the three TCS symptom categories, assigning 1 point for each item present.
RESULTS: OTCS presents without radicular/segmental sensorimotor findings, but with leg/back pain and conus dysfunction, in addition to leg fatigue and spasticity; the latter indicating an upper motoneuron pathology. The 15-item scale showed clinical improvement in 89% of patients at the 3-month follow-up and 68% at the 12-month follow-up. Multivariate analysis of the scale revealed that it accurately predicts outcome of FT resection in 82% of cases. Patients with a preoperative score exceeding 6 points are most likely to benefit from surgery.
CONCLUSIONS: By applying the study\'s inclusion criteria and incorporating the novel 15-item scale, surgeons can effectively select candidates for FT resection in patients with OTCS. The observed outcomes in these selected patients are comparable to those achieved in degenerative spine surgery.

Osteochondroma is one of the most common benign bone tumors, mainly involving the bone ends of long bones, and involving the spine is rare. It often involves the competing, followed by the thoracic and lumbar spine, and rarely involves the sacrum. We report the imaging findings of a solitary osteochondroma of the sacrum. The patient was a 37-year-old woman who presented clinically with progressive low back pain associated with left buttock pain and discomfort. CT and MRI showed that the lesion originated from the left lamina of S1 and grew anteriorly and superiorly, resulting in compressive resorption of the L5 vertebral bone, left foraminal stenosis and adjacent nerve root swelling. The patient underwent surgery and the mass was completely excised and recovered well postoperatively. Osteochondroma arising from the sacrum is rare and can lead to compressive resorption of adjacent bone, and imaging techniques are conducive to the localization and characterization of the lesion and provide useful information for clinical treatment.

BACKGROUND: Civilian gunshot wounds to the spine are an increasingly common injury in the USA. A majority of the available research is focused on a military population suffering high energy missile injury. Minimal research has focused on civilian ballistic injuries to the lumbosacral spine as the available studies focus on the entire spine due to limited numbers.
OBJECTIVE: Characterize ballistic injuries to the lumbosacral spine and develop a model to predict the presence of neurological deficit based upon a patients presenting fracture morphology.
METHODS: Retrospective chart review.
METHODS: One hundred forty-eight consecutive patients that were presented to an urban level 1 trauma center with ballistic injures to the spine involving the levels L1-S2.
METHODS: Neurological status at presentation and final follow up using the American Spinal Injury Association (ASIA) Impairment Scale.
METHODS: IRB approval was obtained, and retrospective chart review was performed. Extracted data included patient demographics, neurological status on presentation and final follow-up, fracture morphology, assessment of stability, other associated injuries, and surgical procedures performed. Proportional analysis was performed to characterize the fractures and their associated neurological injuries. Chi-square testing was done to identify fracture characteristics associated with neurologic injury. A multiple logistical regression was performed using fracture characteristics highly associated with neurological deficit to develop a model to predict neurologic deficit. The model was then validated with a receiver operator curve.
RESULTS: Of the 148 patients, 14 patients underwent spinal surgery with the most common indication being decompression and foreign body removal. There was a high incidence of intra-abdominal injury (73.6%). Fractures were characterized by level, affected vertebral component, and spinal canal involvement. Neurological injury was classified using the ASIA scale at presentation and final follow up. Odds-ratios of vertebral fracture characteristics showed neurologic deficit was highly associated with pedicle fractures (OR=9.07 [4.14-21.54] - 95% CI), lamina fractures (OR=6.42 [3.16-13.62] - 95% CI), facet fractures (OR=5.95 [2.90-12.79] - 95% CI), intra-canal bone (OR=12.79 [5.98-29.05] - 95% CI), and an intra-canal trajectory (OR=1078 [4.48-28.98]) - 95% CI. Multiple logistic regression was performed to construct a predictive model of neurologic deficit which showed that intra-canal trajectory, pedicle fracture and facet fracture are associated with neurologic deficit. An ROC curve was made with an area of 0.849 ([0.7853 to 0.9128 - 95% CI], p<.0001) demonstrating a good model fit.
CONCLUSIONS: Ballistic injuries to the lumbosacral spine involve complex injury patterns in an often polytraumatized patient. Fractures involving the pedicle, lamina, and facet are highly associated with neurologic injury, as is a trans-canal trajectory. A patients fracture morphology can be used to predict if a neurologic deficit is present.

Rare lumbosacral junction kyphosis due to S1-S2 hemivertebra in a 40-year-old woman was managed surgically, improving neurological disturbances, and low back pain. Early intervention is vital for congenital anomalies.

Symptomatic sacral arachnoid cysts are extremely rare in pediatric patients, resulting in a lack of consensus regarding optimal treatment measures. The current study evaluated the clinical symptoms and surgical indications, techniques, and outcomes of pediatric patients who underwent treatment for sacral arachnoid cysts with the aim of developing recommendations for follow-up and treatment.
This retrospective study included pediatric patients who underwent surgical treatment for sacral arachnoid cysts between January 2000 and December 2020 at the Department of Pediatric Neurosurgery, Acıbadem University Faculty of Medicine.
Thirteen patients were included in the study, 9 of whom were girls and 4 were boys. Five patients presented with urinary incontinence, 2 of whom also exhibited constipation. Other chief complaints included recurrent urinary tract infections (UTIs) and low-back pain (n = 4 patients each). Urological evaluation was performed in all patients, followed by urodynamic examination in those with urinary symptoms. Spinal MRI showed extra- and intradural sacral cysts in 12 patients and 1 patient, respectively. The latter patient exhibited recurrence during follow-up and underwent reintervention. Samples from the excised cyst walls were sent for pathological examination. Five patients with urinary incontinence, 2 with constipation, 4 with recurrent UTIs, and 3 with low-back pain exhibited resolution of symptoms after treatment. However, 1 patient with low-back pain did not show any improvement in symptoms. No postoperative complications were observed in the current study. The patients were followed-up regularly after surgery, and the mean follow-up duration was 4 years.
Sacral arachnoid cysts in pediatric patients may be associated with urinary system dysfunction and low-back pain. Surgery is the treatment of choice for symptomatic patients and those with enlarged cysts with radiological evidence of compression, and the morbidity and mortality rates associated with surgery are low.

Chordomas are most frequently found in the sacrum, vertebral column, and skull base. Achieving gross-total resection (GTR) has been shown to optimize overall survival (OS); however, the efficacy of radiotherapy (RT) for patients with GTR is currently not well understood. Given that RT may negatively impact patient quality of life, the aim of this study was to evaluate the utility of RT for improving OS in patients who have undergone GTR of spinal chordoma through analysis of the national Surveillance, Epidemiology, and End Results (SEER) database.
The SEER database (1975-2018) was queried for all adult patients (≥ 21 years) who underwent GTR for spinal chordoma. Bivariate analysis was conducted using chi-square testing for categorical variables, and the log-rank test was performed to find the associations of clinical variables with OS. Cox proportional hazards models were generated for multivariate analyses of the associations among clinical variables and OS.
A total of 263 spinal chordomas that underwent GTR were identified. The mean age of all included patients was 58.72 years, and 63.9% of patients were male. In addition, 0.4% had dedifferentiated histology. The mean follow-up was 75.54 months. Of all patients, 152 (57.8%) received no RT and 111 (42.2%) received RT. Patients with sacral tumor location (80.9% vs 51.4%, p < 0.001) were more likely not to undergo RT when compared to patients with vertebral column location. In multivariate analysis, only age ≥ 65 years was associated with poorer OS (HR 3.16, CI 1.54-5.61, p < 0.001). RT did not have a statistically significant association with OS.
RT after GTR of chordoma did not improve OS among SEER chordoma patients to a value that achieved statistical significance. Additional multicenter prospective studies are needed to determine the true efficacy of RT after GTR of spinal chordoma.

BACKGROUND: Longitudinal sacral fractures are usually a matter of controversy regarding decision-making for reduction, fixation, and approach. Percutaneous and minimally invasive techniques present perioperative difficulties, but with fewer postoperative complications compared to open techniques. The objective of this study was to compare the functional as well as radiological outcomes of the Transiliac Internal fixator (TIFI) versus Iliosacral screw (ISS) fixation of sacral fractures applied percutaneously in a minimally invasive technique.
METHODS: A Prospective comparative cohort study was conducted in a level 1 trauma center in a university hospital. The study included 42 patients with complete sacral fractures, 21 patients have been allocated to each group (TIFI group & ISS group). The clinical, functional, as well as radiological data, were collected and analyzed for the 2 groups.
RESULTS: The mean age was 32 (18 -54 years), and the mean follow-up was 14 (12 -20 months). There was a statistically significant difference in favor of the TIFI group regarding a shorter operative time (P = 0.04) as well as less fluoroscopy time (P = 0.01) whereas there was less blood loss in the ISS group (P = 0.01). Both the mean Matta\'s radiological score, the mean Majeed score as well as the pelvic outcome score were comparable between the 2 groups with no statistically significant difference.
CONCLUSIONS: This study suggests that both TIFI and ISS through a minimally invasive technique represent valid methods for sacral fracture fixation with a shorter operative time, less radiation exposure in TIFI and less blood loss in the ISS. However, the functional, as well as radiological outcomes, were comparable between the 2 groups.