Sacral Resection and Reconstruction

This chapter provides a comprehensive overview of sacral tumor resections, one of the most technically demanding procedures in musculoskeletal oncology due to the sacrum's deep location, complex anatomy, and proximity to critical neural, vascular, and visceral structures. It outlines the clinical spectrum of sacral tumors, including chordomas, chondrosarcomas, giant cell tumors, and metastatic lesions, and emphasizes the importance of multidisciplinary planning in optimizing oncological and functional outcomes. The chapter reviews sacral anatomy, biomechanics, and neural and vascular relationships, underscoring their implications for surgical planning. Classification systems and levels of sacrectomy are described, with correlation to anticipated neurological deficits and biomechanical instability. Surgical approaches, including posterior-only and combined anterior-posterior techniques, are detailed with attention to safe dissection, nerve root preservation, and en bloc resection principles. Reconstruction strategies for restoring spinopelvic continuity are extensively reviewed, highlighting techniques such as dual iliac screw fixation, four-rod constructs, anterior column support, and the role of soft tissue flaps. Outcomes and complication profiles are critically analyzed, with emphasis on functional recovery and quality of life. By integrating oncological, anatomical, biomechanical, and reconstructive principles, this chapter serves as a definitive guide to sacral resections and spinopelvic reconstruction.