OBJECTIVE: Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors’ institutional case series. METHODS: The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed. RESULTS: The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision. CONCLUSIONS: The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.

For many spine surgeons, patients with metastatic cancer are often present in an emergent situation with rapidly progressive neurological dysfunction. Since the Patchell trial, scoring systems such as NOMS and SINS have emerged to guide the extent of surgical excision and fusion in the context of chemotherapy and radiation therapy. Yet, while multidisciplinary decision-making is the gold standard of cancer care, in the middle of the night, when a patient needs spinal surgery, the wealth of chemotherapy data, clinical trials, and other medical advances can feel overwhelming. The goal of this review is to provide an overview of the relevant molecular biomarkers and therapies driving patient survival in lung, breast, prostate, and renal cell cancer. We highlight the molecular differences between primary tumors (i.e., the patient’s original lung cancer) and the subsequent spinal metastasis. This distinction is crucial, as there are limited data investigating how metastases respond to their primary tumor’s targeted molecular therapies. Integrating information from primary and metastatic markers allows for a more comprehensive and personalized approach to cancer treatment.

The role of prophylactic musculocutaneous flap closure following posterior spine surgery remains under-characterized. This study presents a single-institution experience with paraspinous-only musculocutaneous flap reconstruction among high-risk patients following spine surgery. Associations between risk factors, surgical indication, intraoperative characteristics, and postoperative wound complications are explored. A retrospective chart review identified all cases of prophylactic paraspinous flap reconstruction following posterior spine over an 11-year period. Patients who had uncomplicated postoperative courses were compared to those who developed wound complications. Multivariate logistic regression characterized associations among risk factors, surgical indication, and wound complications. Two hundred fifty-seven patients underwent primary prophylactic closure using paraspinous musculocutaneous flaps only. 49.4% female, with a mean age of 60.7±13.9 years. Surgical indications included degenerative disease (n=124, 48.2%), tumor (n=78, 30.4%), deformity (n=22, 8.6%), congenital anomaly (n=18, 7.0%), and trauma (n=15, 5.8%). This population exhibited high-risk features, including diabetes (19.5%), history of smoking (53.3%), prior spine surgery (58.8%); mean body mass index was 30.1±6.9. Wound complications occurred in 37 patients (14.4%). Postoperative complications coincided with greater number of incised levels, higher degree of instrumentation, and longer closure length. Prophylactic flap closure was associated with wound complication rates consistent with the literature in cohorts with substantial comorbidity burden. Outcomes were predominantly influenced by procedural factors rather than baseline patient characteristics. The findings support the feasibility of prophylactic flap closure in high-risk patients across the spectrum of spinal indications. Controlled studies are necessary to evaluate effectiveness.

Chordomas are rare, highly morbid tumors arising from notochordal progenitor cells along the spinal axis, associated with severe neurological complications and high recurrence rates. Their resistance to conventional therapies and limited options beyond surgical resection and high-dose radiation underscore the urgent need for novel therapeutic targets. Publicly available preliminary RNA sequencing data from the Chordoma Foundation identified chitinase-3-like 1 (CHI3L1), a secreted glycoprotein implicated in immune checkpoint regulation and epithelial–mesenchymal transition (EMT), as a promising candidate for chordoma immunotherapy. Yet, the comprehensive function of CHI3L1 in chordoma immune response remains unclear. To evaluate its presence in chordoma, we employed RNA-based analyses alongside enzyme-linked immunosorbent assays (ELISA) on commercially available chordoma cell lines (JHC7, U-CH12, U-CH1, U-CH1-N) and human chordoma tumor specimens. Our results demonstrate elevated CHI3L1 expression in chordoma cells relative to notochordal precursors, with comparative analyses revealing higher CHI3L1 expression in the primary tumor relative to recurrent samples. These findings suggest the potential role of CHI3L1 in chordoma tumorigenesis, emphasizing its relevance as a biomarker and therapeutic target for primary tumors. Future studies are necessary to elucidate the mechanistic role of CHI3L1 in chordoma immune evasion and to explore targeted interventions that may improve patient outcomes in this aggressive cancer.

Bow hunter's syndrome (BHS), or rotational vertebral artery (VA) occlusion, is a rare cause of vertebrobasilar insufficiency resulting from dynamic compression of the VA during head rotation. Classically described at the atlantoaxial level with rotational occlusion, subaxial and nonrotational variants exist and can remain underdiagnosed as standard vascular imaging often fails to reveal positional occlusion. A 54-year-old man with no vascular risk factors presented with recurrent posterior circulation strokes despite medical management. Conventional imaging identified a left VA occlusion but failed to reveal the cause. Dynamic digital subtraction angiography revealed paradoxical reopening of the left VA with neck extension, confirming BHS at the C6-7 level. The patient underwent direct decompression and anterior cervical decompression and fusion, resulting in restoration of VA flow and clinical stabilization. This case highlights an underrecognized diagnostic pitfall of BHS through a presentation where static imaging suggested a fixed VA occlusion. Nonrotational variants at a subaxial level may mask positional occlusion. Dynamic imaging should be pursued in patients with recurrent posterior circulation infarcts despite seemingly explanatory static image findings. Recognition of these atypical patterns can help timely intervention to achieve durable prevention of further ischemic events. https://thejns.org/doi/10.3171/CASE2666.