Case 1, 71 years, female, gastric cancer, adenocarcinoma, stage IV
A 71-year-old female presented with gastric cancer, specifically adenocarcinoma, staged as IV based on UICC guidelines. The patient was referred to our clinic after 4 weeks of unsuccessful conservative management for pathological unilateral transforaminal sacral fracture due to MBD (Figure 1). Surgical intervention was deemed necessary. The procedure involved the use of two SACRONAIL® guided by a fluoroscopic navigation system (Brainlab, Munich, Germany), utilizing preoperative CT images. The surgery was successful without any associated complications. Postoperatively, the patient was advised for full weight-bearing, which she achieved with the assistance of walking aids. The patient reported a significant decrease in pain intensity, from 8/10 to 5/10 on the numeric rating scale (NRS). Both postoperative CT and X-ray modalities demonstrated correct implant positioning, without any intraforaminal penetration. Opioid use was notably reduced (Table 1), leading to the patient's discharge after an 11-day hospital stay. Patient satisfaction, as per the NASS patient satisfaction score [24], was reported as 2, indicating an acceptable outcome despite the limited improvement in health status. Unfortunately, the patient passed away 111 days post-surgery due to the aggressive nature of the underlying tumor.
Figure 1 Patient 1 A- Axial CT and MRI scan presenting pathological sacral fracture, B- postoperative CT, C- X- ray postoperative
Case 2, 47 years, female, invasive ductal breast cancer, stage 4
A 47-year-old female with invasive ductal breast cancer in stage 4, presented with a decline in walking ability and increased pain. Imaging showed a mixed lesion involving the entire sacrum and dorsal ilium with unilateral transforaminal fissure (Figure 2). Non-operative pain treatment showed limited efficacy. Surgical intervention involved the placement of a single SACRONAIL® using fluoroscopic navigation guidance. The patient reported adequate pain relief post-surgery and self-assessment revealed improved function and overall satisfaction with the procedure. Subsequent radiotherapy was administered 6 weeks after surgery. Follow-up evaluations indicated a significant reduction in self-reported pain, with continued improvement at the 3-month mark (Table 1). Minimal opioid use was reported after 12 months, demonstrating satisfactory results with a NASS score of 2. Radiographic assessments at each follow-up up to the 12 months visit showed no signs of implant failure or loosening.
Figure 2 Patient 2 A- preoperative CT scan showing sacral fracture, B- postoperative CT scan, C- X-rays demonstrating no implant failure 12 months postoperative
Case 3, 59 years, male, Non-Hodgkin lymphoma stage IVB (Ann- Arbor)
A 59-year-old male with Non-Hodgkin lymphoma in stage IVB (Ann Arbor) had previously undergone one course of chemotherapy (R-Pola-CHP). During the second chemotherapy cycle, he developed immobility and an inability to walk due to significant pelvic involvement (Figure 3). Four additional chemotherapy courses were planned. The patient struggled to carry out daily activities independently. Surgical intervention provided significant pain relief. The procedure utilized CT navigation (O-arm, Medtronic, Dublin, Ireland), resulting in high patient satisfaction and improved pain management, reflected in a NASS score of 1 (indicating met treatment expectations). The patient could not bear full weight due to overall exhaustion and lumbar plexus invasion. Neurological rehabilitation was initiated. Additionally, a pathological humeral shaft fracture was addressed through osteosynthesis with humeral nailing following the SACRONAIL® placement. No surgical complications were encountered. Chemotherapy resumed 2 weeks post-surgery. Unfortunately, the patient was lost to structured follow-up. During the last consultation 4 months post-surgery, the patient demonstrated full weight-bearing using a walker.
Figure 3 Patient 3 A- preoperative CT scan showing sacral fracture, B- intraoperative CT scan, C- X- Rays demonstrating no implant failure 4 months postoperative
[TABLE 1]