• Hormuzdiyar H Dasenbrock, Michelle J Clarke, Ali Bydon, Matthew J McGirt, Timothy F Witham, Daniel M Sciubba, Ziya L Gokaslan, and Jean-Paul Wolinsky.
• Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland 21287, USA.
• Neurosurgery. 2012 Mar 1;70(1 Suppl Operative):82-7; discussion 87-8.

BackgroundThe most important predictor of survival for patients with sacral chordomas is an initial en bloc resection with negative margins. However, obtaining negative margins can be technically challenging. Intraoperative navigation may be helpful in attempting an excision with negative margins.ObjectiveThis is the first report of partial sacrectomy guided by frameless stereotactic navigation.MethodsThree patients with a mean age of 58.7 years underwent en bloc resection of sacral chordomas aided by image guidance. Intraoperatively, the reference arc was clamped to the spinous process of L5 and the bony landmarks of S1 were used for registration. Subsequently, the drill was registered, allowing the osteotomy trajectory to be visualized in real time with reference to the patients' anatomy and tumor location.ResultsNone of the patients had any intraoperative or postoperative complications. Two patients with smaller tumors (5 cm) had negative margins, whereas the third patient with an 11.5 cm tumor had marginal margins. With an average follow-up of 44 months, none of the patients have had a recurrence of the tumor.ConclusionThe use of frameless stereotaxy during the en bloc resection of sacral tumors is safe and feasible. Frameless stereotactic navigation was a useful adjunct to preoperative imaging and to the surgeon's anatomic knowledge. Image guidance was used during the osteotomies to decrease the likelihood of injury to vital adjacent structures or violation of the tumor capsule and to increase the likelihood that the appropriate surrounding tissue was resected to attempt a wide or marginal resection.

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