CORR Insights 1 : Sacral Insufficiency Fractures are Common after High-dose Radiation for Sacral Chordomas Treated With or Without Surgery

C hordoma is a rare malignant tumor of the vertebral column that is thought to arise from notocordal rest cells. The tumors characteristically occur in the midline of the neuro-central axis, from the skull base to the sacrum. The highest percentage of these are seen distally, frequently arising from the sacrococcygeal junction, and surgical resection is the treatment of choice for these tumors. However, the complex anatomy of the neural axis can make obtaining acceptable margins challenging. The ideal surgical treatment consists of resection with wide margins, but it remains challenging to preserve essential neural function and avoid injury to visceral and vascular structures during resection. Frequently, margins are positive, marginal, or contaminated [7–9] and adjuvant treatment strategies must be considered. The most common adjuvant treatment employed is radiation therapy, but because chordomas often are radioresistant, high dose radiotherapy (> 60 Gy) generally is used [1]. Highly conformal strategies such as proton beam or stereotactic radiosurgery techniques are commonly employed to maximize dose to the operative bed. Some institutions have employed neoadjuvant radiation as a strategy to try and improve local control—as is the protocol at the authors’ institution [1]. One of the critiques of radiation therapy is that it can cause pathological fractures of bones that lie in the radiation field [4]. While prior studies of chordoma have appropriately pointed out the major morbidity and mortality associated with sacral resections [5, 7, 10], the authors recognized a disparity between prior studies and their own cohort with respect to this functionally relevant complication of sacral insufficiency fractures. The current paper takes a focused look at this common complication of This CORR Insights is a commentary on the article ‘‘Sacral Insufficiency Fractures are Common after High-dose Radiation for Sacral Chordomas Treated With or Without Surgery’’ by Osler and colleagues available at: DOI: 10.1007/s11999-015-4566-5. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999-0154566-5. J. C. Patt MD, MPH (&) Department of Orthopaedic Surgery, Carolinas Medical Center, Levine Cancer Institute, 1025 Morehead Medical Dr. Suite 300, Charlotte, NC 28204, USA e-mail: joshua.patt@carolinashealthcare.org; joshuapatt@hotmail.com CORR Insights Published online: 30 October 2015 The Association of Bone and Joint Surgeons1 2015