The surgical neurovascular anatomy relating to partial and complete sacral and sacroiliac resections: a cadaveric, anatomic study

Purpose: Pelvic and sacral surgeries are considered technically difficult due to the complex multidimensional anatomy and the presence of significant neurovascular structures. Knowledge of the key neurovascular anatomy is essential for safe and effective execution of partial and complete sacral resections. The goal of this anatomic, cadaveric study is to describe the pertinent neurovascular anatomy during these procedures. Methods: Three embalmed human cadaveric specimens were used. Sacrectomies and sacroiliac joint resections were simulated and the structures at risk were identified. Both anterior and posterior approaches were evaluated. Results: During sacroiliac joint resection, L5 nerve roots are at high risk for iatrogenic injury; the vasculatures at greatest risk are the common iliac vessels and internal iliac vessels with L5–S1 and S1–S2 high sacrectomies. Minor bleeding risk is associated with S2–S3 osteotomy because of the potential to damage superior gluteal vessels. S3–S4 osteotomy presents a low risk of bleeding. Adjacent nerve roots proximal to the resection level are at high risk during higher sacrectomies. Conclusions: Several sacrectomy techniques are available and selection often depends on the specific case and surgeon preference; nevertheless, anatomic knowledge is extremely important. Considering the highly variable anatomic relations of the vascular bundles, a preoperative evaluation with CT or MRI with vascular reconstruction may be helpful to decrease bleeding risk by preemptively binding the internal iliac vessels in cases where higher tumors are present. To decrease the risk of damaging nerve roots, it is recommended to perform the resection as close to the involved foramina as possible.