BACKGROUND CONTEXT: Sacral and sacrococcygeal chordomas present surgical and clinical challenges distinct from those of chordomas in the mobile spine. Over the last 30 years, 3 primary treatment modalities have emerged: wide surgical resection alone, surgical resection with radiotherapy (RT), and increasingly definitive RT. However, no studies have directly compared outcomes among the 3 treatment methods. PURPOSE: To compare local recurrence (LR), overall survival (OS), perioperative outcomes, and complications among patients with primary solitary sacral or sacrococcygeal chordomas treated with wide surgical resection alone, surgical resection with RT, or definitive RT. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: A total of 113 patients with sacral or sacrococcygeal chordoma who were treated at a single institution between January 1994 and February 2024. OUTCOME MEASURES: Primary outcome measures were LR and OS. Secondary outcome measures were 30-day and long-term complications. METHODS: Differences in LR and OS among treatment groups were analyzed using multivariable Cox proportional hazard models weighted by inverse probability of treatment weights. Rates of 30-day complications were compared using chi-squared tests; incidence of complications at any time following treatment was modeled using a negative-binomial regression model. RESULTS: Median follow-up was 7.6 years (interquartile range, 2.7-11). A total of 55 patients (49%) underwent wide surgical resection alone, 40 (35%) underwent wide surgical resection with neoadjuvant or postoperative adjuvant RT, and 18 (16%) received definitive RT. Negative margins were achieved in 83 patients (87%) undergoing surgery. OS varied significantly across treatment modalities and was shorter among patients who underwent surgical resection alone (hazard ratio [HR], 2.01; 95% confidence interval [CI], 0.96-4.20) or definitive RT (HR, 3.73; 95% CI, 1.15-12.1) compared to patients who underwent surgery with RT. LR was seen in 31 patients and did not differ across treatments in multivariable analysis (p=.3); the HRs for surgery with RT and definitive RT were 0.48 (95% CI, 0.17-1.31) and 1.01 (95% CI, 0.25-4.12), respectively, relative to surgery alone. Among patients who received RT, a higher biologically effective dose was associated with a lower risk of LR (HR, 0.92; 95% CI, 0.86-0.98; p=.01). Complication rates at 30 days differed among the surgery plus RT (85%), surgery alone (55%), and definitive RT (5.6%) groups (p<.001), but total complication rates at final follow-up did not vary significantly across groups. CONCLUSIONS: Wide surgical resection has been the recommended treatment for solitary primary sacral and sacrococcygeal chordoma. The addition of an RT regimen may improve LR and survival. Although definitive RT demonstrated short-term outcomes comparable to those of surgery alone, longer follow-up is required to determine the durability of response and the late-toxicity profile. Therefore, definitive RT should be considered selectively rather than as a replacement for surgery.
BACKGROUND CONTEXT: Pseudarthrosis is a known complication following multilevel anterior cervical discectomy and fusion (ACDF), yet data remain limited on its incidence and risk factors in multilevel procedures in the modern era. PURPOSE: This study aimed to characterize the incidence of pseudarthroses and identify associated risk factors in patients undergoing 3-or 4-level ACDF procedures without posterior fixation, while also evaluating the potential role of low-dose rhBMP-2 in promoting fusion and supporting anterior-only surgical strategies. STUDY DESIGN: Retrospective single-center observational cohort study. PATIENT SAMPLE: A total of 226 Patients were treated by 3-or 4-level ACDF. OUTCOME MEASURES: Radiological records, including independent review of interspinous motion, Cobb angle, bony bridging, and fusion rate, were collected. Surgical-related information and complications were also recorded. METHODS: A retrospective review of adults who underwent 3-or 4-level ACDF with anterior plating between 2011 and 2024 was performed at a single academic institution. Patients were excluded if follow-up imaging was <12 months or if they had a prior cervical procedure, corpectomy, or combined anterior-posterior surgery. Demographic, surgical details, and outcome data were collected. Pseudarthrosis was assessed using dynamic flexion-extension radiographs evaluating interspinous motion and change in Cobb angle. When flexion-extension imaging was not available, fusion status was evaluated using static radiographs and/or computed tomography. The primary outcome measure was fusion status at 1 year. Secondary outcome measures were postoperative complications, readmission, and reoperation rates. Continuous variables were reported as median (interquartile range) and compared using the Wilcoxon rank-sum test. Categorical variables were presented as percentages and compared using Pearson's chi-square or Fisher's exact tests when cell counts were low. Multivariable logistic regression was performed to identify independent predictors of outcome variables. RESULTS: A total of 206 patients were included (median age 57 [51-66] years; 59.7% female; 66.0% White). Most underwent 3-level fusion (85.9%), and recombinant human bone morphogenetic protein (rhBMP-2) was used in 48.5%. In total, pseudarthroses occurred in 28 patients (13.6%), with 13 (6.3%) patients having symptomatic pseudarthrosis. Pseudarthroses occurred in 13.0% (n=23) of 3-level constructs versus 17.2% (n=5) of 4-level constructs (p=.56). Pseudarthrosis rates did not vary significantly by implant type. Patients with any smoking history had higher pseudarthrosis rates compared with nonsmokers (23.3% vs 6.7%, p<.001). Among patients with any smoking history, rhBMP-2 was significantly associated with reduced pseudarthrosis incidence (14.0% vs 36.1%, p=.017). Among all patients, multivariable logistic regression identified rhBMP-2 use as independently protective of pseudarthrosis (odds ratio=0.15, 95% confidence interval 0.04-0.55, p=.004). However, rhBMP-2 was identified as an independent predictor of increased complication rates (odds ratio=2.70, 95% confidence interval 1.01-7.16, p=.047), with transient dysphagia being the most frequent complication (n=15, 93.8%). CONCLUSIONS: A total of 3-and 4-level ACDF without posterior fusion demonstrated much lower nonunion rate compared to historic and recently reported rates, with pseudarthroses occurring in 13.6% of patients and symptomatic pseudarthroses occurring in 6.3% of patients. Among all patients, rhBMP-2 use was associated with 6. 7-fold lower odds of pseudarthrosis. Smoking history was strongly associated with nonunion, and rhBMP-2 use appeared to mitigate this risk among smokers. These findings support individualized fusion strategies and selective use of biologic augmentation in high-risk patients. Published by Elsevier Inc.
