Massive Sacral Chordoma Resection with Spinopelvic Fixation: Postoperative Arterial Bleeding Managed by Angioembolization—A Lesson Learned

Abstract Chordomas are rare, slow-growing, locally aggressive malignant tumors arising from notochordal remnants, most commonly involving the sacrum. Their deep location, large size at presentation, proximity to critical neurovascular and visceral structures, and relative resistance to chemotherapy and conventional radiotherapy make management challenging. Surgical resection with wide margins remains the cornerstone of treatment. However, sacral chordoma surgery is associated with significant morbidity, including massive blood loss and postoperative hemorrhagic complications. We report a case of a giant sacral chordoma complicated by life-threatening postoperative arterial bleeding successfully managed with angiographic embolization. A 65-year-old male presented with chronic low back pain for 1 year and progressive urinary retention for 5 months. Neurological examination revealed mild bilateral S1 weakness and perineal sensory impairment. Imaging revealed a large heterogeneous sacrococcygeal mass with destruction of the sacrum up to S1 and pelvic extension. The patient underwent posterior tumor resection with sacrectomy and spinopelvic fixation. Postoperatively, he developed massive hemorrhage refractory to surgical re-exploration. Digital subtraction angiography identified active bleeding from a branch of the obturator artery, which was successfully controlled with selective angioembolization. Sacral chordoma surgery carries a high risk of vascular complications due to tumor hypervascularity and proximity to pelvic vessels. Persistent postoperative bleeding should prompt early angiographic evaluation. Endovascular embolization is a minimally invasive and effective strategy for controlling arterial hemorrhage. Early recognition and management of postoperative arterial bleeding using angiographic embolization can be lifesaving. Multidisciplinary planning and vigilance are essential to optimize outcomes in complex sacral chordoma surgery.