Monday, December 24, 2007

Rehabilitation after Total Sacrectomy<

Rehabilitation after Total Sacrectomy

Total sacrectomies are surgeries performed to remove big level tumors of the sacrum and its surrounding structures. Early diagnosis of sacral tumors is difficult because of their mild symptoms which usually resemble low put a bet on pain or sciatica.1 Therefore at the time of diagnosis, the lesion are large and require removal of the entire sacrum to do clean margins. Total sacrectomy is a difficult surgery due to the site and size of the tumor and the different pelvic organs involved. Immediately postoperatively, patients entail education on bed mobility, verbs training, and therapeutic exercises. Physical and professional therapists play an momentous role in shooting up function and increasing patients' independence next to activities of day by day living.


This paper will review the physical psychiatric therapy treatment for patients following total sacrectomy. Common complications and functional restrictions following surgery will be discussed. Total sacrectomy is in many cases the singular curative treatment for patients with sacral tumors. Goal of rehabilitation is restorative near an emphasis on increasing functional nouns while maintaining structural integrity of the surgical site.


SACRAL ANATOMY


The human sacrum is designed to tolerate increased axial loads next to upright ambulation and stance. Five separate vertebrae fuse together to form the big triangular shape of the sacrum.5 The sacrum articulates with the final lumbar vertebrae, the coccyx, and the ilium through the sacroiliac joints on any side. Body weight and axial loads are transmitted from the sacrum to the sacroiliac joint and on to the pelvis in sitting, standing, and ambulation.2


The sacral neural plexus is formed by the lumbosacral trunk next to contributions from the anterior rami of S1-3 and part of S4, next to the remainder of the last sacral resolve joining the coccygeal plexus.5 The sacral and lumbar nerve roots bring together at the level of the S-2 pelvic foramina. The lumbosacral trunk join the first sacral ramus at the medial margin of psoas leading.3 These rami converge to the greater sciatic foramen to form the upper and lower bands. The upper and larger fastening formed by the union of the lumbosacral trunk and the first, second, and third sacral rami form the sciatic effrontery at the level of the S3 foramina.5 The lower tie which is formed by the junction of fragment of the third and fourth sacral rami becomes the pudendal impudence. The pudendal nerve exits the greater sciatic foramen and reenters the second-rate sciatic foramen by passing around the sacrospinous ligament. This boldness innervates the coccygeal and levator muscles of the pelvic floor as well as the external anal sphincter. The perianal sensation is served by the coccygeal roots (S4-S5).3 The superior and inferior gluteal nerves exit the greater sciatic foramen near the sciatic nerve. Smaller nerves to the quadratus femoris, gemelli and obturator internus muscles, and posterior cutaneous and perforate cutaneous nerves also leave the pelvis next to the sciatic nerve.3 The sympathetic nerves responsible for timely transport of spermatozoa from the testes to the seminal vesicles and antegrade ejaculation out of the urethra also enjoy a close relationship to the sacrum. The parasympathetic nerves responsible for vascular reflexes to sustain erectile function arise from the anterior S2-4 gall roots that comprise the pelvic splanchnic nerve4 (Figure 1).


In addition to the extensive meet people of nerves in the sacral region, familiarity of vascular structures is essential when performing a total sacrectomy. The aorta divides in to right and left adjectives iliac artery (CIA) at the level of L4. These diverge and descend to divide into external and internal iliac arteries at the lumbosacral T-junction. The external iliac artery supplies most of the lower extremity and the internal iliac artery supplies the pelvic viscera, perineum, and gluteal region. The relationship of the vessels within the pelvic cavity is demonstrated in Figure 2.5 The venous anatomy follows the arterial anatomy but may enjoy individual variations.4


TOTAL SACRECTOMY


Surgical Techniques


Total sacrectomy involves removal of the sacrum next to its attachments to the lumbar vertebrae and the ilium. This surgery is done for removal of malignant sacral tumors such as chondrosarcomas, Chordomas, Ewing sarcoma, or metastatic lesions.6.7 Benign lesion including giant cell tumors, osteoblastomas, or aneurysmal bone cysts may also be resected with a total sacrectomy, but more of the sacral structure may be preserved.8 Patients next to recurrent tumors or those whose tumors come to nothing to respond to radiation are also candidates for a total sacrectomy.9 Goal of surgery is usually complete resection of the tumor beside clean margins. Patients may endure chemotherapy or radiation prior to surgery to reduce the tumor size and ensure a successful surgical outcome.


There are several operative techniques reported for total sacrectomy.10,11 The declaration for the type of surgical resection depends on the degree of sacral destruction, amount of intrapelvic disease, and involvement of the sacroiliac joint. In advanced stages of cancer where the aspiration of surgery is palliative, a less invasive approach may be elected.3


The staged anterior, posterior approach is a common technique used for resection of elevated level big sacral tumors. This approach involves a rectus abdominis pedicle flap reconstruction to close the huge surgical null and void created by the sacrectomy. The aim of the anterior procedure is to access the tumor anteriorly and ligate the main vessel. The anterior procedure also allows the surgeon to resect the rectum if necessary.9 During the anterior procedure a longitudinal midline incision from 2-3 cm above the umbilicus to the symphysis pubis is made (Figure 3 anterior incision). The bowel is removed to the side to access the tumor and allow for bilateral partial anterior sacroiliac osteotomy. The abdominal skin is closed and a drain is placed at the site of the incision. Because of interruption of the autonomic presacral nerves, patients may experience week long episodes of ileus following the anterior procedure.7 During the anterior procedure, a rectus abdominis myocutaneous flap is created and used during the posterior procedure to steep the surgical void not here from en bloc resection of the sacrum (Figure 4).


After the abdomen is closed, the long-suffering is turned prone for sacral resection through the posterior midline approach. The posterior incision extends from L2 to the end of the coccyx. Every effort is made to preserve the nerves surrounded by the sacral region while performing an en bloc resection of the sacrum with the neoplasm3 (Figure 5). After resection of the sacrum, the rectus abdominis myocutaneous flap previously mentioned is used and shaped to riddle the soft tissue defect overlying the sacrum.


Complete resection of the sacrum and removal of the sacroiliac joint decreases stability and freight bearing capacity of the spine and lower extremities during sitting, standing, and walking. Some surgeons use spinopelvic reconstruction using rods, bolts, screw, and grafts to regain vertical and rotational spinopelvic stability12 (Figure 6). In cases where on earth the first part of the sacral segment is disappeared intact, the pelvis is weakened by 50% but is still competent to withstand normal loads contained by standing and ambulation. In these cases the soft tissue flap is sufficient and a pelvic reconstruction is not perform.13


There may be multiple complications following total sacrectomy. Massive blood loss of up to 11,000 ml or more, wound infection, neurologic deficits, sphincter disturbances of the bladder and rectum, and loss of sexual function are some adjectives complications.1,9 Urinary retention and rectal insensitivity requires the entail for self catheterization and a strict bowel regimen. If only the L5 resolve is preserved, patients may require a brace for ambulation. They may have difficulty going up and down stairs minor to partial loss of gluteus maximus function and decreased hip extension. Although contained by most patients hypertrophy of the hamstrings and adductor muscles may compensate for this loss allowing for a close to mundane gait pattern.


In proclaim to avoid shearing forces at the site of the flap posteriorly, sitting is contraindicated for 10 to 14 days after surgery. This restriction may be extended in patients who require wound irrigation and drainage after surgery. Therefore functional tasks and activities of day by day living are performed surrounded by supine, sidelying, or standing positions.


REHABILITATION FOLLOWING TOTAL SACRECTOMY


Rehabilitation goals for patients next to cancer in the acute diligence setting lie surrounded by 2 major category: restorative and supportive. Stage and type of cancer, curative or palliative medical treatment dictate the type of rehabilitation goal set for patients. In cases where on earth surgery is done with a curative aspiration, rehabilitation goals may be restorative. In such cases every try is made to return the patient to an independent plane of function. In cases where surgery is done for palliative reason, rehabilitation goals are supportive to abet patients regain partial independence next to their activities of on a daily basis living and improve their part of life. This piece of the paper discusses the restorative rehabilitation course following a staged anterior, posterior total sacrectomy. Table 1 outlines physical dream therapy interventions for patients immediately after total sacrectomy surrounded by the acute care setting.


COMMON IMPAIRMENTS


Impairments see after total sacrectomy fall into 2 category: (1) those resulting from the surgical procedure and (2) those resulting from prolonged bed rest and complications following surgery. Impairments from the surgical procedure depend on the severity of nerve and tissue reduce to rubble during surgery. Decreased lower extremity strength may be present if the sciatic nerve is severed. Resection of the pudendal impudence may result in sensory impairments, bowel and bladder dysfunction, and sexual dysfunction.14 Resection perform below the S3 vertebrae would preserve sphincter function. However, resection of bilateral S2-S4 nerve roots head to urinary, fecal incontinence and impotence in men. Unilateral preservation of the S2 nerve roots can keep going bowel continence for patients.14


Deep vein thrombosis, pneumonia, infections, skin break, and generalized deconditioning down are some of the more adjectives and general impairments see as a result of bed rest following surgery.


Immediately after surgery, patients are often placed on bed rest on a Clinitron Rite Hite Air Fluidized Therapy Bed15 for 1 to 3 days. Clinitron bed are designed to promote wound healing and prevent skin break down. To serve patients with mobility on the Clinitron bed a trapeze is placed above the bed to assist next to bed mobility and transfers out of the bed.


Physical therapy is usually initiated postoperative daylight 3. Physical therapy evaluation must include a thorough motor and sensory evaluation of the lower extremity, trunk, and upper extremity. Bed mobility, verbs training, and patient and relations education are 3 celebrated general short-term restorative goal. Progress with short-term goal and treatment intensity depends on patient's common physical and medical condition after surgery and the presence or absence of postsurgical complications. As indicated sitting is almost other contraindicated for 10 to 14 days after a total sacrectomy to protect the incision site and allow time for healing. Therefore tuition and independence near safe out of bed verbs is the primary focus of physical therapy intervention during the first postoperative week. To ensure tolerant independence and sanctuary with the supine to stand verbs, patients are instructed in log rolling, using their upper extremities to flex the trunk and assisted in lower extremity transfer out of bed. This verbs is often done next to maximum assistance of 2 therapists during the first 1 to 3 days after the initial evaluation. The even of assistance is gradually decrease based on patients' progress near the technique. A realistic short-term aspiration (3 days after initial evaluation) would be a transfer out of bed that requires minimum to moderate assistance of one individual (Table 1).


Patient, family, and the nursing staff are learned on transfer training as ably as proper positioning in bed with broken up sidelying to prevent skin breakdown. Lower extremity range of motion exercises are initiated for patients on equal day as initial evaluation. Patients can achieve supine and sidelying open chain active selection of motion exercises for the ankles, knees, and hips while in the bed short any restrictions. Once the patient is competent to tolerate standing, closed chained lower extremity exercises are initiated to increase strength and tolerance (Table 1).


Active range of motion and resistive upper extremity exercises are also prescribed during the first week of psychiatric help to maintain over adjectives endurance and upper extremity strength for ambulation beside an assistive devices. Pulmonary toilet is initiated on the day of initial evaluation and reinforced throughout treatment.


Gait training is initiated on the fourth or fifth postoperative days (second day after initial evaluation). Patients should be monitored for orthostatic hypotension as a result of prolonged bed rest. Once the merciful is able to declare 5 to 10 minutes of standing without an unusual blood pressure response (systolic/diastolic blood pressure drops of less than 25/10 mm mercury on going from lying to standing), ambulation next to a rolling walker is initiated. It is advise that patients only ambulate a short distance (less than 20 feet) contained by the room initially. This is to allow close access to the bed should the patient surface light-headed. Ambulation distances are increased daily as forgiving's tolerance improves. A rolling pedestrian is used to aid with stance and ambulation initially.


During the subsequent 2 weeks postoperatively, physical therapy continues next to increasing an individual's ability to verbs into and out of bed with greater nouns, increasing ambulation distances to 250 feet near a rolling walker, initiating stair negotiation (postoperative afternoon 7-8), and increasing repetitions of therapeutic exercises. The intensity of the exercise program is in the swing of things on an individual basis and depends on lenient's prior level of function, course of hospital stay, and progress near rehabilitation. Barring postoperative complications, patients generally return home, using a rolling ambler and able to climb stairs using a railing and a wicker 2 weeks after surgery.


In addition to the training provided by physical therapist, patients work with employment therapists to gain nouns in self thoroughness activities. Occupational dream therapy is often initiated at equal time as physical therapy. Prior to discharge from the hospital the nursing staff educate patients on self catheterization and bowel regimen; however, patients often times obligation home care services to sustain them with this postoperative complication. Most patients are discharged home next to an ability to verbs out of bed independently and ambulate 250 to 500 feet beside a rolling walker.


CONCLUSION


Rehabilitation following total sacrectomy is stimulating and rewarding at the same time. Increasing tolerant independence and safekeeping with transfers while maintain sitting restriction is one of the hardest goals to get done during therapy. The intensity and progression of analysis is often predetermined due to the long surgical procedure, extensive blood loss, and possible complications following surgery. Patients are usually able to ambulate 250 to 500 foot with a rolling perambulator and are discharged from an acute setting 18 to 20 days after the surgery.


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