The project is being implemented with the support of UNICEF Ukraine and with financial support from the Government of Norway.
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Clinical Case
Post-operative rehabilitation following Selective Dorsal Rhizotomy and Neuro-Orthopedic Surgery
Dott. Paolo Tavassi
UDGEE Santa Marinella - Department of Neurorehabilitation - Bambino Ges˘ Children's Hospital
Clinical Case
S.D b. 15/09/2012
- Outcomes of periventricular leukomalacia
- Diagnosis: SPASTIC DIPLEGIA as a result of Cerebral Palsy, with increased tone in distal areas
Initial Evaluation - 01/2020
• Neuromotor profile consistent with spastic diplegia
• Passive mobilization shows joint limitation at the tibiotarsal level
• All floor posture transitions are autonomously achievable
• The child is able to reach sitting and standing positions independently; the latter is achieved with upper limb support
• Independent ambulation is possible, characterized by: anterior trunk displacement, bilateral pelvic anteversion, lower limbs in triple flexion with internal rotation, and bilateral forefoot weight-bearing
• Tibiotarsal dorsiflexion poorly reducible to 90 , with initial retractions
Initial Evaluation – 01/2020
Medical History
Included in a rehabilitation program
Good family compliance.
AFO orthoses in use
Periodic botulinum toxin injections
..and than?
Pre-Operative Evaluation
Shared assessments
TEAM MEETING
Physiatrists, neurosurgeons,
therapists, technicians, surgical team
Post-surgical perspectives
Comprehensive 360-degree view of the patient.
Surgical approach
Selective Dorsal Rhizotomy (SDR) procedure
SDR Procedure
´In general anesthesia, patient prone, neurophysiological monitoring (EMG-triggered stimulation parameters: THR 0.2 ms, 1 Hz; TETANIC 0.1 ms, 50 Hz for 1 sec. Recording muscles: adductor longus, vastus lateralis, tibialis anterior, peroneus longus, gastrocnemius, abductor hallucis, anal sphincter bilaterally, iliopsoas). Midline skin incision from L1 to L3, median fascia incision, skeletonization of L2 lamina and partial of L1 and L3; L2 laminotomy; median dural incision and suspension; opening of the arachnoid; identification of midline (filum terminale and conus medullaris); rhizotomy performed as follows:
TOTAL section: left 50.6%; right 56.8%.
Hemostasis, watertight dural suture (verified with Valsalva maneuver), replacement of L2 lamina fixed with silk-0; muscular, fascial, subcutaneous and skin closure.ª
Days 1–5:
Post-SDR Rehabilitation
• Rest
• Guidelines and precautions
• Family education
• Gentle mobilization
• Antigravity postural transitions
• Initiation of sitting position
Transfer to UDGEE, S. Marinella
Post-SDR Rehabilitation
Week 1
- Stretching
- Selective activation
- Sitting position
- Positioning orthoses
Post-SDR Rehabilitation Week 2
- Sitting and balance training
- Assisted standing with standing frame
- Transfers
- Selective activations
Post-SDR Rehabilitation From week 3
- Stabilization of upright posture
- Gradual resumption of gait
- Search for suitable assistive devices
- Work on rhythm and cadence
Post-SDR Rehabilitation
Post-SDR Rehabilitation Discharge Goals
Recovery of physiological joint range of motion at hip, knee, and tibiotarsal joints
Active recruitment of lower limb muscles
Postural balance in sitting and functional use of upper limbs
Consolidation of autonomous postural transitions on horizontal and vertical planes
Promote acquisition of positive support reaction and trunk balance over lower limbs in upright position with orthoses
Gait training with orthoses and quad canes as needed
Facilitate selective flexion-extension of hip, knee, and ankle joints and reduce pathological synergy during gait
Active recruitment of lower limb muscles and gait training
Surgical and Functional Physiatric Evaluation
´Following orthopedic specialist visit, surgical correction of bilateral equinus foot was indicated
Surgical Intervention
´
Fibrotomy-based Achilles tendon lengthening performed, achieving correction of equinus
deformity and full ankle dorsiflexionª
Post-Orthopedic Surgery Rehabilitation
POST-OPERATIVE INDICATIONS
• Maintains orthoses
• Dressings clean and dry, to be changed as needed
• Orthoses can be removed for 3 hours in the morning and 3 hours in the afternoon
• Begin gentle mobilization of both ankles
• No weight-bearing for 15 days
Post-Orthopedic Surgery Rehabilitation
Goal: Recovery of joint range of motion
Stretching
Orthotic positioning
Maintenance of joint length
Post-Orthopedic Surgery Rehabilitation
Goal: Recovery of active ankle dorsiflexion •Ball exercises •Activation exercises •Muscle strengthening
Post-Orthopedic Surgery Rehabilitation
Goal: Recovery of verticalization
Standing table • Sit-to-stand transitions • Maintenance of upright position
Post-Orthopedic Surgery Rehabilitation
Goal: Balance and postural control •Standing perturbation exercises
Reaching tasks
Balance board
Post-Orthopedic Surgery Rehabilitation
Goal: Load distribution and alternation
• Balance board with increasing difficulty
• Single-leg support exercises
• Play-based squatting to encourage posterior load shift
Post-Orthopedic Surgery Rehabilitation
Goal: Recovery of correct gait pattern and ambulation
•Initial gait with double support
•Gait with pelvic support
•Exercises to vary lateralization
Post-Orthopedic Surgery Rehabilitation
Main Goal
Recovery of functional gait with the most correct pattern possible
How do we achieve it? Working toward gradual Objectives!
Post-Orthopedic Surgery Rehabilitation
Difficulty progression
Exercise
Learning Assessment
PRE:
Post-Orthopedic Surgery Rehabilitation
POST:
Post-Orthopedic Surgery Rehabilitation
Shared Goals with Community Services
• Bilateral selective segmental recruitment of the tibiotarsal joint
• Postural transitions, maintenance and control of achieved postures (correcting compensations)
• Focus on movement selectivity and trunk-limb coordination, using the pelvis as a pivot to minimize compensations and improve load transfer between sides
• Maintain optimal musculoskeletal conditions to minimize stiffness
• Sit-to-stand training without upper limb involvement
• Play-based squatting to promote posterior weight shift, guided from the pelvis
• Standing training with/without balance board for better posture and weight distribution
• Enhance single-leg control with weight-shifting exercises
• Gait pattern improvement with scapular guidance to promote dissociation of shoulder and pelvic girdles; include multidirectional walking (forward, backward, lateral)
• Elastic bands used during therapy to reduce femoral internal rotation and enhance proprioceptive input for external rotation
6-Month Follow-Up
New assessment:
• Need for intensive gait training → LOKOMAT • Improved gait stability → CHANGE OF ORTHOSES
6-Month Follow-Up
• Improved hindfoot control
• Better proximal stability
• Transition from AFO to NH T2
Take Home Message
Importance of clinical assessments
Collaboration with the family and communitybased services
Ongoing communication with the medical team
Proposal of targeted therapeutic exercises
Interdisciplinary teamwork
Goaloriented therapeutic planning
Vite che aiutano la Vita
This document was prepared in 30 slides by the Bambino Ges˘ Children’s Hospital on June 18, 2025. The contents are strictly confidential; reproduction or disclosure, even partial, is prohibited without the prior written consent of the Bambino Ges˘ Children’s Hospital