Rehabilitation guidelines following Sacrectomy
Much of the surgery carried out on the Sarcoma Unit at RNOH is unusual. We
have therefore devised guidelines which outline the goals patients should be
aiming to achieve during their rehabilitation. These are guidelines and every
patient should be assessed and treated as an individual, therefore, there may
be variation in timing and outcome but the restrictions MUST remain the
same.
Patients who have been diagnosed with a tumour and then undergone
orthopaedic surgery are, if appropriate, referred for pre/post-operative
chemotherapy or radiotherapy. These treatments will impact on their
rehabilitation. (Not all tumours are malignant and not all tumours are
chemotherapy or radiotherapy sensitive).
(Refer to the Appendix for further details)
Example of a Sacrectomy
RC/SH/KS March 2014
1
Review March 2016
Sacrectomy procedure
This can be sub-categorised into:
 Total sacrectomy – division of bone at the L5/S1 disc with removal of the sacrum.
Even if the ala on one side of the S1 vertebra is retained it is still considered a total
sacrectomy as there is a loss of spinopelvic continuity. The pelvic ring is
reconstructed to establish bilateral union between the lumbar spine and ilium. This is
done with metal work and/or bone grafting.
 Subtotal sacrectomy – division of bone at the level of S1 vertebra, through the level of
S1 foramina, with removal of sacrum distal to this. Both the ala of the S1 vertebra are
preserved thus preserving spinopelvic continuity.
 Partial sacrectomy – division of bone at or below the body of S2 vertebra, through the
level of the S2 foramina, with removal of sacrum distal to this.
 Hemisacrectomy – division of the sacrum in the sagital plane with removal of half of
the sacrum.
Indications:
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Primary bone tumour affecting the sacrum
Secondary infiltration of the sacrum by rectal carcinoma and retroperitoneal tumours
Possible complications:
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Recurrence of tumour
Loss of bladder and / or bowel control
Neurologic dysfunction affecting lower limbs
Wound healing / Infection
Failure of metalwork if reconstruction undertaken for total sacrectomy
Instability of pelvic girdle
Pain
Pelvic bleeding
Sexual dysfunction
Psychological implications
Expected outcome:
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Dependent on amount of sacrum removed and nerves sacrificed
May take 12 – 18 months to achieve optimal function even if input towards the end is
periodic.
Able to mobilise with an aid.
Independent with relevant personal care and domestic activities (with or without
equipment) or provision made for assistance with this on discharge.
Contact sports and impact activities should not be participated in.
Muscles affected:
RC/SH/KS March 2014
Review March 2016
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
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Dependent on the surgical approach taken any of the following could be affected;
abdominals, back extensors, gluteals, piriformis, hip abductors, iliopsoas (hip flexors),
pelvic floor muscle
Depending on amount of sacrum removed and nerves sacrificed, weakness can occur
distally in lower limbs
Pre-operative phase
If possible patients will be seen pre-operatively to:
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Complete pre-operative ASIA assessment
Assess current functional level
Review gait/mobility including walking aids, orthoses
Assess proprioception/balance
Assess pre-operative ROM
Look at general health
Assess social history including home physical environment, social situation, functional
status, work and leisure
 Explain post-operative management and expectations
Initial rehabilitation phase
0 to 12 weeks
Goals:
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Optimise tissue healing. A suitable cushion may need to be considered to aid this.
Ensure adequate pain control
Improve lower limb strength and maintain ROM
Patient to be independently mobile with appropriate walking aid.
To be independent in relevant personal care activities, (with or without adaptive
equipment) or provision made for assistance with this on discharge.
To be independent and safe in all relevant functional transfers (with or without
adaptive equipment) or provision made for assistance on discharge.
Restrictions:
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No sitting until wound status allows and consultant permits
No lying supine until wound status allows and consultant permits
No hip abduction against gravity
May be weight-bearing restrictions during mobility
Orthotic appliances:
RC/SH/KS March 2014
Review March 2016
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
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Issued if surgical procedure requires one or if deemed necessary following
assessment by therapist, e.g. may require AFO in the case of foot-drop if nerve
sacrificed.
Pain relief:
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Ensure adequate analgesia
Teach resting positions
Teach relaxation techniques
Patient education:
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Post operative restrictions
Rehabilitation guidelines
Expectations of post-operative functional outcome
Education regarding functional activities
Don/doff orthotics if applicable
Bladder and bowel self-management if applicable
Physiotherapy rehabilitation:
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Repeat ASIA assessment post-operatively and on discharge to assess for potential
motor or sensory loss in lower limbs
From day 1 post-operatively educate patient to rest in side lying and provide regular
assistance to roll into alternate side lie, with the aid of sliding sheets, for pressure
relief
Commence static muscle strengthening and circulatory exercises from day 1 postoperatively
Provide appropriate individual exercise programme to maintain ROM and restore
strength in lower limbs and core muscles, adhering to post-operative restrictions
Teach patient bed mobility including getting in/out of bed moving from side lying to
standing without sitting
Teach to don/doff any required orthotic devices for mobility
Gait re-education with appropriate walking aid adhering to any weight bearing
restrictions
Practice stairs as appropriate
Encourage self management and independence with exercise programme
Arrange appropriate follow-up physiotherapy, in an out-patient or community setting,
on discharge. If the patient is having chemotherapy or radiotherapy transfer
information also needs to be sent to the physiotherapist at that centre
Occupational Therapy rehabilitation
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Review seating needs taking the post operative outcome and precautions into
consideration including a wheelchair if needed and a suitable pressure cushion
Assess and practise transfers and advise on / organise any necessary adaptive
equipment such as padded raised toilet seats
RC/SH/KS March 2014
Review March 2016
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
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Assess and practice personal care management especially if there are restrictions
on bending forwards or in relation to the wound
Facilitate management of fatigue and energy conservation
Provide advice on and practice relaxation techniques if appropriate
Address any other relevant functional difficulties such as domestic ADLs, work,
leisure
Refer, if indicated, to relevant community services for ongoing home assessment
and provision of equipment.
Address any relationship/intimacy issues
RC/SH/KS March 2014
Review March 2016
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Intermediate rehabilitation phase
12 weeks to 6 months
Goals:
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Can resume sitting on advice of consultant. Needs to gradually build up sitting
tolerance
Improve lower limb strength and maintain ROM
Improve pelvic/core stability
Improve gait pattern/progress walking aids
May resume driving once x-ray reviewed and surgeons in agreement and the patient
has adequate lower limb control
Patient education:
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Advice regarding pacing of activities
Advice regarding return to functional activities
Continued pain management
Physiotherapy rehabilitation:
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Commence ROM and strengthening work against gravity (grade 3 >) in lower limbs
once good ROM and strength have been gained with gravity eliminated, if wound
permits
Hydrotherapy may be beneficial at this stage if wound permits
Gait re-education
Progress walking aid
Core stability strengthening
Postural re-education
Lower limb proprioception training
Weight transference training
Balance re-training – dual leg to start, progressing to unilateral
Encourage self management and independence with exercise programme
Occupational Therapy rehabilitation
(seen if referred and appropriate for rehabilitation at this stage)
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Re-assess personal care management, transfers and domestic ADLs.
Discussion re: work including ergonomics if relevant.
Pacing / Energy conservation techniques.
Safer handling techniques, taking into consideration the walking aids the patient has
progressed onto.
Address any relationship/intimacy issues
RC/SH/KS March 2014
Review March 2016
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Late rehabilitation phase
6 months to 1 year
Goals:
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Return to an optimal functional level
Patient education:
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Advise that there may continue to be an improvement in function for up to 18 months
post op
Continued pacing advice
Continued pain management
Continued advice regarding functional activities
Physiotherapy rehabilitation:
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Core stability strengthening – especially in dynamic positions
Progression of mobility aids as appropriate
Encourage to attend local pool to continue hydro exercises if appropriate
Postural re-education
Gait re education
Encourage self management and independence with exercise programme
Occupational Therapy rehabilitation
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To review if required and work upon any difficulties the patient may still be experiencing
including return to work, leisure and relationship / intimacy issues.
RC/SH/KS March 2014
Review March 2016
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science
Appendix
Some chemotherapy and radiotherapy side effects and implications for
treatment:
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Bone marrow toxicity, ↓white cell count, ↓platelets, ↓Hb and ↓rate of healing. White
cell count will be at its lowest approximately 10 days post chemotherapy and signs of
wound infection should be watched for. Hydrotherapy should not be undertaken at
this point
Nausea, vomiting, diarrhoea, ↓appetite, lethargy and ↓exercise tolerance.
Physiotherapy will be particularly important during and immediately after chemo and
radiotherapy, as patients often lose ROM and strength after a cycle. Community
physiotherapy may need to be arranged after discharge if the patient is too unwell to
attend for outpatient treatment. The occupational therapist may need to advise on the
practical implications of the symptoms such as meal and drink preparation, laundry
and hygiene. Relaxation techniques may also be used to reduce nausea and vomiting
in addition to reducing anxiety levels associated with food and meal times.
Anxiety and depression – these can diminish people’s concentration, ability to
assimilate information and motivation to carry out activities. The therapists, among
other treatment, will identify goals which increase a person’s sense of control.
Fatigue – needs to be addressed / acknowledged as it can affect a person’s physical
and cognitive ability to carry out normal activities. The therapists will need to take this
into consideration and tailor the rehabilitation accordingly.
Anaemia which can lead to tiredness, lethargy and breathlessness)
Radiotherapy only:
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Fibrosis of soft tissues – Can continue for up to 2 years and may lead to contractures.
Passive exercise is very important during and immediately post radiotherapy to
prevent loss of ROM
Demineralisation of bone – increases risk of fracture
Redness, soreness and sensitivity of the skin to heat – care of the skin is important.
Heat modalities are contraindicated post DXT. Application of lotions and manual
treatments are contraindicated during DXT, but can be used with caution post DXT.
Electrical modalities e.g. TNS and FES can be used with caution
RC/SH/KS March 2014
Review March 2016
In association with the UCL Institute of Orthopaedics and Musculoskeletal Science