Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva

La Parálisis Cerebral (PC) es una condición discapacitante, crónica, no progresiva y permanente, secundaria a una lesión del cerebro fetal inmaduro, que condiciona a limitaciones de predominio motor (alteraciones en el movimiento y la postura); clínicamente la manifestación primaria más frecuente es...

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Autores:
Caro Moreno, Julian Enrique
Tipo de recurso:
Fecha de publicación:
2023
Institución:
Universidad Nacional de Colombia
Repositorio:
Universidad Nacional de Colombia
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spa
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https://repositorio.unal.edu.co/handle/unal/83105
https://repositorio.unal.edu.co/
Palabra clave:
610 - Medicina y salud::616 - Enfermedades
Espasticidad
Trastornos del movimiento
Niños con parálisis cerebral
Cerebral palsied children
Movement disorders
Parálisis Cerebral
Rizotomía Dorsal Selectiva
Espasticidad
Cerebral Palsy
Selective Dorsal Rhizotomy
Spasticity
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openAccess
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Reconocimiento 4.0 Internacional
id UNACIONAL2_2e747a2a026f356aa0bb72a65b7ae35e
oai_identifier_str oai:repositorio.unal.edu.co:unal/83105
network_acronym_str UNACIONAL2
network_name_str Universidad Nacional de Colombia
repository_id_str
dc.title.spa.fl_str_mv Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
dc.title.translated.eng.fl_str_mv Functional outcomes in ambulatory children with cerebral palsy operated with selective dorsal rhizotomy
title Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
spellingShingle Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
610 - Medicina y salud::616 - Enfermedades
Espasticidad
Trastornos del movimiento
Niños con parálisis cerebral
Cerebral palsied children
Movement disorders
Parálisis Cerebral
Rizotomía Dorsal Selectiva
Espasticidad
Cerebral Palsy
Selective Dorsal Rhizotomy
Spasticity
title_short Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
title_full Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
title_fullStr Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
title_full_unstemmed Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
title_sort Desenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectiva
dc.creator.fl_str_mv Caro Moreno, Julian Enrique
dc.contributor.advisor.none.fl_str_mv Mendoza Pulido, Juan Camilo
dc.contributor.author.none.fl_str_mv Caro Moreno, Julian Enrique
dc.contributor.orcid.spa.fl_str_mv https://orcid.org/0000-0001-9709-7811
dc.subject.ddc.spa.fl_str_mv 610 - Medicina y salud::616 - Enfermedades
topic 610 - Medicina y salud::616 - Enfermedades
Espasticidad
Trastornos del movimiento
Niños con parálisis cerebral
Cerebral palsied children
Movement disorders
Parálisis Cerebral
Rizotomía Dorsal Selectiva
Espasticidad
Cerebral Palsy
Selective Dorsal Rhizotomy
Spasticity
dc.subject.lemb.spa.fl_str_mv Espasticidad
Trastornos del movimiento
Niños con parálisis cerebral
Cerebral palsied children
dc.subject.lemb.eng.fl_str_mv Movement disorders
dc.subject.proposal.spa.fl_str_mv Parálisis Cerebral
Rizotomía Dorsal Selectiva
Espasticidad
dc.subject.proposal.eng.fl_str_mv Cerebral Palsy
Selective Dorsal Rhizotomy
Spasticity
description La Parálisis Cerebral (PC) es una condición discapacitante, crónica, no progresiva y permanente, secundaria a una lesión del cerebro fetal inmaduro, que condiciona a limitaciones de predominio motor (alteraciones en el movimiento y la postura); clínicamente la manifestación primaria más frecuente es la espasticidad, y es el signo característico de la alteración motora en la población con PC. Describir las diferencias entre los resultados de las pruebas funcionales aplicadas antes y después de intervención neuroquirúrgica con Rizotomía Dorsal Selectiva (RDS), en pacientes ambulantes con PC espástica operados entre 2014 al 2022 en el Instituto Roosevelt (IR), además describir las diferencias en el grupo de niños con características clínicas y funcionales similares no operados. Se trata de un estudio observacional, retrospectivo y descriptivo. Se revisaron las bases de datos disponibles del IR para la selección de niños con PC espástica ambulantes operados de RDS y de los grupos de niños con características similares dentro del periodo mencionado. Tomando como medidas de desenlace las pruebas funcionales como: GMFM-66, 6MWT, PEDI, escala de Ashworth y FMS, con clasificación de GFMCS para los niños operados como para el grupo de emparejamiento. En el presente estudio se encontró que los niveles iniciales y de seguimiento de GMFCS permanecieron sin cambios como los reportados en la literatura. Además, se puede inferir que el cambio en GMFM-66 en el seguimiento fue significativo comparando con uno de los grupos conformados (grupo número 1), pero no ocurre de igual forma con el grupo número 2 dadas las múltiples limitaciones metodológicas existentes. El uso de pruebas funcionales como medida de desenlace es una buena estrategia para evaluar la efectividad de la RSD, aunque se deben realizar más estudios y contar con muestra de pacientes más grandes para sacar indicaciones precisas para su aplicación, pero este es un primer paso para que en un futuro su uso sea parte de un protocolo de intervención. (Texto tomado de la fuente)
publishDate 2023
dc.date.accessioned.none.fl_str_mv 2023-01-24T20:41:26Z
dc.date.available.none.fl_str_mv 2023-01-24T20:41:26Z
dc.date.issued.none.fl_str_mv 2023
dc.type.spa.fl_str_mv Trabajo de grado - Especialidad Médica
dc.type.driver.spa.fl_str_mv info:eu-repo/semantics/masterThesis
dc.type.version.spa.fl_str_mv info:eu-repo/semantics/acceptedVersion
dc.type.content.spa.fl_str_mv Text
dc.type.redcol.spa.fl_str_mv http://purl.org/redcol/resource_type/TM
status_str acceptedVersion
dc.identifier.uri.none.fl_str_mv https://repositorio.unal.edu.co/handle/unal/83105
dc.identifier.instname.spa.fl_str_mv Universidad Nacional de Colombia
dc.identifier.reponame.spa.fl_str_mv Repositorio Institucional Universidad Nacional de Colombia
dc.identifier.repourl.spa.fl_str_mv https://repositorio.unal.edu.co/
url https://repositorio.unal.edu.co/handle/unal/83105
https://repositorio.unal.edu.co/
identifier_str_mv Universidad Nacional de Colombia
Repositorio Institucional Universidad Nacional de Colombia
dc.language.iso.spa.fl_str_mv spa
language spa
dc.relation.references.spa.fl_str_mv 1. A Fasano, G Broggi, G. B. R. A. S. (1978) ‘Surgical treatment of spasticity in cerebral palsy’, Childs Brain. doi: 10.1159/000119785.
2. Abbott, R., Forem, S. L. and Johann, M. (1989) ‘Selective posterior rhizotomy for the treatment of spasticity: a review’, Child’s Nervous System, 5(6), pp. 337–346. doi: 10.1007/BF00271889.
3. Alimović, S. (2012) ‘Visual impairments in children with cerebral palsy’, Hrvatska Revija Za Rehabilitacijska Istrazivanja, 48(1), pp. 96–103. doi: 10.32677/ijch.2019.v06.i09.008.
4. Australian Cerebral Palsy Register (2018) ‘Australian Cerebral Palsy Register Report’, (December), p. 18. Available at: https://cpregister.com/wp-content/uploads/2019/02/Report-of-the-Australian-Cerebral-Palsy-Register-Birth-Years-1995-2012.pdf.
5. Avery, L. M. et al. (2003) ‘Rasch analysis of the gross motor function measure: Validating the assumptions of the Rasch model to create an interval-level measure’, Archives of Physical Medicine and Rehabilitation, 84(5), pp. 697–705. doi: 10.1016/s0003-9993(03)04896-7.
6. Bailes, A. F. et al. (2018) ‘Caregiver knowledge and preferences for gross motor function information in cerebral palsy’, Developmental Medicine and Child Neurology, 60(12), pp. 1264–1270. doi: 10.1111/dmcn.13994.
7. Berker, A. N. and Yalçin, M. S. (2008) ‘Cerebral Palsy: Orthopedic Aspects and Rehabilitation’, Pediatric Clinics of North America, 55(5), pp. 1209–1225. doi: 10.1016/j.pcl.2008.07.011.
8. Blumetti, F. C. et al. (2019) ‘Orthopaedic Surgery in Dystonic Cerebral Palsy’, Journal of Pediatric Orthopaedics, 39(4), pp. 209–216. doi: 10.1097/BPO.0000000000000919.
9. Cans, C. (2000) ‘Surveillance of cerebral palsy in Europe: A collaboration of cerebral palsy surveys and registers’, Developmental Medicine and Child Neurology, 42(12), pp. 816–824. doi: 10.1017/S0012162200001511.
10. Cerebral, L. (2013) ‘Prevalence of risk factors for cerebral palsy in two centers in Popayán’, Pediatria, 46(2), pp. 65–70. doi: 10.1016/S0120-4912(15)30088-4.
11. D’Aquino, D. et al. (2018) ‘Selective dorsal rhizotomy for the treatment of severe spastic cerebral palsy: efficacy and therapeutic durability in GMFCS grade IV and V children’, Acta Neurochirurgica, 160(4), pp. 811–821. doi: 10.1007/s00701-017-3349-z.
12. Eliasson, A. C. et al. (2006) ‘The Manual Ability Classification System (MACS) for children with cerebral palsy: Scale development and evidence of validity and reliability’, Developmental Medicine and Child Neurology, 48(7), pp. 549–554. doi: 10.1017/S0012162206001162.
13. Fargel, J. W., Weinmann, H. M. and Bakker, H. H. (1979) ‘Postures, Motility and Respiration of Low‐risk Pre‐term Infants’, Developmental Medicine & Child Neurology, 21(1), pp. 3–27. doi: 10.1111/j.1469-8749.1979.tb01577.x.
14. Fernando Ortiz, Mónica Rincón, J. C. M. (2016) Texto de Medicina Física y Rehabilitación. 1a. ed. Edited by M. Moderno. Bogota D.C.
15. Gabrieli, A. P., Dias, L. and Drumond, O. (1995) ‘Progressäo da luxaçäo do quadril na paralisia cerebral após rizotomia seletiva posterior: relato de 4 casos’, Rev. bras. ortop, 30(1/2), pp. 65–8.
16. Graham, H. K. et al. (2016) ‘Cerebral palsy’, Nature Reviews Disease Primers, 2. doi: 10.1038/nrdp.2015.82.
17. Grunt, S. et al. (2014) ‘Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: A systematic review of the literature’, Developmental Medicine and Child Neurology, 56(4), pp. 302–312. doi: 10.1111/dmcn.12277.
18. Hidecker, M. J. C. et al. (2011) ‘Developing and validating the Communication Function Classification System for individuals with cerebral palsy’, Developmental Medicine and Child Neurology, 53(8), pp. 704–710. doi: 10.1111/j.1469-8749.2011.03996.x.
19. Koman, L. A., Smith, B. P. and Shilt, J. S. (2004) ‘Cerebral palsy’, Lancet, 363(9421), pp. 1619–1631. doi: 10.1016/S0140-6736(04)16207-7.
20. Landau, W. M. and Hunt, C. C. (1990) ‘Dorsal Rhizotomy, A Treatment of Unproven Efficacy’, Journal of Child Neurology, 5(3), pp. 174–178. doi: 10.1177/088307389000500301.
21. Lanska, D. J. (2013) ‘Early controversies over athetosis: Ii. treatment’, Tremor and Other Hyperkinetic Movements, 3, pp. 1–15. doi: 10.5334/TOHM.163.
22. Michael-Asalu, A. et al. (2019) ‘Cerebral Palsy: Diagnosis, Epidemiology, Genetics, and Clinical Update’, Advances in Pediatrics, 66, pp. 189–208. doi: 10.1016/j.yapd.2019.04.002.
23. Morris, C., Galuppi, B. E. and Rosenbaum, P. L. (2004) ‘Reliability of family report for the Gross Motor Function Classification System’, Developmental Medicine and Child Neurology, 46(7), pp. 455–460. doi: 10.1017/S0012162204000751.
24. novak, I. et al. (2013) ‘A systematic review of interventions for children with cerebral palsy: State of the evidence’, Developmental Medicine and Child Neurology, 55(10), pp. 885–910. doi: 10.1111/dmcn.12246.
25. Novak, I. et al. (2017) ‘Early, accurate diagnosis and early intervention in cerebral palsy: Advances in diagnosis and treatment’, JAMA Pediatrics, 171(9), pp. 897–907. doi: 10.1001/jamapediatrics.2017.1689.
26. Patel, D. R. et al. (2010) ‘Developmental disabilities across the lifespan’, Disease-a-Month, 56(6), pp. 305–397. doi: 10.1016/j.disamonth.2010.02.001.
27. Patel, D. R. et al. (2020) ‘Cerebral palsy in children: A clinical overview’, Translational Pediatrics, 9(1), pp. S125–S135. doi: 10.21037/tp.2020.01.01.
28. Patel, D. R. and Soyode, O. (2005) ‘Pharmacologic interventions for reducing spasticity in cerebral palsy’, Indian Journal of Pediatrics, 72(10), pp. 869–872. doi: 10.1007/BF02731118.
29. Privat, J. M. et al. (1976) ‘Sectorial posterior rhizotomy, a new technique of surgical treatment for spasticity’, Acta Neurochirurgica, 35(1–3), pp. 181–195. doi: 10.1007/BF01405946.
30. Rethlefsen, S. A., Ryan, D. D. and Kay, R. M. (2010) ‘Classification systems in cerebral palsy’, Orthopedic Clinics of North America, 41(4), pp. 457–467. doi: 10.1016/j.ocl.2010.06.005.
31. Rosenbaum, P. L. et al. (2003) ‘Prognosis for Gross Motor Function in Cerebral Palsy: Creation of Motor Development Curves’, Obstetrical & Gynecological Survey, 58(3), pp. 166–168. doi: 10.1097/01.ogx.0000055751.17527.56.
32. Rosenbaum, P. L. et al. (2008) ‘Development of the Gross Motor Function Classification System for cerebral palsy’, Developmental Medicine and Child Neurology, 50(4), pp. 249–253. doi: 10.1111/j.1469-8749.2008.02045.x.
33. Russell, D. J. et al. (1989) ‘the Gross Motor Function Measure: a Means To Evaluate the Effects of Physical Therapy’, Developmental Medicine & Child Neurology, 31(3), pp. 341–352. doi: 10.1111/j.1469-8749.1989.tb04003.x.
34. Russell, D. J. et al. (2000) ‘Improved scaling of the gross motor function measure for children with cerebral palsy: Evidence of reliability and validity’, Physical Therapy, 80(9), pp. 873–885. doi: 10.1093/ptj/80.9.873.
35. Sellers, D. et al. (2014) ‘Development and reliability of a system to classify the eating and drinking ability of people with cerebral palsy’, Developmental Medicine and Child Neurology, 56(3), pp. 245–251. doi: 10.1111/dmcn.12352.
36. Shevell, M. (2019) ‘Cerebral palsy to cerebral palsy spectrum disorder’, Neurology, 92(5), pp. 233–235. doi: 10.1212/WNL.0000000000006747.
37. Trabacca, A. et al. (2016) ‘Multidisciplinary rehabilitation for patients with cerebral palsy: Improving long-term care’, Journal of Multidisciplinary Healthcare, 9, pp. 455–462. doi: 10.2147/JMDH.S88782.
38. Wang, H. Y. and Yang, Y. H. (2006) ‘Evaluating the responsiveness of 2 versions of the gross motor function measure for children with cerebral palsy’, Archives of Physical Medicine and Rehabilitation, 87(1), pp. 51–56. doi: 10.1016/j.apmr.2005.08.117.
39. Wang, K. K. et al. (2018) ‘Selective dorsal rhizotomy in ambulant children with cerebral palsy’, Journal of Children’s Orthopaedics, 12(5), pp. 413–427. doi: 10.1302/1863-2548.12.180123.
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46. Hagglund G, Wagner P. Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskelet Disord 2008; 9: 150
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48. Ailon T, Beauchamp R, Miller S, et al. Long-term out come after selective dorsal rhizotomy in children with spastic cerebral palsy. Childs Nerv Syst 2015; 31: 415– 23.
49. Dudley RW, Parolin M, Gagnon B, et al. Long-term functional benefits of selective dorsal rhizotomy for spastic cerebral palsy. J Neurosurg Pediatr 2013; 12: 142–50
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51. van de Pol LA, Vermeulen RJ, van’t Westende C, et al. Risk factors for dystonia after selective dorsal rhizotomy in nonwalking children and adolescents with bilateral spasticity. Neuropediatrics 2018; 49: 44–50
52. Bolster EA, van Schie PE, Becher JG, van Ouwerkerk WJ, Strijers RL, Vermeulen RJ. Long-term effect of selective dorsal rhizotomy on gross motor function in ambulant children with spastic bilateral cerebral palsy, compared with reference centiles. Dev Med Child Neurol 2013; 55: 610–6
53. Warwick j. Peacock, and lori, et al. Functional outcomes following selective posterior rhizotomy in children with cerebral palsy. J neurosurg 74:380-385, 1991
54. Mariusz Pawłowski, Jakub S. Gąsior, Marcin Bonikowski. Long-term benefits from selective dorsal rhizotomy in a young patient with cerebral palsy. Volume 24, Issue 2, August 2017, Pages 256-260
55. Petra E M van Schie, R Jeroen Vermeulen, Willem J R van Ouwerkerk, et al. Selective dorsal rhizotomy in cerebral palsy to improve functional abilities: evaluation of criteria for Selection. Childs Nerv Syst. 2005 Jun;21(6):451-7.
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institution Universidad Nacional de Colombia
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spelling Reconocimiento 4.0 Internacionalhttp://creativecommons.org/licenses/by/4.0/info:eu-repo/semantics/openAccesshttp://purl.org/coar/access_right/c_abf2Mendoza Pulido, Juan Camilo05468ef5aa72883133a909cb7aaf1e66Caro Moreno, Julian Enrique45910b0ab6594604dcd09641c67bb4f7https://orcid.org/0000-0001-9709-78112023-01-24T20:41:26Z2023-01-24T20:41:26Z2023https://repositorio.unal.edu.co/handle/unal/83105Universidad Nacional de ColombiaRepositorio Institucional Universidad Nacional de Colombiahttps://repositorio.unal.edu.co/La Parálisis Cerebral (PC) es una condición discapacitante, crónica, no progresiva y permanente, secundaria a una lesión del cerebro fetal inmaduro, que condiciona a limitaciones de predominio motor (alteraciones en el movimiento y la postura); clínicamente la manifestación primaria más frecuente es la espasticidad, y es el signo característico de la alteración motora en la población con PC. Describir las diferencias entre los resultados de las pruebas funcionales aplicadas antes y después de intervención neuroquirúrgica con Rizotomía Dorsal Selectiva (RDS), en pacientes ambulantes con PC espástica operados entre 2014 al 2022 en el Instituto Roosevelt (IR), además describir las diferencias en el grupo de niños con características clínicas y funcionales similares no operados. Se trata de un estudio observacional, retrospectivo y descriptivo. Se revisaron las bases de datos disponibles del IR para la selección de niños con PC espástica ambulantes operados de RDS y de los grupos de niños con características similares dentro del periodo mencionado. Tomando como medidas de desenlace las pruebas funcionales como: GMFM-66, 6MWT, PEDI, escala de Ashworth y FMS, con clasificación de GFMCS para los niños operados como para el grupo de emparejamiento. En el presente estudio se encontró que los niveles iniciales y de seguimiento de GMFCS permanecieron sin cambios como los reportados en la literatura. Además, se puede inferir que el cambio en GMFM-66 en el seguimiento fue significativo comparando con uno de los grupos conformados (grupo número 1), pero no ocurre de igual forma con el grupo número 2 dadas las múltiples limitaciones metodológicas existentes. El uso de pruebas funcionales como medida de desenlace es una buena estrategia para evaluar la efectividad de la RSD, aunque se deben realizar más estudios y contar con muestra de pacientes más grandes para sacar indicaciones precisas para su aplicación, pero este es un primer paso para que en un futuro su uso sea parte de un protocolo de intervención. (Texto tomado de la fuente)Cerebral Palsy (CP) is a disabling, chronic, non-progressive and permanent condition, secondary to an immature fetal brain lesion, which conditions predominantly motor limitations (alterations in movement and posture); Clinically, the most common primary manifestation is spasticity, and it is the characteristic sign of motor impairment in the CP population. To describe the differences between the results of the functional tests applied before and after neurosurgical intervention with Selective Dorsal Rhizotomy (RDS), in ambulatory patients with spastic CP operated between 2014 and 2022 at the Roosevelt Institute (IR), in addition to describing the differences in the group of children with similar clinical and functional characteristics who did not undergo surgery. This is an observational, retrospective and descriptive study. The available IR databases were reviewed for the selection of ambulatory children with spastic CP who underwent RDS surgery and groups of children with similar characteristics within the aforementioned period. Taking as outcome measures the functional tests such as: GMFM66, 6MWT, PEDI, Ashworth scale and FMS, with GFMCS classification for the operated children as well as for the matching group. In the present study it was found that the initial and follow-up levels of GMFCS remained unchanged from those reported in the literature. In addition, it can be inferred that the change in GMFM-66 at follow-up was significant compared to one of the groups formed (group number 1), but it does not occur in the same way with group number 2 given the multiple existing methodological limitations. The use of functional tests as an outcome measure is a good strategy to evaluate the effectiveness of the RSD, although more studies must be carried out and have a larger patient sample to obtain precise indications for its application, but this is a first step for that in the future its use be part of an intervention protocolEspecialidades MédicasSe trata de un estudio observacional, retrospectivo y descriptivo. Se revisarán las bases de datos disponibles del IR (sistema de registro de información FileMaker e historias clínicas), para la selección de niños con PC espástica ambulantes que hayan sido operados de RDS entre el 2014 al 2022 y los grupos de niños con características similares. Se tomarán las medidas de desenlace y se registrarán los resultados finales de las pruebas mencionadas a continuación: GMFCS, 6MWT, PEDI, escala de Ashworth y FMS para los niños operados como para el grupo de emparejamiento.48 páginasapplication/pdfspaUniversidad Nacional de ColombiaBogotá - Medicina - Especialidad en Medicina Física y RehabilitaciónFacultad de MedicinaBogotá - ColombiaUniversidad Nacional de Colombia - Sede Bogotá610 - Medicina y salud::616 - EnfermedadesEspasticidadTrastornos del movimientoNiños con parálisis cerebralCerebral palsied childrenMovement disordersParálisis CerebralRizotomía Dorsal SelectivaEspasticidadCerebral PalsySelective Dorsal RhizotomySpasticityDesenlaces funcionales en niños con paralisis cerebral deambulantes intervenidos con rizotomia dorsal selectivaFunctional outcomes in ambulatory children with cerebral palsy operated with selective dorsal rhizotomyTrabajo de grado - Especialidad Médicainfo:eu-repo/semantics/masterThesisinfo:eu-repo/semantics/acceptedVersionTexthttp://purl.org/redcol/resource_type/TM1. 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Ont Health Technol Assess Ser. 2017; 17(10): 1–186.Desenlaces funcionales en niños con parálisis cerebral deambulantes intervenidos con rizotomía dorsal selectivaEstudiantesInvestigadoresPúblico generalLICENSElicense.txtlicense.txttext/plain; charset=utf-85879https://repositorio.unal.edu.co/bitstream/unal/83105/1/license.txteb34b1cf90b7e1103fc9dfd26be24b4aMD51ORIGINAL80829001-2023.pdf80829001-2023.pdfEspecialidad Médica en en Medicina Física y Rehabilitaciónapplication/pdf1082119https://repositorio.unal.edu.co/bitstream/unal/83105/2/80829001-2023.pdf909e4f20cc20ef9de28050c755976c72MD52THUMBNAIL80829001-2023.pdf.jpg80829001-2023.pdf.jpgGenerated Thumbnailimage/jpeg3479https://repositorio.unal.edu.co/bitstream/unal/83105/3/80829001-2023.pdf.jpgdcd414202dfe4217bd88bb03781eec54MD53unal/83105oai:repositorio.unal.edu.co:unal/831052023-08-14 23:03:55.902Repositorio Institucional Universidad Nacional de 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