Rehabilitation in Lumbar Spinal Surgery

Abstract

The chapter has elaborated the role of Physical therapy rehabilitation in assessment and management of patients undergoing Lumbar Spinal Surgery pre- and post - operatively. Further need of pre-habilitation in patients undergoing surgery was emphasized to obtain optimal results after surgery. Outcome measures used widely for assessment of patient before spinal surgery and after surgery was discussed to have an overview of recovery process. Phase-wise goals, precautions and rehabilitation protocols were discussed starting from immediate post-operative phase till return to activity/sports. Special emphasis was laid on the importance of home exercise regimen. Recent advances in management of Lumbar spinal surgery post operative cases like Virtual Reality was discussed in the end for upgrading information on achieving better patient outcomes.

1. Introduction

Low back pain (LBP) is one of the leading musculoskeletal problems common in most age groups. The lifetime prevalence of low back pain is reported to be 84% [1]. The most common cause of LBP is nonspecific in nature, that is, either origin of pain in from the structures around lumbar region (muscles, ligaments, intervertebral disc, facets, etc.) or it is centrally mediated (imbalance in sensory processing and descending pain mechanisms) [2]. Guidelines published globally recommend early screening of risk factors leading to LBP including psychosocial components. Based on cause identified administration of multicomponent approach (including rest, hot/cold application, electrotherapy modalities, exercises), prevention strategies (posture and ergonomic modifications) along with behavior modifications were suggested interventions for LBP [1]. In certain LBP pathologies categorized as degenerative lumbar spine disorders (lumbar disc herniation, spondylolisthesis, spinal canal stenosis) efficacy of non-surgical versus surgical intervention is still not clear. The criteria for indicating patient for surgery are – failed conservative treatment, unmanageable pain, worsening of neurological compromise (sensory & motor loss), Cauda equina syndrome. This chapter will give rehabilitation overview pre- and post – operatively for patients with degenerative lumbar spine disorders.

2. Pre - operative phase

“Pre-habilitation” aims to augment functional outcomes by enhancing physical function and perception of pain during & after surgery by education including activity modifications in patients awaiting lumbar surgery. Studies have highlighted the role of pre-habilitation not only improve surgical outcome, but also reduces hospital stay and financial burden as compared to classic post-operative rehabilitation given alone [3].

Patient referred for pre- operative rehabilitation, should undergo thorough evaluation to understand lesion behavior [4]. This includes:

Posture – to identify postural compensations due to pain.

Range of motion (ROM) – Assessment of Lumbar ROM along with hip mobility.

Movements (static and repeated) – Pain response and discomfort felt by patient with LBP on static holding of position as well as on repeated motions.

Strength – Endurance of major muscle groups around lumbar region (Abdominals & Back Extensors) along with myotome assessment (L1 – S1) Recruitment of Transverse Abdominis.

Sensations and reflexes – Alterations in sensation (pin prick, touch, temperature) in dermatomes (L1 – S5) and spinal reflexes (Knee jerk, Ankle jerk, Plantar reflex).

Therapists will identify provocative postures, movements and thus determine directional preference which reduces pain. Irrespective of method of assessment or treatment used, avoid positions that increases intradiscal pressure leading to pain peripheralization.

2.1 Outcome measures

Patient rated outcome measures are commonly used to assess following parameters:

Patient reported function and activity limitation – Oswestry Disability Index (ODI) is 10 item questionnaires about the level of difficulty faced during function and activity with six options in each item. Higher scores indicate more disability [5].

The Roland Morris Disability Questionnaire (RMDQ) – Self rated disability as a result of LBP can be measured by the patient [6].

Pain – Visual analogue scale (VAS) – VAS is a simple tool consisting of 10 cm horizontal line to assess pain intensity [7].

Health related quality of life – SF-36 – It is self-reported measurement of health by patient, comprising of 36 questions under 8 domains [8].

Anxiety and depression – Hospital Anxiety and Depression Scale (HADS) is used to assess nonphysical symptoms of depression (7 questions) and anxiety (7 questions) in LBP patients. Cut off score ≥ 8 indicates the presence of anxiety and depression [9].

Fear Avoidance – Fear Avoidance Belief Questionnaire (FABQ)- It is a 16-item questionnaire with 2 sub-sections – Work subscale and Physical Activity subscale [10]. This scale is widely used in patients with LBP to understand work, ADLs & levels of physical activity are affected due to fear of increasing pain.

Patient reported treatment effects – Patient Enablement Instrument (PEI) – The scale is a patient rated outcome measure to assess containing 6 questions allowing patient to rate enablement to cope with problem after consultation with doctor/rehabilitation specialist [11].

2.2 Pre-operative rehabilitation protocol

Patient education is an integral part of therapy in surgical cases. Most of the time this aspect has been overlooked resulting in increased apprehensions and confusions regarding surgery, intended outcome and recovery time in patient’s as well as caregivers’ mind also. Detailed description of patient’s problem and possible surgical solutions with help of educational booklet, models or videos should be explained. Proper guidance regarding recovery time, precautions, and exercises to be followed before and after surgery should be discussed [12]. Description of exercises to be performed day-wise/week wise should be given as mentioned in Table 1.

Goals; Patient education Description of patho-biomechanics of lumbar spine & disc Education about surgical procedure, expected outcomes, milestones of progression, precautions & contraindications after surgery. Awareness of body position and mechanics while performing ADLs Decrease/centralize/abolish pain. Patient shall demonstrate and practice Transverse Abdominis (TrA) contraction maintaining spine in neutral position in different postures. Independence in home exercise program (HEP)

Precautions; Avoid prolonged sitting/driving for more than 20 minutes. Avoid lifting or carrying activities. Avoid activities requiring repetitive loading of spine (e.g., jogging, running etc)

Rehabilitation protocol; Relative rest Modalities for pain relief (US, TENS, Ice) Lumbar stabilization (Tummy Tuck -in) initiated in unloaded position (crook lying) and advanced to loaded position (sitting, standing etc) Active ROM of lumbar spine (direction determined in examination) to reduce, centralize or abolish pain. Repetitions/sets/hold time/rest time – as tolerated by patient.

Table 1.

Pre-operative rehabilitation protocol for patients undergoing Lumbar surgery.

(Recreated from Gage T. Lumbar Microdiscectomy. In: Mosca JC, Cahill JB, Tucker CY, editors. Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician. Elsevier; 2006. p, 328.)

3. Overview of surgical procedures

Commonest surgical procedures used in patients with intractable back pian are Lumbar Microdiscectomy (LMD), Instrumented lumbar fusion surgery. LMD is performed in reverse Trendelenburg’s position and midline incision (3 to 6 cm) is done over the affected segment. Paraspinal muscles are stripped and retracted to open interspace. Interspinous ligaments are spared, however ligamentum flavum is resected to perform foraminotomy. The nerve root is retracted medially, posterior longitudinal ligament and nucleus present lateral to nerve root are cut to perform nucleotomy. Damage to ligamentum flavum and paraspinal muscles is not repaired, but lumbar fascia is repaired using absorbable sutures [12].

Posterior lumbar interbody fusion (PLIF) was aimed to provide rigid spinal stabilization along with decompression of surrounding neural structures and correction in vertebral alignment. It is a 4-step procedure including Exposure & decompression; Spinal instrumentation & fixation using titanium/steel rods, plates, screws, and/or wires; Anterior column reconstruction & interbody fusion and Internal stabilization and closure of the area. In stage 3 procedures to restore disc height were performed by distraction without increasing tension in neural structures. Complete discectomy was done, and vertebral end plates are scraped till fresh bleeding. Bone graft is prepared by chipped bone from iliac crest or allograft material and placed over vertebral bone without soft tissue interposition [12].

4. Post-operative rehabilitation protocol

Communication with operating surgeons is critical for understanding early precautions and activity restrictions. However, a therapist based on clinical judgment can initiate early rehabilitation after lumbar spinal surgery. Recent evidence has suggested early mobilization encourages patient’s positive self-belief and ultimately enhance their ability to return to work and functional independence [4]. Research has shown conflicting findings regarding initiation of rehabilitation immediately after lumbar surgery but none of the studies has reported any adverse effect. Rather supported the fact that early lifting of post operative limitation results in lesser number of problems [13].

However, initiation of spinal stabilization exercises before and after surgery is key to success in surgical interventions. Studies have suggested that recruitment of lumbar Transversus Abdominis (TA) and Multifidus (MF) muscles is not balanced in patients with long standing LBP as these muscles fine tune the motion at segmental level, thus affecting lumbar stability. Further presence of chronic pain in back in surgical cases along with fear & anxiety in minds of patients undergoing surgery will further inhibit their activation. Thus, activation of these muscles is very much essential to “switch on” stabilization role played by these muscles before as well as after surgery. This can be achieved initially in unloaded position with help of verbal, visual or tactile feedback and gradually progressing to loaded positions to improve motor control [4].

Focus on improving/maintaining range of motion and flexibility of joints adjacent to lumbar spine is important postoperatively. This enables healing at surgical site and simultaneously overall range can be improved. Most of the exercises should be done in supine position after disc surgery to offload the spine. Double Knee to chest exercise helps to stretch thoracolumbar fascia; single knee to chest improve hip mobility & stretch proximal sciatic nerve (Figure 1); lower trunk rotation improves blood flow & reduce disc pressure. Repetitions and sets should be decided as per patient’s tolerance [4].

Figure 1.

Sciatic nerve mobilization (with spine supported).

Initiation on walking program in immediate post operative phase is widely recommended by surgeons as well as rehabilitation experts [4]. Following lumbar surgery, it has multifaceted role such as:

• Improving overall blood flow – Prevent deep vein thrombosis.

• Promotes cardiovascular fitness.

• Provides nutrition to Intervertebral disc – rhythmic loading & off-loading improves imbibition, nutrition and promotes healing.

• Gentle stretching of sciatic nerve – prevents adhesion formation around nerve and improves blood flow.

The role of neural mobilization in post-surgical cases to prevent risk of nerve root adhesions is crucial. However, the lumbar spine should be maintained in neutral position and nerve should be elongated carefully (not more than 6–8% of its length). Dosage depends upon the patient’s response. Excessive lengthening of nerve may reduce blood flow resulting in ischemic pain [4, 12]. The rehabilitation in immediate post operative phase is mentioned in Table 2.

PHASE I: Postoperative (Day 1–6)

Goals; Protection of surgical site Pain control Initiate walking as tolerated. Independence in performing bed mobility, sit-to-stand and toileting by Day 2

Precautions; Avoid prolonged sitting/driving for more than 20 minutes. Avoid bending, lifting, and carrying activities (>10 pounds). Avoid Valsalva maneuver. Avoid all sporting activities.

Rehabilitation Protocol; Initiate and practice Log rolling transfers while sitting from supine lying (Figures 2 & 3). Basic exercises – abdominal drawing in, gluteal squeezes, ankle foot pumps. Same exercises are suggested for home exercise program after discharge. Lumbar stabilization in crook lying (Figure 4). Walking session to be initiated with or without support for 5–10 minutes on level surface (1–3 sessions/day as tolerated). Patients are discharged 1–2 days post -operatively.

Criteria for Discharge: Demonstration of supine to sit transfers by patient. Gained proper understanding of body mechanics during ADLs (i.e., avoid lumbar flexion. Independent walking with or without assistive devices. Demonstrate independence in donning & doffing of lumbar corset

Table 2.

Immediate Post-operative rehabilitation protocol for patients undergone Lumbar surgery.

(Recreated from Nigrini CM and Camarillo RM. Lumbar spine Microdiscectomy surgical rehabilitation. In: Brotzman SB and Manske RC editors. Clinical Orthopedic Rehabilitation- An evidence-based approach. 3rd ed. Elsevier Mosby; 2011, p. 326–337)

Figure 2.

Log rolling (starting position).

Figure 3.

Log rolling to left side.

Figure 4.

Lumbar stabilization in crook lying (Transversus abdominis contraction).

Table 3 depicts rehabilitation protocol in after immediate post- operative phase [4, 12].

PHASE II: PROTECTED MOBILIZATION (Postoperative Week 1–3)

Goals: Protection of surgical site Pain control Improve walking tolerance to 30 minutes.

Precautions; Avoid prolonged sitting/driving for more than 20 minutes. Avoid bending, lifting, and carrying activities (>10 pounds). Avoid Valsalva maneuver. Avoid sports activities

Rehabilitation protocol; Relative rest – walking, unloaded cycling. Soft tissue mobilization Intervention for pain relief (US, TENS, Cryotherapy) Lumbar stabilization initiated in supine/prone lying.

Criteria for Progression; Patient can demonstrate: Proper sitting postures and body mechanics while transfers Lumbar stabilization in unloaded position

PHASE III: NEUTRAL STABILIZATION (Postoperative Week 3–8)

Goals; Restore Lumbar ROM Improve muscle imbalance. Improve tolerance to loaded positions. Independence in walking without support on level surface Return to work (light to moderate) and Activities of Daily living (ADLs). Adherence to precautions while during work and ADLs.

Precautions; Avoid prolonged flexed postures (sitting/driving) Avoid activities involving repeated spinal loading (jogging)

Rehabilitation protocol; Transverse Abdominal exercises in different positions (Figures 5 & 6) Progression of bridging exercises (for gluteus maximus) Progression of strength training of Hip Abductor (Figure 7) Initiate active Lumbar ROM - Quadruped rocking (with lumbar flexion & neutral spine) (Figure 8), Seated Knee extensions (Figure 9) and progress to lumbar active ROM in standing. (Figure 10) Non-impact lower limb cardiovascular exercises – stationary bicycling, treadmill etc. Strength training of upper and lower limb muscles maintaining spine in neutral.

Criteria for Progression; Full active Lumbar ROM Demonstrate proper mechanics while squatting. Lower limb muscle strength – 4 out of 5 Ability to demonstrate neutral spine in loaded positions.

PHASE IV: DYNAMIC STABILIZATION (Postoperative Week 8–14)

Goals; Demonstrate 5/5 lower limb strength. Perform dynamic stabilization without discomfort. Able to perform repetitive lumbar spinal motion in all planes. Ability to return to actual working situations and perform recreational activities. For athletes: Ability to return to play.

Precautions; Avoid aggravation of symptoms

Rehabilitation protocol; Progression of core stabilization strengthening Progression of cardiovascular training – initiation of jogging Progression in strength training Repetitive motions in directions that centralize pain. Progress aerobic conditioning

Criteria for Progression; Full pain free active ROM of Lumbar spine No lower limb neural tension signs Demonstrates B/L normal flexibility. Lower extremity strength 5/5. Good body mechanics in dynamic activities.

Table 3.

Post-operative rehabilitation protocol after discharge for patients undergone Lumbar surgery.

Figure 5.

Transverse abdominis contraction with single leg lift.

Figure 6.

Transverse abdominis contraction with double leg lift.

Figure 7.

Hip abductor strengthening (side lying).

Figure 8.

Quadruped rocking – Starting position (with spine in neutral) & end position.

Figure 9.

Seated knee extension (with ankle dorsiflexion).

Figure 10.

Standing Lumbar flexion – Starting position (with spine in neutral) & end position.

5. Home exercise program

Limited evidence is available regarding the efficacy of home exercise regimen following lumbar surgery. Experimental study showed that supervised exercises are more effective in reducing pain and disability following lumbar surgery as compared to home-based intervention or no exercises [14]. But sample size of the study was small and adherence rate while exercising at home was not checked. Therefore, emphasis should be laid on improving patient’s motivation and involvement of patient in designing home exercise program as per their preferences [13]. Fears in doing exercises at home without supervision should also be dealt with proper patient education as well as opting alternate modes to monitor progress such as telerehabilitation.

6. Recent advances in rehabilitation following Lumbar surgery

The role of virtual reality-based interventions in managing patients after spinal cord injury has been researched well [15] but its application in rehabilitation after spinal surgery is limited. Because of its unique features such as simulation of real-world environment along with ability to capture body’s movement, velocity and give visual/auditory/tactile feedbacks makes it a promising rehabilitation tool for management of medical conditions. Recent systematic review has identified promising use of virtual reality in assessment and training following cervical spine surgeries to enhance patient recovery [16] but lacks any experimental fingings. Applicability of virtual reality in management of LBP has been recently discussed [17] but its direct role after lumbar spinal surgery needs to be extensively studied and documented.

7. Conclusions

The chapter has summarized the role of rehabilitation in lumbar surgery. Health care professionals should lay emphasis on pre- operative rehabilitation to ensure early recovery in post operative phase. Proper education and engagement of patients in deciding treatment options is important. Immediate post operative rehabilitation leads to faster reduction in pain and disability. Suitable assessments in phasic manner, following precautions and exercises as recommended will bring better surgical outcomes.

Acknowledgments

No funding involved by any agency.

Conflict of interest

The authors declare no conflict of interest.