Lumbar Spine Post Surgical Lecture

Question 1

Cauda Equina Syndrome =

Answer 1

large central disc prolapse

Severe LBP

Sciatica – often bilaterally,often L5/S1

Saddle and or genital sensory disturbance

Bladder, bowel and sexual dysfunction

Emergency decompression surgery

Question 2

When to refer…

Answer 2

Red Flags
Trauma
Intractable pain
Primarily leg pain >6-8 weeks.

Neurologic sign
> Significant motor weakness:
> NOT an indication for surgery, but a relative indication.

Progressive instability
Others…..

Question 3

Bottom Line: The goal of spinal surgery is:

Answer 3

Decompression
Stabilization

Question 4

A good surgeon’s indications for spinal surgery

Answer 4

Healthy nonsmoker (smoking increases risk of failure 2-3x)

Realistic goals: simple ADLs.

Many years of other modalities:
Including weight loss
and exercise.

One or two levels involved.

Question 5

Lumbar Disc Herniated Nucleus Pulposus (HNP)

Answer 5

Protrusion or extrusion of disc material causing neural impingement.

Despite immediate gratification, remember that the HNP = disc degeneration.
> therefore - They May Be Back.

Question 6

Lumbar HNPTreatment

Answer 6

If the indications are good (Spengler, et al.), over 90% success can be expected:
> A very gratifying moment in spine surgery!

Surgery: Laminectomy with Discectomy:
> Minimally invasive approach.

Question 7

Laminectomy-

Answer 7

can be partial or full, indicated for small unilateral disc protrusion, can result in loss of anatomic stabilization (complete laminectomy)

Question 8

Discectomy-

Answer 8

can be partial or full. Full discectomy requires spinal fusion.

Question 9

Central Spinal Stenosis =

Answer 9

Degenerative changes causing narrowing of the spinal canal and or foramen

A consequence of aging

Midsagittal diameter (CT)

Cross sectional area (CT)

Question 10

Midsagittal diameter (CT):

Answer 10

Less than 10mm = absolute stenosis.

Less than 13mm = relative stenosis.

Question 11

Cross sectional area (CT):

Answer 11

100mm2 or less = stenosis.

sequence of aging

Question 12

Lateral Spinal Stenosis

Answer 12

Degenerative changes causing narrowing of the intervertebral foramen

A consequence of aging

Question 13

Decompression=

Answer 13

removal of all anatomy causing stenosis after strong anti-inflammatory treatment of soft tissues.

Question 14

Instability

Answer 14

Spondylolysis: defect in the pars articularis

Spondylolisthesis: forward slip

Spinal Fusion with metal and bone graft replacing disc

Question 15

Post-operative principles for any surgical procedure

Answer 15

Post-operative protocol: healing times and procedural based

Know all Restrictions- dependent on surgeon
> Typically- no heavy lifting (>10lbs) for up to 3 months, movement restrictions- depends on procedure and surgeon
> Brace use

Question 16

Recovery Potential
Consider patient factors:

Answer 16

Work status.
Confounding health issues.
Job satisfaction.
Smoking.

Question 17

Post-operative principles for any surgical procedure

What are the Structural impairments?

Answer 17

Post operative swelling

Potential circulatory and pulmonary complications

Jt stiffness and decreased motion due to injury and post op precautions

Muscle atrophy due to immobilization

Decreased strength

Question 18

What are the Functional impairments?

Answer 18

Use a functional assessment tool at the initial exam as your objective exam post surgery is limited to basically a screening exam and function.

Oswestry and neck disability index can be useful.

Question 19

Maximum protection phase

Answer 19

Educate pt in self management strategies

Decrease post operative pain

Prevent infection

Minimize post operative swelling

Prevent post operative complications

Prevent jt stiffness and soft tissue contracture

Minimize ms atrophy

Maintain strength and motion in areas above and below surgical site

Maintain functional mobility while protecting the operative site

Question 20

Educate pt in self management strategies

Answer 20

Rx: instruct in safe positioning and limb mvmts and any post operative precautions

Question 21

Decrease post operative pain

Answer 21

Rx: relaxation/breathing exercises, modalities, ROM

Question 22

Prevent infection

Answer 22

Rx- review wound care

Question 23

Minimize post operative swelling

Answer 23

RX: elevation, compression, ms pumping, lymph drainage massage

Question 24

Prevent post operative complications

Answer 24

RX: active ex to stimulate circulation, deep breathing ex,

Question 25

Prevent jt stiffness and soft tissue contracture

Answer 25

Rx: PROM, AAROM, AROM

Question 26

Minimize ms atrophy

Answer 26

Rx: isometric exercises

Question 27

Maintain strength and motion in areas above and below surgical site

Answer 27

Rx: A/ARROM

Question 28

Maximum protection phase - laminectomy

Answer 28

Post operative management similar for fusion and laminectomy

Recovery time quicker with laminectomy

Pts may be placed in Philadelphia collar or lumbosacral orthosis

Question 29

Maintain functional mobility while protecting the operative site

Answer 29

Rx: adaptive equipment as needed

Question 30

Patient Education

Answer 30

Rehab program, expectations

Restrictions- dependent on surgeon
> Typically- no heavy lifting (>10lbs) for up to 3 months, movement restrictions- depends on procedure and surgeon

Wound management and pain control

Functional mobility

Exercises- walking, isometrics in supine, AROM- heel slides, SAQ, ankle pumps

Question 31

Fusion

Answer 31

PTs must teach patients how to move again without stressing segment above and below the fusion

Common for a fusion patient to “wear out” the segments above and below the fusion.

Question 32

PTs play an important role in preventing the need for surgery!

Answer 32

Early and direct referral to PT!