Surgical Considerations - Lumbar Fusion Flashcards
When is surgery indicated?
If conservative treatment fails over time over a reasonable time frame (2 to 6 months), dependent on:
- Response from PT
- Patient participation requirements
- Effectiveness of other treatment (Meds, injections, biologics)
- Worsening of neurological symptoms
-Motor deficits lasting more than 4 months
What are the different Surgical options?
- Lumbar Laminectomy
- Lumbar Foraminotomy
- Lumbar Discectomy and Fusion
What are the Characteristics of the Lumbar Laminectomy? What is a disadvantage to this?
This is an approach where the corresponding lumbar level’s lamina is removed, decreasing the compression on the nerve roots
- The Primary disadvantage to a compete laminectomy is that the surgical segment loses its anatomical stabilization
- A laminectomy is typcially chosen over a fusion in patients with a small unilateral disk protrusion
What are the Characteristics of the Lumbar Foraminotomy?
This is a procedure that increases the space within the nerve intervertebral foramen to decrease pressure on a nerve root
What are the Characteristics of the Lumbar Discectomy and Fusion?
When is it indicated? What are the effects of this procedure?
This is utilized to decrease nerve root compression, as well as correct alignment and/or provide stability in the case of spondylolisthesis
- Fusions are indicated when the patient presents with axial pain combined with instability, severe arthritic degenerative changes or peripheral pain that is not controlled.
- The effects of a fusion may expedite the degenerative process, create a hypermobility at adjacent spinal segments and alter overall spinal mechanics
With Lumbar Discectomy and Fusion, what are the 2 different surgical techniques? What is the primary difference between the two?
- Transforaminal Lumbar Interbody Fusion (TLIF): This is a unilateral approach
- Posterior Lumbar Interbody Fusion (PLIF): This is a bilateral approach
Lumbar Discectomy and Fusion
What takes place during an Transforaminal Lumbar Interbody Fusion (TLIF)?
- This involved a vertical incision centrally along the posterior spine
- Excision of the appropriate disc(s)
- Internal fixation of the relevant vertebral levels using bone from the facetectomy and autologous bone from the iliac crest
This technique has been shown to have a decreased complication rate, decreased blood loss and a shorter operation length compared to PLIF
With the Transforaminal Lumbar Interbody Fusion (TLIF) and Posterior Lumbar Interbody Fusion (PLIF), what are the restriction post-op?
- NO bending
- NO lifting
- NO twisting
Post-Lumbar Surgery, what should the Subjective Exam focus on?
- Red/Yellow flag screening
-Intake and OM
-Increase in neurological sx in ipsilateral LE and/or contralateral LE - Understanding of the full scope of the surgery
-What are the restrictions from the surgeon?
-Parameters of wearing th TLSO brace - Do they have assistance at home?
- What level of activity do they need to get back to?
What are the structure(s) affected by surgery?
Primary, secondary, tertiary
- Primary: Vertebra of the L-spine; IVD
- Secondary: Nerve roots and immediate surrounding tissues
- Tertiary: Surround tissues disrupted by surgery to access the primary tissues
Post-Lumbar Surgery, What does the Physical Examination entail?
- Integumentary Exam
- Neurological Exam
- Lumbar AROM/PROM
- Muscle Performance Testing (if allowed)
- Palpation
Post-Lumbar surgery, with the Physical Examination, when should an Integumentary Exam take place and what is expected?
- Before and after treament
- We expect to find redness, erythema and maybe eccymosis around incision.
- Signs to look out for are signs of necrosis, excessive tenderness or edema, increased heat and drainage; which indicated infection and/or delayed healing
The most common complication from surgery is infection and/or wound complications
Post-Lumbar surgery, with the Physical Examination, what is done during Neurological Exam?
There may be sensation deficits depending on severity of patients prior sx
- Baseline for Dermatome and Myotome Testing based on affected levels
Post-Lumbar surgery, with the Physical Examination, what is done during Lumbar AROM/PROM?
This should NOT be performed if they still have continued bending, lifting, and twisting restrictions
- AROM and PROM at the Hip within the patients tolerance and will typically be limited in all directions
Post-Lumbar surgery, with the Physical Examination, what takes place during Muscle Performance Testing?
This may or may not be done based on patient presentation; if performed it will be done at a submaximal level
- This gives an idea of their muscle activiation ability
Post-Lumbar surgery, with the Physical Examination, What is expected during palpation?
- TTP of Paraspinals, QL, Glute Med., Piriformis
Muscle guarding can be a large contributor
What is the Prognosis for an Post-op Lumbar surgery?
This will vary based on:
- Natural History (The bodys ability to heal its self over time; co-morbilities may affect healing times and/or quality)
- Primary tissue healing times (Bone)
- Return to activity/sport timeline (highly variable based on patients activities and participation)
- Social determinants of health (SDOH)
What are the Phases of Rehab for Post-op Lumbar Surgery?
With the 1st phase of rehab what is the rehab focus?
Pt will being therapy the day after surgery while still in the hospital, Acute SOH. The primary mechanisms of pain is nocicpetive but they may also have peripheral neuropathic pain, secondary to nerve root irritation. The goal of this phase is to protect the surgical procedure, pain and swelling control and return to basic ADL’s independently
With the 2nd phase of rehab what is the rehab focus?
Pt will be in the subacute SOH with nociceptive pain but with less severity and irritability. The goal of this phase is to progress lumbar AROM, increase strength and normalize lumbar and LE movement patterns
With the 3rd phase of rehab what is the rehab focus?
Pt should have minimal to no pain symptoms, pt will be in the chronic SOH. The goal of this phase is to return to all of their normal daily activities and progress towards higher level activities
With the 4th phase of rehab what is the rehab focus?
This is the return to all their higher level activities such as sport activity and higher demand work
With Phase 1, What are the Precautions, Goals, and Interventions?
Treatment approach is to control pain, modulate post-op symptoms and regain ROM
Precautions
- NO bending, lifting, or twisting
- Lifting weight restriction
Goals
- Protect fusion
- Control pain and inflammation
Interventions
- Soft tissue work on lumbar paraspinals, QL, glutes
- Ice
- Isometricss
- Walking
- Education on posture, activity modification, donning and doffing of TLSO
With Post-Op Lumbar Surgery, what is the Critera to Progress from Phase 1 to Phase 2?
- The ability to perform bed mobility and STS independently
- Well-controlled pain symptoms
