1. Discectomy, Laminectomy and Fusion: Therapy and Post-surgery Recovery
Workshop 3
Discectomy, Laminectomy and Fusion: Therapy and Post-surgery Recovery

2. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE
Maureen Dwight, Registered Physiotherapist, Clinical Musculoskeletal Specialist, ISAEC Practitioner
Co-founder Spine Therapy Network
Director The Orthopaedic Therapy Clinic

3. The Facts: Spinal surgery rates are increasing worldwide
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4. Most frequent surgeries are for:
Spinal stenosis
Disc herniation
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5. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE
Many of us are involved with these patients pre-op
- but should we be?
Many of us never see these patients post-operatively
- but should we?
Many of us never receive referrals directly from the surgeon’s post-op.
- why not? I

6. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE
The controversies
No literature to support therapy
Post-operative rehab is not needed – wastes resources.

7. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE
Education is as effective as therapeutic exercise programs.
Should we be providing full behavioural rehab programs or single discipline exercise programs?
Post-operative rehab increases the risk for further surgery.

8. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE
Spinal Stenosis

9. The Facts: Spinal stenosis surgery increasing due to aging population
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10. 66 y. o. female with spinal stenosis
66 y.o. female with spinal stenosis. Should she have therapy or surgery? What would you tell her?
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11. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE STENOSIS
Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review Alison H. McGregor , PhD , et al Spine vol 39 #13 pp , 2014

12. The Facts
Conservative care for spinal stenosis: Little support in the literature
We need better quality studies

13. The Facts
Surgery for spinal stenosis has better short term outcomes than conservative care
The difference lessens over the long term > 1 yr*
*American pain society CPC 2009
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14. 66 y.o. female with spinal stenosis What would you tell her?
It’s her choice.
Surgery will have a better short term result but over the long term there is little difference.
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15. Cochrane review - Rehab after spinal stenosis surgery
Is there a role for therapy after surgery to improve outcomes?
What is the gap?

16. Cochrane 2014 Spinal Stenosis surgery systematic review Post-surgical outcomes
Moderate improvement in function
58-69%
Low Satisfaction rates
15-81%
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17. Cochrane 2014 Spinal Stenosis surgery systematic review
Evidence of trunk muscle dysfunction
Muscles are known to be damaged by surgery
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18. Cochrane 2014 Spinal Stenosis surgery systematic review
Pre-review statement: These findings would suggest that Rehab would be promising post-op in improving outcomes
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19. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review
Review question: Whether active rehab programs after spinal stenosis have an impact on functional outcomes and whether these programs are better than “usual care”?

20. Same 66 y.o. old
Now post-op for spinal stenosis with residual back and leg pain.
Wants to garden this spring.

21. Can you help her to: Reduce her low back pain? Reduce her leg pain?
Improve her function?

22. When should she start therapy?
Should she be afraid of hurting her surgery results with exercise?

23. 1726 articles to review 3 included
Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review
1726 articles to review 3 included

24. Definition of “usual care”:
Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review
Definition of “usual care”:
Post-operatively provided limited advice to stay active
Brief general program of exercise directed at preventing DVT

25. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review
Recommendations Moderate evidence supporting rehab post spinal stenosis surgery

26. Cochrane review - Rehab after lumbar stenosis surgery
Can you help her to:
Reduce her low back pain?
Yes
Active rehab is better than usual care in the short term for reducing post-operative low back pain

27. Cochrane review - Rehab after lumbar stenosis surgery
Can you help her to:
Reduce her leg pain?
Yes - Active rehab is better than usual care in the short and long term for reducing post-operative low back pain and leg pain

28. Cochrane review - Rehab after lumbar stenosis surgery
Can you help her to:
Improve her function?
Yes - now & for the future
Active rehab is better than usual care in both short term and long term functional status post-spinal stenosis surgery

29. Cochrane review - Rehab after lumbar stenosis surgery
When should she start therapy?
Active rehab within 6 mos. post-op is more effective than usual care to improve:
Function
LBP
No difference in leg pain

30. Cochrane review - Rehab after lumbar stenosis surgery
When should she start therapy?
Active rehab started within 12 mos. post-op is more effective than usual care to improve:
function
lbp
leg pain

31. Rehabilitation Following Surgery for Lumbar Spinal Stenosis A Cochrane Review
Should she be afraid of hurting her surgery results with exercise? No
There was no increased risk of re-operative rates in these studies.

32. Disc Herniations

33. 29 y.o. male athlete Acute L5 root with L5-S1 disc herniation confirmed on MRI. 3/12 post-onset
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34. Should he have therapy or surgery?
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35. Natural history of disc herniation recovery 38% - clinically improved 1/12 53% - clinically improved 2/12 73% - clinically improved 3/12

36. The Facts
Conservative care for disc herniation: Little support in the literature
We need better quality studies

37. The Facts
Surgery has better short term outcomes than conservative care
The difference lessens over the long term > 1 yr.

38. 29 y.o. male athlete What do you tell him? It’s his choice.
Surgery will have a better short term result but over the long term there is little difference.

39. Same 29 y.o. male athlete now post-op Microdiscectomy & Laminotomy Continues to have back and leg pain

40. When should he start to exercise. What intensity of program is best
When should he start to exercise? What intensity of program is best? Should he worry about damaging the surgery?

41. Should you develop post-op education handouts
Should you develop post-op education handouts? Should he see a CBT therapist and/or a rehab program counsellor for a comprehensive program?

42. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE LUMBAR DISC SURGERY
Cochrane review 2014
Rehab after lumbar disc surgery
T Oosterhuis et al
Updated 2002

43. Cochrane review - Rehab after lumbar disc surgery
Surgeries included:
Discectomy
Microdiscectomy
Laminectomy with microdiscectomy
8 new studies met the criteria, 22 in total

44. Cochrane review - Rehab after lumbar disc surgery
Included studies where post-operative care began:
Immediately post-op
4-6 months post-op
1 year or longer post-op .

45. Cochrane review - Rehab after lumbar disc surgery
Looked at exercise programs vs. Rehab programs
Rehab programs definition:
Multidisciplinary programs
Stretch and strength exercises
Behavioral graded activity

46. Cochrane review - Rehab after lumbar disc surgery
In these studies:
The exercise interventions provided were uncontrolled
And highly variable

47. Cochrane review - Rehab after lumbar disc surgery
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Conclusions:
No high or moderate- quality evidence identified.
Further high quality randomized controlled studies needed

48. Cochrane review conclusions - Rehab after lumbar disc surgery
These programs lead to a faster decrease in pain & better function than no treatment (low quality)
High-intensity exercise programs lead to slightly faster decrease in pain & disability than low-intensity programs (very low quality)
Home exercise programs for pain relief, disability or global perceived effect were as effective as supervised exercise programs (very low quality)

49. Cochrane review - Rehab after lumbar disc surgery
Education on it’s own did not have as strong an outcome as physiotherapy exercise programs (low quality)
There is less support for including a full rehab program than providing an exercise only program in the immediate post-op period (low quality)

50. 29 y. o. male athlete When should he start exercise
29 y.o. male athlete When should he start exercise? Exercise programs started at 4-6 months post-op are better than no Rx

51. When should he start exercise
When should he start exercise? ISSLS award winner – McGregor, A Anticipation of therapy is enough to improve short term outcomes

52. 29 y.o. male athlete
Exercise at 4-6/12 post-op better than no treatment for:
pain reduction
Improving function

53. Intensity of exercise
High intensity exercise may be better than lower in the short term for:
improving functional status
reducing pain

54. Should he exercise with you or independently
Should he exercise with you or independently? No difference between HEP and supervised for short term pain relief Let him choose.

55. Should you develop education handouts
Should you develop education handouts? Physiotherapy has better results than education only programs

56. Should he see a CBT therapist and/or go to a rehab program
Should he see a CBT therapist and/or go to a rehab program? No benefit with these programs immediately post- op. (prior to 4 months)

57. Should he worry about damaging the surgery
Should he worry about damaging the surgery? No reports of re- operation rates in these studies

58. Lumbar Spine Fusion Rehab
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59. No Cochrane review, few systematic reviews published on post-operative spinal fusion rehabilitation

60. Madera, M et al – The Role of Physical Therapy and Rehabilitation after Lumbar Fusion Surgery for Degenerative Disease: A Systematic Review NASS 2016
Therapy at 12 weeks results in lower-cost outcomes than at 6 weeks.
No protocols for the programs

61. Multi-centre, randomized, controlled trial Compared fusion to therapy
UK 2005 multi-hospital post-op fusion study
Multi-centre, randomized, controlled trial
Compared fusion to therapy
Pts with chronic lbp > 12 months

62. Rehab program
5-7 sessions per week
Supervised for the first 3/52
Follow-ups 1, 3, 6 & 12 months
Program consisted of
Stretching
Spinal stabilization exercises
Aerobic exercises
Hydro-therapy

63. UK 2005 multi-hospital post-op fusion study
Fusion is slightly more effective in reducing disability due to chronic lbp than intense rehab
Rehab is more cost- effective
Rehab has less side effects

64. Side effects Fusion 11% Rehab 0%
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65. Exercise therapy after fusion with CBT has additional impacts
Spinal fusion
Abbot et al – Leg pain and psychological variables predict outcome 2-3 years after lumbar fusion surgery, Eur Spine J 2011
Exercise therapy after fusion with CBT has additional impacts

66. 60% fusions considered successful after the 1st surgery
Spinal fusion
60% fusions considered successful after the 1st surgery
19% re-operation rate

67. Based on these facts rehab should make a difference in outcomes!
Spinal fusion
Based on these facts rehab should make a difference in outcomes!

68. Decreasing outcomes with repeat fusions
30% 2nd surgery successful
15% 3rd surgery successful
5% 4th surgery successful
20% experience increase in symptoms

69. Failures several years later
Spinal instability 12% after 1 surgery 50% after 4

70. Entering the Unknown
Failed back surgery Post-laminectomy syndrome

71. Causes of failure to achieve relief post- surgical Recognize that the symptoms may or may not be related to the reason for the original surgery

72. Only 20% of post- operative back symptoms will be identified based on traditional spinal assessments

73. The advanced spine practitioner’s role in post-surgical recovery
Our understanding of the surgery and its sequelae can help in recovery
We can help to improve successful outcomes by recognizing the pre-existing, the non-related and what is unlikely to be corrected by surgery
We can recognize what is not typical and know how to manage it

74. We all play a part in the spinal post- surgical team
Is it a competition NO
We all play a part in the spinal post- surgical team
Surgeon
Therapist
Psychologist
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75. Thank you

77. Role of the APC
Causes of immediate failure to achieve relief post- surgical
Incorrect initial dx A review of the literature shows only 30% of disc surgeries have true radicular pain

78. Role of the APC
Causes of immediate failure to achieve relief post- surgical
Technical error
This one we can’t help with

79. THE VALUE OF THE ADVANCED SPINE PRACTITIONER IN POST-OPERATIVE CARE STENOSIS
More opportunity for therapists to work with our surgeons on these outcomes a rapidly rising rates of spinal stenosis surgery due to an aging population Put Deyo rates

80. Role of the APC Poor patient selection
Causes of immediate failure to achieve relief post- surgical
Poor patient selection
Know our Start back, PHQ9, PCS
However may be given too much wt.

81. Role of the APC Infection
Causes of temporary relief followed by pain recurrence within a few months
Infection
Know the signs and symptoms and screen for it

82. Role of the APC Re-herniation
Causes of temporary relief followed by pain recurrence within a few months
Re-herniation
? Rate
Screen for it

83. Role of the APC
Significant predictors of radiological nerve root compression on MRI Put correlations
Dermatomal radiation Increased pain on coughing, sneezing or straining +ve SLR EMG ongoing denervation

84. Role of the APC
Causes of temporary relief followed by pain recurrence within a few months
Battered root syndrome -Root aggravated by surgery

85. Role of the APC
Battered root syndrome
Study on acupuncture post- op

86. Role of the APC
Causes of temporary relief followed by pain recurrence within a few months
Epidural fibrosis Put in the questions Is this really the problem

87. Role of the APC
Failures several years later
Prevention of future failure is an important consideration of the APC

88. Role of the APC Spinal stenosis – same level or adjacent level
Failures several years later
Spinal stenosis – same level or adjacent level

89. Role of the APC
Significant predictors of radiological nerve root compression on MRI Put correlations
Dermatomal radiation Increased pain on coughing, sneezing or straining +ve SLR EMG ongoing denervation

90. The role of the APC

91. Case History #1 Post-op Symptoms
Constant anterior hip & groin tightness
Intermittent discomfort lumbar & lateral hip. Extends to the knee when exacerbated.

92. Case History #1 Post-op Symptoms
Constant anterior hip & groin tightness
Intermittent discomfort lumbar & lateral hip. Extends to the knee when exacerbated.

93. Case History #1 Post-op Symptoms Worse: skating or walking too long
Better: analgesics and rest

94. Case History #1 Post-op Symptoms Worse: skating or walking too long
Better: analgesics and rest

95. Case History #1
Would he benefit from therapy? What treatment would you recommend?

96. Is this a typical outcome?
Spinal Stenosis outcomes
Function improvement post-op %
Satisfaction rates post-op 15-81%

97. 66 yo female
Spinal stenosis surgery
Unhappy with the outcome
4/12 post-op
Still has low back pain when she walks
Can’t stand to cook holiday dinners

98. Case History #2
Would she benefit from therapy? What treatment would you recommend?

99. Applying the Evidence – the Role of the APC
Does he require: a. Imaging or other testing? b. referral to the surgeon, interventionist or chronic pain specialist? c. Additional pharmacology support? d. Less pharmacology support?

100. Applying the Evidence – the Role of the APC
post-operative infection?
Re-herniation
Any other concerns?

101. Applying the Evidence – the Role of the APC
Clinical Action Educate client as to expectation of surgery Educate on concept of mechanical low back Begin therapy and monitor outcome to determine if clinical decision is correct

102. THE ROLE OF THE ADVANCED SPINE PRACTITIONER IN POST-SURGICAL RECOVERY
Our expertise in understanding the surgery and their sequelae can help in
Avoiding over and under activity
Avoiding over and under medication
Improving patient confidence in the recovery and in their surgeon by recognizing the cause of their symptoms
Limiting the need for future surgeries

103. Applying the Evidence – the Role of the APC
Understanding the surgery Goal of Discectomy - relieving leg pain. Was this Goal achieved? Yes Dermatomal pattern is no longer fully consistent with L5-S1. Pain is intermittent on activity - mechanical

104. The advanced spine practitioner’s role in post-surgical recovery is much larger
We can: 1. improve patient satisfaction with their surgery 2. improve patient quality of life 3. reduce unnecessary imaging 4. reduce unnecessary medication

105. THE ROLE OF THE ADVANCED SPINE PRACTITIONER IN POST-SURGICAL RECOVERY
Our roles is to recognize what is not typical
and to know how to manage it

106. THE ROLE OF THE ADVANCED SPINE PRACTITIONER IN POST-SURGICAL RECOVERY
To which I defer to my surgical and interventional colleagues to speak on.

107. Case History #1
Post-op – completely pain free for 1/12 1/12 post-op started core exercises 2/12 returned to skating Goal is to resume playing hockey Is back at work full time, no restrictions

108. Case History #1
Frustrated: Feels the surgery failed

109. Applying the biologically compelling argument
What do we know – He is now 5/12 with symptoms that increase with exercise