Evaluation and Rehabilitation after Adult Lumbar Spine Surgery

Purpose: With an increase in the proportion of elderly patients, the global burden of spinal disease is on the rise. This is gradually expected to increase the number of surgical procedures all over the world in the near future. As we know, rehabilitation following spine surgery is critical for optimal recovery. However, the current literature lacks consensus regarding the appropriate post-operative rehabilitation protocol. The purpose of this review is to evaluate the optimal protocol for rehabilitation after lumbar spine surgery in adults. Materials and Methods: The goals of rehabilitation after lumbar spine surgery are to improve physical and psychosocial function and may include multiple modalities such as physical therapy, cognitive behavioral therapy, specialized instruments, and instructions to be followed during activities of daily living. In recent years, not only are a greater number of spine surgeries being performed, but various different techniques of lumbar spine surgery and spinal fusion have also emerged. (1) Our review summarizes post-operative rehabilitation under the following headings-1. Historical aspects, 2. Subjective functional outcomes, and (3) Actual rehabilitation measures, including balance. Results: Physical therapy programs need to be patient-specific and surgery-specific, such that they consider patient-reported outcome measures and take into consideration the technique of spinal fusion used and the muscle groups involved in these surgeries. By doing so, it is possible to assess the level of functional impairment and then specifically target the strengthening of those muscle groups affected by surgery whilst also improving impaired balance and allowing a return to daily activities. Conclusions: Rehabilitation is a multi-faceted journey to restore mobility, function, and quality of life. The current rehabilitation practice focuses on muscle strengthening, but the importance of spinal balance is less elaborated. We thus equally emphasize muscle strengthening and balance improvement post-lumbar spine surgery.

Comprehensive Rehabilitation of a Patient With Foot Drop Secondary to Lumbar Canal Stenosis: A Case Report

One of the most prevalent degenerative musculoskeletal conditions is lumbar spinal canal stenosis (LSS), which is characterized by narrowing of the lumbar spinal canal that pressures the nerve roots and cauda equine. LSS, when treated surgically, usually presents with foot drop as its major complication. Foot drop is a common presentation of several clinical diseases, traditionally characterized as severe weakening of ankle and toe dorsiflexion. Foot drop has a great impact on patients' lives, lowering their quality of life and affecting their activities of daily living. Ankle dorsiflexion weakness leads to foot drop and a high-stepping gait, which can cause multiple falls and accidents. This case study aimed to assess the efficacy of a customized physiotherapy program in a 50-year-old woman with paraparesis along with left foot drop and post-surgery complications following lumbar decompression and spinal fusion at L3-S1 (lumbar-sacral) level after a jerk experienced by her while working out in the gym. The objective was to determine the impact of individualized exercises on the patient's strength, gait, balance, and pelvic floor function over a 12-week rehabilitation period. The interventions included lower limb exercises (stretching exercises, strengthening exercises, and weight-bearing exercises), pelvic floor exercises, and core stability training. The findings demonstrated significant improvements in the patient's functional outcomes, as evidenced by enhanced scores in the Berg Balance Scale, Manual Muscle Testing, Dynamic Gait Index, Barthel Index, and Stanmore Assessment Questionnaire. Notable progress was observed in the strength, balance, gait, and pelvic floor function, highlighting the positive influence of targeted physiotherapeutic interventions. This case underscores the importance of tailored exercise plans in addressing the complexities of post-surgery challenges, emphasizing the potential for comprehensive recovery and improved overall quality of life through personalized physiotherapy.

The Impact of Physical Therapy After Lumbar Fusion Surgery

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

To determine if outcomes varied between patients based on physical therapy (PT) attendance after lumbar fusion surgery.

SUMMARY OF BACKGROUND DATA

The literature has been mixed regarding the efficacy of postoperative PT to improve disability and back pain, as measured by patient-reported outcome measures. Given the prevalence of PT referrals and lack of high-quality evidence, there is a need for additional studies investigating the efficacy of PT after lumbar fusion surgery to aid in developing robust clinical guidelines.

METHODS

We retrospectively identified patients receiving lumbar fusion surgery by current procedural terminology codes and separated them into 2 groups based on whether PT was prescribed. Electronic medical records were reviewed for patient and surgical characteristics, PT utilization, and surgical outcomes. Patient-reported outcome measures (PROMs) were identified and compared preoperatively, at 90 days postoperatively and one year postoperatively.

RESULTS

The two groups had similar patient characteristics and comorbidities and demonstrated no significant differences between readmission, complication, and revision rates after surgery. Patients that attended PT had significantly more fused levels (1.41 ± 0.64 vs. 1.32 ± 0.54, P =0.027), longer operative durations (234 ± 96.4 vs. 215 ± 86.1 min, P =0.012), and longer postoperative hospital stays (3.35 ± 1.68 vs. 3.00 ± 1.49 days, P =0.004). All groups improved similarly by Oswestry Disability Index, short form-12 physical and mental health subsets, and back and leg pain by Visual Analog Scale at 90-day and 1-year follow-up.

CONCLUSION

Our data suggest that physical therapy does not significantly impact PROMs after lumbar fusion surgery. Given the lack of data suggesting clear benefit of PT after lumbar fusion, surgeons should consider more strict criteria when recommending physical therapy to their patients after lumbar fusion surgery.

LEVEL OF EVIDENCE

Level-Ⅲ.

Enhanced Recovery After Surgery Protocols and Spinal Deformity

The authors outline a review of preoperative, intraoperative, and postoperative considerations surrounding adult spinal deformity. Preoperative management topics include imaging, hemoglobin A1c levels before spine surgery, osteoporotic management, and prehabilitation. Topics surrounding intraoperative management include the use of antibiotics, liposomal bupivacaine, and Foley catheters. The authors also discuss postoperative questions surrounding analgesia, nausea and vomiting, thromboembolic prophylaxis, and early mobilization. Throughout their discussion, the authors incorporate enhanced recovery after surgery protocols to hopefully lead to future discussions regarding optimizing complex spinal patients.

Effect of gluteal muscle strengthening exercise on sagittal balance and muscle volume in adult spinal deformity following long-segment fixation surgery

This study aimed to investigate the changes in gluteal muscle volume and the effects of such changes in spinal alignment as a result of postoperative gluteal muscle strengthening exercise (GMSE) in patients following long-segment fixation for adult spinal deformity (ASD). Eighty-three consecutive patients (average age, 70.1 years) were analyzed. Three-dimensional CT scans were conducted to obtain serial axial gluteus muscle image slices. The size of each muscle area in every image slice was measured by Computer Aided Design and the sum of each muscle area was calculated. At the last follow-up, the sagittal vertical axis was significantly greater in the basic postoperative exercise group (1.49 mm vs. 17.94 mm), and the percentage of optimal sagittal alignment was significantly higher in the GMSE group (97.8% vs. 84.2%). At the last follow-up, the gluteus maximus volume was significantly higher in the GMSE group (900,107.1 cm³ vs. 825,714.2 cm³, p = 0.036). For the increase in muscle volume after 1 year, gluteus maximus and medius volumes showed a significant intergroup difference (+ 6.8% vs. + 2.4% and + 6.9% vs. + 3.6%). The GMSE protocol developed in this study could effectively increase gluteal muscle volume and maintain the optimal sagittal balance in patients with ASD.

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

PURPOSE

This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

STUDY DESIGN

This is a review article.

METHODS

Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

RESULTS

Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

CONCLUSION

Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.

Rehabilitation in adult spinal deformity

Adult spinal deformity causes significant health-related problems such as pain and disability in adults. Currently, there are several non-operative management strategies such as pain medications, physical modalities, exercises, bracing or interventional procedures. Specific exercises including strengthening of back and abdominal muscles, neuromuscular re-education for daily tasks, and active self-correction are vital to improve postural control and spinal stability. Bracing for a few hours a day can help reduce pain and provide spinal stability in adults. In case of severe disability and pain unresponsive to non-operative treatments, spinal fusion with instrumentation is an alternative. Postoperative rehabilitation can help to reduce pain and disability and improve return to activity or work. Protecting the spine early after surgery and timing of initiation of exercises with respect to osseointegration and bone remodeling phases are important principles of postoperative rehabilitation. In this review, rehabilitation in adult spinal deformity is discussed in the light of the literature.

The effects of the addition of motor imagery to home exercises on pain, disability and psychosocial parameters in patients undergoing lumbar spinal surgery: A randomized controlled trial

CONTEXT

Patients who have suffered from persistent symptoms often undergo lumbar spinal surgery (LSS). Motor imagery should be added to postoperative home exercises to reduce patient complaints.

OBJECTIVE

The aim of this study was to compare the effects of home exercise plus motor imagery and only home exercise in patients undergoing LSS.

DESIGN

A randomized controlled study.

SETTINGS

This study was designed by researchers at Dokuz Eylul University.

PARTICIPANTS

Thirty-seven patients undergoing LSS were randomized to motor imagery group (n = 19) and control group (n = 18).

MAIN OUTCOME MEASURES

Pain was measured by Visual Analogue Scale, disability related to low back pain by Oswestry Disability Index, pain-related fear by Tampa Scale of Kinesiophobia, depression by Beck Depression Inventory, quality of life by World Health Organization Quality of Life Scale-Short Form (WHOQOL-BREF). All assessments were repeated in the preoperative period, three weeks after and six weeks after the surgery.

INTERVENTIONS

Motor imagery group underwent home exercise plus motor imagery program applied by voice recording. Control group underwent only home exercise program. Exercise program compliance was monitored by exercise diary and telephone calls once every week.

RESULTS

There was a significant improvement in pain at rest and during activity, disability, kinesiophobia, depression, physical health and psychological sub-parameters of WHOQOL-BREF between preoperative period, and the third week and sixth week in both groups (p < 0.05). When comparing groups for gain scores, there was a more significant improvement in pain during activity in motor imagery group (p < 0.05). Motor imagery should be addressed as an effective treatment after LSS.

Early Rehabilitation Program and Vitamin D Supplementation Improves Sensitivity of Balance and the Postural Control in Patients after Posterior Lumbar Interbody Fusion: A Randomized Trial

BACKGROUND

The introduction of early rehabilitation exercise is the foundation of treatment post-Posterior lumbar interbody fusion (PLIF) surgery, and the search for additional sources of reinforcement physiotherapy seems to be very important.

METHODS

The patients were randomly divided into the vitamin D3 (n = 15; D3) supplemented group and received 3200 IU per day for five weeks before surgery and the placebo group (n = 18; Pl) received vegetable oil during the same time. The patients began the supervisor rehabilitation program four weeks after surgery.

RESULTS

The limits of stability (LOS) were significantly improved in the D3 group after 5 and 14 weeks (p < 0.05), while in the Pl group, progress was only observed after 14 weeks (p < 0.05). The LOS were also higher in the D3 group than in the Pl group after five weeks of supervised rehabilitation (p < 0.05). In the postural stability (PST) test, significant progress was observed in the D3 group after 14 weeks (p < 0.02). In addition, neither rehabilitation nor supplementation had significant effects on the risk of falls (RFT).

CONCLUSIONS

Vitamin D supplementation seems to ameliorate the effects of an early postoperative rehabilitation program implemented four weeks after posterior lumbar interbody fusion. Early physiotherapy treatment after PLIF surgery combined with vitamin D supplementation appears to be a very important combination with regard to the patients' recovery process.

[Postoperative management of weight bearing and rehabilitation after lumbar spinal surgery]

BACKGROUND

Because of the growing trend of lumbar spinal surgery, it is essential for physicians and physiotherapists to develop standardized postoperative treatment. However, currently postoperative treatment after lumbar spinal surgery is controversial.

PURPOSE OF THE STUDY

The purpose of this review article is to make recommendations for the postoperative treatment of lumbar intervertebral disc surgery, lumbar decompression surgery and lumbar spinal fusion surgery regarding mobilization, weight bearing and rehabilitation. These recommendations are based on current evidence and experience in our institution.

MATERIALS AND METHODS

A selective literature research of relevant publications was conducted in Pubmed. The studies are presented in tabular form.

RESULTS

Patient training, accurate information about the postoperative course, information about limitations and stress possibilities as well as pain management seem to have an important role in the final outcome of the operation. Ideally, these procedures should be performed preoperatively or at the latest or repeatedly from the first postoperative day after lumbar spine surgery. Physiotherapy can have a positive impact on the clinical and functional outcome after lumbar disc, decompression and fusion surgery.

DISCUSSION

Due to the heterogeneity of the intensity, duration and form of physiotherapy or rehabilitation, which are listed as interventions in the various studies, it is only possible to draw limited conclusions about general instructions for action on "physiotherapy" after spinal surgery.

The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review

OBJECTIVE The purpose of this study was to provide a systematic and comprehensive review of the existing literature regarding postfusion rehabilitation. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors conducted an exhaustive review of multiple electronic databases. Potential articles were screened using inclusion/exclusion criteria. Two authors independently analyzed these studies using predefined data fields, including study quality indicators such as level of evidence and availability of accepted patient-reported outcomes measures. These findings were synthesized in a narrative format. A third author resolved disagreements regarding the inclusion of a study. RESULTS Twenty-one articles with I or II levels of evidence were included in the review. The authors divided the findings of the literature review into several groups: rehabilitation terminology, timing and duration of postfusion rehabilitation, the need for rehabilitation relative to surgery-related morbidity, rehabilitation's relationship to outcomes, and cognitive and psychosocial aspects of postsurgical rehabilitation. Current evidence generally supports formal rehabilitation after lumbar fusion surgery. Starting physical therapy at the 12-week postoperative mark results in better outcomes at lower cost than an earlier, 6-week start. Where available, psychosocial support improves outcomes. However, a number of the questions could not be answered with high-grade evidence. In these cases, the authors used "best evidence available" to make recommendations. There are many cases in which different types of caregivers use clinical terminology differently. The data supporting an optimal protocol for postfusion rehabilitation remains elusive but, using the data available, the authors have crafted recommendations and a model protocol, which is currently undergoing prospective study. CONCLUSIONS Rehabilitation has long been a common feature in the postoperative management of patients undergoing spinal fusion. Although caregivers from multiple disciplines agree that the majority of their patients will benefit from this effort, the supporting data remain sparse. In creating a model protocol for postlumbar fusion rehabilitation, the authors hope to share a starting point for future postoperative lumbar fusion rehabilitation research.

How does back muscle strength change after posterior lumbar interbody fusion?

OBJECTIVE There is a lack of evidence of how back muscle strength changes after lumbar fusion surgery and how exercise influences these changes. The aim of this study was to evaluate changes in back muscle strength after posterior lumbar interbody fusion (PLIF) and to measure the effects of a postoperative exercise program on muscle strength and physical and mental health outcomes. METHODS This prospective study enrolled 59 women (mean age 58 years) who underwent PLIF at 1 or 2 spinal levels. To assess the effects of a supervised lumbar stabilization exercise (LSE), the authors allocated the patients to an LSE (n = 26) or a control (n = 33) group. The patients in the LSE group performed the LSEs between 3 and 6 months postoperatively. Back extensor strength, visual analog scale (VAS) scores in back pain, and physical component summary (PCS) and mental component summary (MCS) scores on the 36-Item Short Form Health Survey were determined for the both groups. RESULTS Mean strength of the back muscles tended to slightly decrease by 7.5% from preoperatively to 3 months after PLIF (p = 0.145), but it significantly increased thereafter and was sustained until the last follow-up (38.1%, p < 0.001). The mean back muscle strength was similar in the LSE and control groups preoperatively, but it increased significantly more in the LSE group (64.2%) than in the control group (21.7%) at the last follow-up 12 months after PLIF (p = 0.012). At the last follow-up, decreases in back pain VAS scores were more significant among LSE group patients, who had a pain reduction on average of 58.2%, than among control group patients (reduction of 26.1%) (p = 0.013). The patients in the LSE group also had greater improvement in both PCS (39.9% improvement) and MCS (20.7% improvement) scores than the patients in the control group (improvement of 18.0% and 1.1%, p = 0.042 and p = 0.035, respectively). CONCLUSIONS After PLIF, strength in back muscles decreased until 3 months postoperatively but significantly increased after that period. The patients who regularly underwent postoperative LSE had significantly improved back strength, less pain, and less functional disability at 12 months postoperatively.

Quality of life and disability: can they be improved by active postoperative rehabilitation after spinal fusion surgery in patients with spondylolisthesis? A randomised controlled trial with 12-month follow-up

PURPOSE

The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF).

METHODS

Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n = 48) or usual care group (UCG) (n = 50) 3 months after LSF. EG patients had home-based progressive strength and aerobic training program for 12 months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1 year after intervention.

RESULTS

The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p = 0.69). At 1-year follow-up, 25 % of the EG and 28 % of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95 % CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention.

CONCLUSIONS

The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients.

Bench press and push-up at comparable levels of muscle activity results in similar strength gains

Electromyography (EMG) exercise evaluation is commonly used to measure the intensity of muscle contraction. Although researchers assume that biomechanically comparable resistance exercises with similar high EMG levels will produce similar strength gains over the long term, no studies have actually corroborated this hypothesis. This study evaluated EMG levels during 6 repetition maximum (6RM) bench press and push-up, and subsequently performed a 5-week training period where subjects were randomly divided into 3 groups (i.e., 6RM bench press group, 6RM elastic band push-up group, or control group) to evaluate muscle strength gains. Thirty university students with advanced resistance training experience participated in the 2-part study. During the training period, exercises were performed using the same loads and variables that were used during the EMG data collection. At baseline, EMG amplitude showed no significant difference between 6RM bench press and band push-up. Significant differences among the groups were found for percent change (Δ) between pretest and posttest for 6RM (p = 0.017) and for 1 repetition maximum (1RM) (p < 0.001). Six repetition maximum bench press group and 6RM elastic band push-up group improved their 1RM and 6RM (Δ ranging from 13.65 to 22.21) tests significantly with similar gains, whereas control group remains unchanged. Thus, when the EMG values are comparable and the same conditions are reproduced, the aforementioned exercises can provide similar muscle strength gains.