RNOH Physiotherapy Department

(020 8909 5820)

Rehabilitation guidelines for patients undergoing spinal surgery
As a specialist orthopaedic hospital we recognise that our broad and often complex patient group
needs an individualised rehabilitation approach. This takes into consideration the multi factorial
components contributing to back pain.
Milestone driven
These are milestone driven guidelines designed to provide an equitable rehabilitation service
to all our patients. They will also limit unnecessary visits to the outpatient clinic at the RNOH
by helping the patient and therapist to identify when specialist review is required.
Rehabilitation guidelines for patients undergoing lumbar discectomy
Indications:
Leg pain secondary to nerve root compression (radiculopathy), often with lower back
pain
Possible complications of surgery:
Infection [<1%]
Nerve damage [less than 1%]
Ongoing back/leg pain [5-10% long term]
Dural tear [<5%, higher if prior surgery]
Recurrence [<10% at up to 10 years]
Expected outcome:
Patient reports good relief of leg pain and a significant decrease in back pain.
Back pain can persist and sitting tolerance can be decreased. Improvements can
continue for up to 18 months post operatively
Pre-operatively
When practical the patient will be seen pre-operatively and with consent, the following
assessed as indicated:
Current functional levels
General health
Social/work/hobbies
Posture
Functional R.O.M., e.g. dressing/bending, sitting, sit stand and stairs if appropriate
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Review date 2014

Gait/Mobility including any walking aids, corsets etc

Neurological function and pathodynamics
Post-op expectations, especially long-term self-management and precautions
Patient information leaflet issued to the patient and exercises taught with warnings
Post-operative management explained and log-rolling practised

Post-operatively
Always check operation notes and post-op instructions.
Discuss any deviation from routine guidelines with team concerned.
NB: If dural tear intra-operatively, patient may complain of intense, severe low
pressure headache (i.e. worse on sitting up). In this instance, mobilise as comfort
allows, only after period of flat bed rest prescribed by surgeon (usually between 48
hours and 5 days).
Initial rehabilitation phase: 0 4 weeks
Goals:
1. Mobilise independently and safely
2. Understand good posture and spinal mechanics
3. Independent in home exercise programme (HEP)
4. Understand self-management and pacing concept particularly with ADL and PDL
5. Return to driving at 4-6 weeks
Precautions
For the first 4 weeks, whilst the initial post operative pain settles and the disc begins to heal,
it is advised to be careful with some activities. A sensible approach is advised and a gradual
increase in activities recommended .Current evidence supports a steady paced up increase
in activity whilst respecting post operative soreness, disc healing times, neural sensitivity and
patients previous level of fitness.
1. Sitting should be gradually built up during activities such as eating or relaxing and
should be guided by the development of symptoms. A limit of 15-20 mins is sensible
for the first few days, and once this is comfortable it can be increased gradually. If a
long journey is unavoidable e.g. to get home from hospital, the patient can recline as
a passenger and ensure breaks every 20-30 minutes to mobilise.
2. Avoid prolonged-sitting [>1 hour] for about 4 weeks until neural sensitivity has settled
and strength improved and can then try with care, e.g. in the bath.
3. Walking is unrestricted, and should be increased day by day as comfort allows.
4. Caution with flexion in sitting and standing for the first 4 weeks.
5. Avoid driving until about 3-4 weeks post-operation, or longer if there is a significant
loss of function or sensation in one or both legs/feet. The patient should be able to sit
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disectomy.doc
H.Nafis Updated July 2007/2010/2011/12
Review date 2014

comfortably in the driving position ,drive safely ,turn to look in the mirror and have 100
% reaction times for an emergency stop.
6. For the 1st few days only lift about 1kg (a full kettle ) and then slowly increase .
7. Continue to log-roll until neural sensitivity has settled and strength improved which
takes about 2-4 weeks.
Treatment
Pain relief: Ensure adequate analgesia; suitable positioning.
Patient education: Advice given on sitting relating to patients function.
Reinforce self-management and building up of activities appropriately.
Precautions as above
Postural awareness: Advice given on the importance of good posture especially in sitting.
Exercises: Teach core stability exercises in lying and in functional positions.
Teach lying to standing through side-lying. Teach exercises from patient information leaflet.
Mobility: Ensure patient is independent with transfers and mobility, including stairs if
appropriate. Pre- operative status will affect outcome. If a walking aid is given and was not
used pre-operation, the surgical team will be informed.
On discharge home from hospital
Ensure all patients have outpatient physiotherapy arranged.
The patient should aim to achieve:
1. Independent and safe mobility, including stairs if appropriate
2. Independent and safe in home exercise programme
3. Independent in transfers
Milestones to progress to next rehab phase:
1. Adequate pain relief
2. Basic core stability
3. Starting to build-up normal activities
4. Normal gait pattern
5. Increasing sitting tolerance

Recovery/rehabilitation phase: 4 20 weeks

Goals:
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Review date 2014

1.
2.
3.
4.
5.

Increase normal activity and function

Return to work at 4 weeks (see restrictions below)
Return to sport/gym at 4 weeks (see restrictions below)
Optimise normal movement
Increase lifting

Restrictions
These are designed to allow the disc to continue to heal and the neural sensitivity to settle. It
is balanced against the evidence supporting the return to early function and activity which
decreases the risk of a poor outcome.
1. An appropriate return to work should be planned for about 4 weeks and it should be
phased /part time if appropriate especially if there is a lot of travelling/sitting. If the job
involves heavy manual work the aim would be to return by 3 months with a planned
phased return if appropriate
2. Avoid heavy lifting [>10 kg] until 12 weeks post-operation or until the surgeon advises.
3. Contact sports should be avoided until about 3-4 months or at the surgical teams
discretion
Treatment
Pain relief: Ensure appropriate amount of exercise and activity with appropriate analgesia.
Patient education: Pacing activities within appropriate restrictions. Ensure patient not over
or under exercising. Exercise cautiously particularly with previously aggravating activities.
Postural awareness and encourage normal movement patterns. Advice on healing times of
disc; not smoking and body weight control.
Postural awareness: Reinforce importance of good posture especially when sitting, e.g. at
work, driving and in the bath. Advise on good practice of changing posture regularly.
Exercise: Progress core stability to include leg slides, gym ball, balance work and
proprioceptive training. Progress functional range of movement, avoiding sustained flexion
and extension. General fitness advice, e.g. swimming-start initially with backstroke and addin other strokes as long as comfortable. Can attend gym and return to sport (see
restrictions). Trunk, upper and lower limb conditioning as relevant to patients goals.
Manual therapy:
appropriate.

Soft

tissue/joint

mobilisations/neuropathodynamics

treatment

Milestones to achieve by 20 weeks

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H.Nafis Updated July 2007/2010/2011/12
Review date 2014

as

Recovery can continue up until 18 months so expectations must be individual and realistic:
1. Achieve realistic goals set by patient
2. Return to normal activities
3. Minimal leg pain
4. Continuing with paced exercise programme and good posture
Failure to meet milestones:
Refer back to surgical team
Continue with outpatient Physio whilst still making progress
Consider Referral for rehab/Active back programme
Failure to progress
If a patient is failing to progress, then consider the following:
Possible problem
Leg pain

Neurological
deterioration
Inflamed wound
Exercises painful

Causes
Neural sensitivity

Action
Can take up to 4 weeks to decrease
Ensure adequate analgesia
Keep exercises pain-free
Decrease sitting times slightly
Progressing activities too quickly or too slowly
If persists, refer back to surgical team
Further
disc Review pre-operative neuro status
complications
Closely monitor and inform surgical team
Possible infection
Refer to surgical team or GP
Poor technique
Irritable back still

Patient not exercising Poor

patient
regularly enough or compliance
following restrictions
Altered
neuropathodynamics
Back pain
Common.
Spinal
motion
segment changes.
Check not returning
to
activities
too
quickly
Check technique

Alter exercise programme and correct technique

Ensure exercises are focussed and relate to function
Explain importance of good muscle function and posture
to avoid flare-ups
Assess and treat accordingly
Ensure adequate analgesia
Ensure exercises are appropriate and not increasing too
quickly or too slowly
Not sitting or walking too much
Reassure it can be common

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H.Nafis Updated July 2007/2010/2011/12
Review date 2014

Headaches

Dural tear (1st 4

weeks )
Postural or Altered
neuropathodynamics
other pathology

If has dural tear during surgery, this can take up to 2

weeks to settle
If onset is after 4 weeks post-op, assess and treat if
appropriate and liaise with referrer

Summary of evidence for physiotherapy guidelines

A comprehensive literature search was carried out to identify research relating to
rehabilitation following lumbar discectomy surgery. After reviewing the articles and
information found including discussion with other physiotherapists on the interactive CSP
website ,the physiotherapy guidelines were produced on the best evidence available.
1.Danielsen,JM et al. Early aggressive exercise for post operative rehabilitation after
discectomy. Spine 2000. Vol 25(8) p1015-1020
2.Scrimshaw S,Maher C Randomised Controlled Trial of Neural Mobilisation after Spinal
Surgery.Spine 2001,vol26 (24) p2647-2652
3.Kjelby-Wendt G,Styf J, Early Active Training after lumbar discectomy :A Prospective
,Randomised and controlled study Spine 1998 vol 23 (21) pp2345-2351
4.Carragee E,Helms E, OSullivan G Are postoperative Activity restrictions necessary after
posterior lumbar discectomy? A prospective study of outcomes in 50 consecutive cases.
Spine 1996 vol 21 (16) p1893-1897
5.Bradley A,Lui W, Herkowitz H,Panjabi M ,Tech ,Guiboux J Effect of anular repair on the
healing strength of the intervertebral disc; a sheep model Spine 2000 ,vol 25 (17) p21652170
6.Ostelo-RWJ,de Vet HCW,Waddell-G,Kerckhoffs,Leffers-P,Van-Tulder-MW
Rehabilitation after lumbar disc surgery
The Cochrane Library ,2006 no1 (CD003007)
7.Sparkes V., Laing .J.C., Prevost,A.T. , Bradley M.
The effect of a muscle stabilisation programme on function and the cross-sectional area of
the lumbar multifidus after surgery for prolapsed intervertebral disc
Physiotherapy 2004 vol 2004 p167

In association with the UCL Institute of Orthopaedics and Musculoskeletal Science

I:\Website\2012\Physiotheraphy rehabilitation guidelines\October 2012\Helen Nafis\Physiotherapy rehabilitation guidelines - lumbar
disectomy.doc
H.Nafis Updated July 2007/2010/2011/12
Review date 2014