Information for Physios etc
When to refer to my outpatient clinic?
Follow primary care management : Rest for no more than 48 hours with adequate
analgaesia, gentle mobilisation after that. Physiotherapy referral if not settling within 6 weeks.
Consider Neurosurgical Spinal referral if sciatica is not improving at 6 weeks and / or the patient is significantly disabled by leg pain and not settling with analgesia, if there are progressive motor symptoms. A scan will not alter management in the acute phase unless there is significant motor deficit e.g. ankle weakness or arm weakness.
I am often asked to see patients for an MRI scan as symptoms are not settling or there is concern that manipulation / treatment may worsen symptoms or result in a neurological deficit. I am happy to arrange scans for patients and see them with their results and discuss the options available even if surgery is not required.
Refer urgently for red flag symptoms
There is difficulty with micturition.
There is loss of anal sphincter tone and faecal incontinence.
Saddle anaesthesia by the anus perineum or genitals.
Widespread or progressive motor weakness in the legs or gait disturbance.
Pain is constant, progressive and non-mechanical in nature.
Sciatic symptoms are not resolving after four to six weeks of conservative
treatment.
The patient is systemically unwell, unexplained weight loss.
There is widespread neurology.
There is structural deformity.
ESR is abnormal.
Age <20 or onset >55 years
Thoracic pain
Past history of carcinoma, long course of steroids, HIV
How to manage patients after spinal surgery?
Patients in the private hospital will be seen by a physiotherapist the day after surgery and will be taken through a number of exercises and educated about posture / sitting etc prior to discharge from hospital, a booklet will also be provided about exercises to perform at home once discharged. In addition to this there will be a test of mobility on stairs, bathing and dressing prior to going home.
On the NHS ward patients are seen by a nurse specialist before and after surgery, and provided with an information booklet on exercises to perform at home.
Here is the link to the Oxford University Hospitals information booklet for patients having lumbar spine surgery
Perhaps more useful is the OUH booklet on rehabilitation following spine surgery
After Lumbar Spine Surgery
The guidelines below apply to discectomy, laminicetomy and foraminotomy. Generally, the recovery rate for the microendoscopic discectomy I tend to perform are much more rapid.
Initial Rehabilitation 0-6 weeks
- Mobilise independently and safely
- Continue Home Exercise Programme
- Continue good posture and associated spinal mechanics
- Understand pacing concept and self management with respect to work and home activities
- Return to driving as early as 10 days, this is dependent upon mobility and and neurological deficit. There is no DVLA driving suspension associated with this type of surgery, the guidance is to return to driving once recovered from the effects of surgery
Things to be careful of
- Prolonged Sitting. This can be uncomfortable initially, try and limit periods of sitting tp 15-20 minutes for the first few days, gradually build this up. Avoid sitting for over an hour for the first couple of weeks if possible. If patients need to sit to travel or work then try to break up periods of sitting into blocks of time of less than an hour. The advice is to get up and walk and stretch for a few minutes in the break period.
- Try to avoid standing still for a prolonged period of time
- Walking is unlimited, I would encourage patients to walk as much as is comfortable.
- Avoid any heavy lifting for the first 4-6 weeks, for the first few days limit this to < 5kg
- Occasionally there can be a flare up of leg pain after a discectomy or nerve root decompression. This typically happens about 7-10 days after surgery and is thought to be due to a combination of nerve root swelling and early scar formation. Increased analgesia and continued mobilisation is the best means of improving this in most cases. Very rarely if these symptoms persist or worsen, an early outpatient appointment and MRI scan may be appropriate.
Returning to Work
This is variable and depends of the degree of disability before surgery, the rapidity of recovery and the nature of the job.
With the minimally invasive discectomy technique, patients can return to work within 7-10 days of surgery in a phased manner. It is often advised to start part-time and build from there. If there is a long commute to work, or the work is arduous, then it may be unto 6 weeks before a full-time return to work is possible.
After Cervical Spine Surgery
The majority of these patients will have undergone anterior cervical discectomy and either fusion, or more commonly disc replacement surgery.
Patients are mobilised the same day as surgery, there is no need for a cervical collar. Patients suffering with nocturnal neck pain which is usually posture related can use a soft cervical collar at night which will be supplied.
Initial Rehabilitation 0-6 weeks
- Mobilise independently and safely
- Continue Home Exercise Programme, emphasis on maintaining cervical spine range of movement and posture
- Understand pacing concept and self management with respect to work and home activities
- Achieve full shoulder range of movement, exercise deep neck flexors
- Return to driving as early as 10 days, this is dependent upon mobility and and neurological deficit. There is no DVLA driving suspension associated with this type of surgery, the guidance is to return to driving once recovered from the effects of surgery, and the ability to turn the head from side to side
Things to be careful of
- Prolonged Sitting. This can be uncomfortable initially, try and limit periods of sitting tp 15-20 minutes for the first few days, gradually build this up. Avoid sitting for over an hour for the first couple of weeks if possible. If patients need to sit to travel or work then try to break up periods of sitting into blocks of time of less than an hour. The advice is to get up and walk and stretch for a few minutes in the break period.
- Try to maintain a neutral neck position during sleep, a better pillow may help this or a soft cervical support collar
- Walking is unlimited, I would encourage patients to walk as much as is comfortable.
- Avoid any heavy lifting for the first 4-6 weeks, for the first few days limit this to < 5kg
- Occasionally there can be a flare up of arm or neck pain after a discectomy or foraminotomy. This typically happens about 7-10 days after surgery and is thought to be due to a combination of nerve root swelling and early scar formation. Increased analgesia and continued mobilisation is the best means of improving this in most cases. Very rarely if these symptoms persist or worsen, an early outpatient appointment and MRI scan may be appropriate
With the minimally invasive discectomy technique, patients can return to work within 7-10 days of surgery in a phased manner. It is often advised to start part-time and build from there. If there is a long commute to work, or the work is arduous, then it may be unto 6 weeks before a full-time return to work is possible