Post Laminectomy (Lumbar Spine) Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for patients following a lumbar laminectomy. This protocol is a guideline and should be adapted based on individual patient presentation, surgical findings, pre-operative condition, and progress during rehabilitation. Close communication with the referring surgeon is crucial. Patient education and adherence are paramount to successful outcomes.

Pathophysiology

A laminectomy involves the surgical removal of part or all of the lamina (the posterior arch of the vertebra) to relieve pressure on the spinal cord or nerve roots. This pressure is commonly caused by spinal stenosis, disc herniation, or bone spurs. The procedure aims to decompress the neural elements, reducing pain and improving neurological function. Post-operatively, the stability of the spine may be slightly compromised, and the paraspinal muscles are often weakened and painful due to the surgical approach. Scar tissue formation around the surgical site is also a potential concern.

Phase I: Protection (Weeks 0-4)

Goals: Protect the healing tissues, reduce pain and inflammation, initiate gentle ROM exercises, and educate the patient on proper body mechanics.

• Precautions: Avoid excessive bending, twisting, and lifting (BLT) – generally lifting restrictions are set by the surgeon (typically 5-10 lbs). No prolonged sitting or standing. Log roll when transitioning in/out of bed.
• Pain Management:
  • Modalities: Ice, electrical stimulation (TENS), heat (as tolerated and approved by surgeon).
  • Medications: As prescribed by physician.
• Patient Education:
  • Proper body mechanics for ADLs (Activities of Daily Living).
  • Log rolling technique.
  • Posture awareness and correction.
  • Importance of bracing (if prescribed by surgeon).
  • Home Exercise Program (HEP) instruction and demonstration.
• Exercises:
  • Ankle pumps, quad sets, gluteal sets, heel slides.
  • Pelvic tilts (emphasizing neutral spine).
  • Diaphragmatic breathing exercises.
  • Gentle cervical ROM (if not contraindicated).
• Ambulation: Begin with short walks (5-10 minutes) several times a day, gradually increasing distance and duration as tolerated. Use assistive devices (cane, walker) as needed for balance and stability.

Phase II: Loading (Weeks 4-8)

Goals: Gradually increase spinal loading, improve core stability, restore ROM, and begin light strengthening exercises.

• Precautions: Continue to avoid excessive BLT. Monitor for signs of re-injury (increased pain, radicular symptoms). Progress exercises gradually.
• Pain Management: Continue with modalities as needed.
• Exercises:
  • Progress Phase I exercises as tolerated.
  • Bridging exercises (single leg bridging as tolerated).
  • Partial abdominal curl-ups (emphasizing proper technique).
  • Bird dog exercises (quadruped position, alternating arm/leg lifts).
  • Side planks (modified if needed, progressing to full planks).
  • Standing lumbar extension exercises (Mckenzie approach – as appropriate based on symptoms and surgeon approval).
  • Gentle stretching of hip flexors, hamstrings, and paraspinal muscles.
• Aerobic Exercise:
  • Walking (increase distance and speed).
  • Stationary cycling (low resistance).
  • Elliptical trainer (low impact).
• Manual Therapy: Gentle soft tissue mobilization to address muscle guarding and scar tissue restrictions (as appropriate and approved by surgeon).

Phase III: Return to Function (Weeks 8+)

Goals: Restore full functional capacity, improve strength and endurance, and return to desired activities.

• Precautions: Continue to use proper body mechanics. Avoid activities that provoke symptoms. Gradually increase activity levels.
• Exercises:
  • Progress Phase II exercises, increasing resistance and complexity.
  • Squats (bodyweight, then with light weights).
  • Lunges (forward, lateral).
  • Deadlifts (light weight, emphasizing proper form).
  • Rows (using resistance bands or light weights).
  • Overhead press (light weight, focusing on core stabilization).
  • Plyometric exercises (jumping, hopping – if appropriate and approved by surgeon).
• Functional Training:
  • Simulate work-related activities.
  • Practice lifting and carrying objects with proper technique.
  • Improve balance and coordination.
  • Endurance training to improve work tolerance.
• Sport-Specific Training (if applicable): Gradually reintroduce sport-specific activities, focusing on proper technique and biomechanics.
• Discharge Planning: Provide the patient with a comprehensive home exercise program and strategies for preventing future back pain.

Common Special Tests

These tests can be used throughout the rehabilitation process to assess the patient's condition. Remember to interpret test results in conjunction with the patient's history and other clinical findings.

• Straight Leg Raise (SLR) Test: Assesses for nerve root irritation (e.g., disc herniation).
• Slump Test: More sensitive test for nerve root irritation than SLR.
• Prone Instability Test: Assesses for lumbar segmental instability.
• Quadrant Test: Assesses for facet joint pathology or stenosis.
• FABER Test (Patrick's Test): Assesses for hip joint or sacroiliac joint pathology.
• Muscle Strength Testing (Myotomes): To assess neurological integrity related to specific nerve roots. Examples: L4- ankle dorsiflexion, L5 - great toe extension, S1 - ankle plantarflexion.
• Sensory Testing (Dermatomes): To assess neurological integrity related to specific nerve roots.
• Reflex Testing (Deep Tendon Reflexes): To assess neurological integrity. Examples: Patellar tendon reflex (L4), Achilles tendon reflex (S1).

Disclaimer: This protocol is a general guideline and should not be considered a substitute for professional medical advice. Always consult with a qualified healthcare professional for diagnosis and treatment of any medical condition.