BRINGING SCIENCE TO TREATMENT

Lumbar disc herniation – Part II: post-discectomy rehab

In the first part of this 2-part series, Chris Mallac looked at the likely signs and symptoms of disc herniation, as well as the selection criteria for micro-discectomy surgery in athletes. In this article, he discusses the lengthy rehab period following a micro-discectomy procedure, and provides a host of strength based exercises

Surgeries to alleviate the symptoms of disc herniation, with or without nerve root compromise, include conventional open discectomy, micro-discectomy, percutaneous laser discectomy, percutaneous discectomy and microendoscopic discectomy (MED).

Other surgical terms have been used in the literature such as herniotomy which is synonymous with fragmentectomy or sequestrectomy. The term ‘herniotomy’ is defined as removal of the herniated disc fragment only, and the ‘conventional discectomy’ as removal of the herniated disc and its degenerative nucleus from the intervertebral disc space.

When surgery is required, minimising tissue disruption and strict adherence to an aggressive rehabilitation regimen may expedite an athlete’s return to play1, which explains why micro discectomy is a favoured surgical procedure for athletes.

Micro discectomy procedures involves removing a small part of the vertebral bone over a nerve root, or removing the fragmented disc material from underneath the compressed nerve root. The procedure is performed through a small 1 to 2 inch incision in the midline of the spine. The erector spinae muscles are retracted off the bony lamina of the spine.

The surgeon is then able to enter the spine by removing the ligamentum flavum that covers the nerve roots. The nerve roots can be visualised with operating glasses or with an operating microscope. The surgeon will then move the nerve root to the side and to then remove the disc material from under the nerve root. It is also sometimes necessary to remove a small portion of the associated facet joint to allow access to the nerve root, and to also relieve pressure on the nerve root stemming from the facet joint. This procedure is minimally invasive as the joints, ligaments and muscles are left intact, and the procedure does not interfere with the mechanical structure of the spine.

Surgical outcomes

Overall, athletes with lumbar disc herniation have a favourable prognosis with conservative treatment; more than 90% of athletes with a disc herniation improve with non-operative treatment. Many show a response to conservative therapy with improved pain and sciatica within 6 weeks of the initial onset2. This suggests that the need to operate immediately may be considered hasty.

However, in the event of failed conservative treatment, or with the pressure of an important upcoming competition, surgery may be required in some cases. Even though it involves surgical treatment, micro-discectomy is reported to have a high success rate – more than 90% in some studies3 4. Patients generally have very little pain, are able to return to preinjury activity levels, and are subjectively satisfied with their results.

The success rate of micro-discectomy is comparable between athletes and non-athletes. The following studies are summarised to highlight the success rate of micro-discectomy procedures:

  1. In a study on 342 professional athletes diagnosed with lumbar disc herniation in sports such as hockey, football, baseball and basketball, it was found that successful return to play occurred 82% of the time, and 81% of surgically treated athletes returned for an additional average of 3.3 years5.
  2. Patients have a 75% chance of recovery from a limb paresis that may be associated with a disc herniation after surgical treatment. If the preoperative paresis was mild then they can expect an 84% chance of full recovery. Patients with more severe paresis have less chance of recovery (55%)6.
  3. Wang et al (1999) in a study on 14 athletes requiring discectomy procedures found that in single level disc procedures, the return to sport was 90%. However when the procedure involved 2 levels enjoyed much less favourable results7.
  4. In a study of 137 National Football League players with lumbar disc herniation, surgical treatment of lumbar disc herniation led to a significantly longer career and higher return to play rate than those treated non-operatively8.
  5. Schroeder et al (2013) reported 85% RTP rates in 87 hockey players, with no significant difference in rates or outcomes between the surgical and nonsurgical cohorts9.
  6. A study by Watkins et al (2003) dealing with professional and Olympic athletes showed the satisfactory outcomes of micro-discectomy in terms of return to play, because elite athletes in general were highly motivated to return to play10. Also, athletes who had single-level microdiscectomy were more likely to return to their original levels of sports activities than were those who had two-level microdiscectomies.
  7. A study by Anakwenze et al (2010) investigating open discectomy in National Basketball Association players demonstrated that 75% of patients returned to play again compared with 88% in control subjects who did not undergo the surgery11. Furthermore, for those players who returned, overall athletic performance was slightly improved or no worse than control subjects.
  8. A recent review found that conservative treatment, or micro-discectomy, in athletes with lumbar disc herniation seemed to be satisfactory in terms of returning the injured athletes to their original levels of sports activities12.

These studies conclude that although a diagnosis of lumbar disc herniation has career-ending potential, most players are able to return to play and generate excellent performance-based outcomes, even if surgery is required.

What is also apparent from research studies is that the level of the disc herniation can also determine prognosis following surgery. Athletes shower a greater difference in improvement between operative and non-operative treatment for upper level herniations (L2-L3 and L3-L4) than for herniations at the L4-L5 and L5-S1 levels. Patients with the upper level herniations had less improvement with non-operative treatment and slightly better operative outcomes than those with lower level herniations13.

There are several possible explanations for these findings. A number of studies have shown that reduced spinal canal cross-sectional area is associated with an increased probability of symptomatic disc herniation, and greater intensity of herniation symptoms. The spinal cross-sectional area is the smallest (therefore has a greater potential for nerve compromise) at the most upper lumbar segment and the cross-sectional area increases further down towards the lower lumbar spine14.

The location of the disc herniation (foraminal, posterolateral or central) may also contribute to these differences. In this study, upper lumbar herniations were more likely to occur in the far lateral and foraminal positions than were those at the lower two intervertebral levels15.

Post-surgical rehab

Following micro-discectomy surgery, the small incision and limited soft tissue trauma allows the patient to be ambulatory reasonably quickly, and they are usually encouraged to start rehabilitation at some point in the 2-6 weeks following surgery.

In a review on the efficacy of active rehabilitation in patients following lumbar spine discectomy, it can be concluded that individuals can safely engage in high or low-intensity supervised or home-based exercises initiated at 4 to 6 weeks following first-time lumbar discectomy16.

Herbert et al (2010) found that with effective post-surgical rehabilitation programs, there was a primary emphasis on lumbar stabilisation exercises17(16). Secondly, positive trials tended to initiate rehabilitation earlier in the postoperative period when compared to negative trials (approximately 4 versus 7 weeks). In their case study, they successfully initiated a lumbar stabilisation program 1 week postsurgery in a 29 year old lady, and this focused heavily on lumbar multifidus (LM) and transverse abdominus (TrA) activation exercises that improved function as measured on an Oswestry scale (see below). This approach also improved pain response and TrA and LM function, measured as muscle function under ultrasound and muscle morphology measured under MRI18.

Outcome measures

The most universally used outcome measure following back injury and/or disc surgery is the Oswestry Disability Questionnaire19. The Oswestry Disability Questionnaire provides a quantitative assessment of low-back pain related disability. Individuals rate the difficulty of 10 functional activities (eg walking, standing, lifting) on a scale from 0 to 5, with higher scores indicating greater disability. This questionnaire is reported to have good levels of test – retest reliability, responsiveness, and a minimum clinically important difference estimated as 6%20 Moreover, treatment success has been defined as a 50% reduction in the Modified Oswestry Disability Questionnaire score21(19).

In terms of physical performance measures following back pain and/or disc surgery, a commonly used clinical test is the Beiring-Sorensen Back Extension test (see Figure 1)22. This test is performed in a prone/horizontal body position with the spine and lower extremity joints in neutral position, arms crossed at the chest, lower extremities and pelvis supported with the upper trunk unsupported against gravity.

Rehabilitation program

Presented below is a five-stage rehabilitation plan. The stages involved in rehabilitation are:

  1. Optimise tissue healing – protection and regeneration
  2. Early loading and foundation
  3. Progressive loading
  4. Load accumulation
  5. Maximum load

This program has been designed for a field hockey player having had a L5/S1 lumbar spine discectomy. Although the progressions from one stage to the next are driven by the exit criteria related to that stage, it would be expected that the athlete would progress from post-surgery to ‘fit to compete’ in around 12-13 weeks.

The key features in each stage are as follows:

Optimise tissue healing – protection and regeneration In this phase it is expected that the athlete will remain relatively quiet for 2-3 weeks post surgery. This allows for full tissue healing to occur, including scar tissue maturation. The athlete is allowed to fully mobilise in full weight-bearing; however care must be taken with any flexion and rotation movements and no lifting is allowed.

The athlete can start with the physiotherapist with the aim to manage any gluteal and lumbar muscle trigger points. The athlete can initiate very gentle nerve mobilisation techniques and he/she is taught how to engage the TrA and LM muscles (see Figures 2a and 2b). If the physiotherapist has access to a muscle stimulator (Compex), this can be used in atrophy mode on the lumbar spine multifidus and erector spinae. The key criteria to exit this early stage are pain-free walking and an Oswestry Disability Score of 41-60%.

Early loading and foundation

The primary feature of this stage is that the athlete can start early and low-load strength exercises focusing on muscle activation in a neutral spine position, along with a progressive range of motion program to improve lumbar spine flexion, extension and rotation. In this stage the physiotherapist will guide the athlete through safe and gentle stretches for the hip quadrant muscles such as the hip flexors, gluteals, hamstrings and adductors. The athlete also continues gentle neuro-mobilisation exercises to progress the mobility of the sciatic nerve – a concern in this condition as neural tethering is a possibility due to the scar tissue formation caused by the surgical procedure.

The athlete is also encouraged to begin hydrotherapy in the form of walking in water (waist high) and swimming fitness. In addition, he/she should start a series of low level muscle activation drills in this stage (see table), which is performed every day. An important learning movement in this stage is the ‘broomstick bow’ (Figure 3). This exercise teaches the athlete to hip flex (hip hinge) whilst maintaining a neutral spine. The neutral spine is maintained by using a light broomstick aligned with the spine with the contact points being the occiput, the 6th thoracic vertebrae (T6) and the posterior sacrum.

Example rehabilitation program
Name: Mr X
Injury Date: 23rd July 2015
Injury: L5/S1 Micro-discectomy
STAGE ONE: OPTIMISE TISSUE HEALING - PROTECTION AND REGENERATION
Approx 14-20 days
LIMITATIONSAllowed full weight bearing
Care with any spine flexion and/or rotation movements No lifting
MANAGEMENT PLANDetailsExit criteria
TREATMENTGentle soft tissue myofascial glutes and hip muscles
Gentle self administered neural stretches start
2 week ROM and load limitation OBPS painfree walking
REHABNo direct abdominal loading
Learn TrA activation and LM activation exercises
COMPEX if available- atrophy mode
S + CNil
Reminders1. Deep relaxed breathing with all exercises.
2. Set inner unit before you lift or change a position Neutral-Brace-Breathe
STAGE TWO: EARLY LOADING + FOUNDATION
Approx 2 weeks
AIMSRestore range of movement (F/E/ROT)
Start early loading - low load and low speed
Prevent adhesions and neural tethering
LIMITATIONSNo heavy lifting
No strong contractions
No aggressive outer range stretching
MANAGEMENT PLANDETAILSEXIT CRITERIA
TREATMENTMyofascial releases paraspinals and gluteals
Stretch - hamstrings, adductors, hip flexors,
rotators
Gentleneural stretches
Manual therapy to pelvis
OBPS 21-40%
REHABEVERY DAY

1. BIRD-DOG 1 sec pause 10 x 10secs each way
2. Supine DL Bridge 10 x 10 secs
3. Broomstick bows 3 x 15
4. Sidelie plank 3 x 20 secs each side
Continue with Compex on atrophy mode for multifidus and paraspinals
OBPS 21-40%
S + CStart pool walking and swimmingOBPS 21-40%
STAGE THREE: PROGRESSIVE LOADING
Approx 2 weeks
AIMSContinue range of movement (F/E/ROT)
Progressive loading - moderate load and low speed
Prevent adhesions and neural tethering
LIMITATIONS
MANAGEMENT PLANDETAILSEXIT CRITERIA
TREATMENTMyofascial releases paraspinals and gluteals
Stretch - as above + QL and obliques
Moderate neural stretches
Manual therapy to pelvis
OBPS 21-40%
REHAB1. Prone alternating arm and leg (3 sec hold) 3 x 10 each side
2. Standing wall extensions (ball against neck) 10 x 10secs
3. Broomstick bow (band resistance) 3 x 15 reps
4. Side plank 3 x 20 secs each side
5. Standing twisties (small range) 3 x 10 each side
6. Crook lie pelvic rotation (band) 3 x 10 each way
OBPS 21-40%
S + CPool running and swimmingOBPS 21-40%
STAGE FOUR: LOAD ACCUMULATION
Approx 4 weeks
MANAGEMENT PLANDETAILSEXIT CRITERIA
TREATMENTContinue with triggers and neurals
REHABALTERNATE DAYS

1. SWISS ball holds 3 x 20secs
2. RDL (bar) 3 x 10 reps
3. Kneeling hip thruster 3 x 15 reps
4. Side plank 3 x 30 secs each
5. Standing twisties (mid range) 3 x 10 each way
6. Crook lie pelvic rotation 3 x 10 each way
7. Deadbug antirotation press 3 x 10 each way
8. Quadruped walk outs 3 x 10 (as far as you can).
OBPS 0-20% Sorensen Test 90 secs
S + CWeek 1: Gentle running – run 30m, walk 20m – 10 minutes max
Week 2/3: Build running volume
Week 4: Build to sprint speed and light skills training
Max velocity running as per pre-injury
STAGE FIVE: MAX LOAD
Approx 2 weeks
TREATMENTCONTINUE WITH ALL SOFT TISSUE AND NEURALSEXIT CRITERIA
STRENGTHALTERNATE DAYS

1. Back extension holds 3 x 45 secs
2. Supine hip thruster 3 x 10
3. Barbell good morning (neutral spine) 3 x 10
4. Standing twisties (full range) 3 x 10 each way
5. Crook lie pelvic rotation 3 x 10 each way
6. Deadbug antorotation press 3 x 10 each way
7. Elbow plank 3 sets of 5 deep breaths
OBPS 0-20% Sorensen test 180 seconds
S + CStart moderate skills and team phase play
Progress fitness and gym strength
Confidence in all hockey related skills

Progressive loading

In this third phase the athlete continues with a range of movement progression and the physiotherapist progresses manual therapy on the pelvis and lumbar spine. Neuro-mobilisation techniques are also progressed. The major change in this stage is the progression of load on many of the strength and muscle control exercises. Two exercises to mention here are the ‘standing twisties’ and the ‘crook lying pelvic rotation’ exercise (Figures 4 and 5). These movements are the introductory rotation based movements. The primary progression regarding fitness drills is that the athlete can start pool running drills.

Load accumulation

This is the stage where the athlete starts to progress the load in strength-based exercises. Resistance is used in the form of barbell load and band resistance. Three unique exercises performed here are the ‘kneeling hip thruster’, ‘deadbug antirotation press’ and the ‘quadruped walkout’ (Figures 6-8 – described in detail in the online database of exercises). The athlete also starts running drills at this stage and it would be expected that as well as building running volume, the athlete should progress over four weeks to close to full sprint speeds. This is also the stage whereby they would commence light to moderate sports specific skills drills. The other feature of this stage is that the athlete commences the ‘Sorensen test’ exercise (Figure 9) and it would be expected that they can maintain the position for a minimum of 90 seconds before progressing to the next stage.

Maximum load

In this final stage, the athlete progresses all strength and core exercises to maximum loads, and they work with the fitness coach on returning to squat and functional gym lift movements. Skill progression is also advanced along with sprint and agility drills. The final exit criteria prior to progressing to unlimited training and strength work is they must maintain the ‘Sorensen test’ for 180 seconds and their self reported Oswestry scale should be somewhere between 0-20%.

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