Back Surgery

General Information
Case no.	19.A Back Surgery
Authors	Josh Fede, PT, DPT, MTC, CSCS, USATF-L1 Brian Goonan, PT, DPT, Board Certified Clinical Specialist in Orthopaedic Physical Therapy Scott Siverling, PT, DPT, Board Certified Clinical Specialist in Orthopaedic Physical Therapy, Fellow of the American Academy of Orthopedic Physical Therapy
Diagnosis	Lower back, right lateral hip, and right foot pain
Setting	Acute care hospital
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Understand any postoperative complications and when you refer back to physician. Understand postoperative restrictions for this particular surgery and be able to provide education to the patient. Identify goals, provide education, discuss support and home setup, and prepare for discharge.

Medical
Chief complaint	Chronic right-sided lower back pain, lateral hip pain, and foot pain
History of present illness	The patient is a 51-year-old man who reports approximately 2.5-year history of progressive lower back pain with right lower extremity (RLE) pain and weakness. As his sensation diminished in the right lower leg, his gait was adversely affected, and ultimately, he underwent an L5–S1 lumbar microdiscectomy 1 year ago. He recently went back to his surgeon for 1-year follow-up. Currently, he continues to have radicular symptoms down his RLE, including “shooting” pain down into the heel of his foot, numbness along the lateral and posterior aspects of the RLE, and gross weakness. He feels that he has exhausted conservative management with previous physical therapy and pain management. He discussed surgical options with his physician, and his physician recommended a multilevel fusion (L4–L5/L5–S1) in order to relieve his radicular symptoms. Benefits and risks of the surgery were discussed with the patient and he agreed to move forward with the elective procedure.
Past medical history	Hypertension, hypercholesterolemia, gastroesophageal reflux disease (GERD)
Past surgical history	L5–S1 discectomy, cholecystectomy, appendectomy
Allergies	None
Medications	Lisinopril, Lipitor, Omeprazole
Precautions/orders	Activity as tolerated

Social history
Home setup	Lives in a two-story home with his wife and three children. Bedroom is on the second floor. Has a guest bedroom and half bath on the first floor.
Occupation	Financial advisor
Prior level of function	Independent with functional mobility and activities of daily living (ADLs). Married father of three children. (+) driver
Recreational activities	Occasionally plays basketball in the summer. Works out at the gym once or twice times a week but has not exercised in over 1 year.

Vital signs	Hospital day 1, postoperative, ward
Blood pressure (mmHg)	135/84
Heart rate (beats/min)	85
Respiratory rate (breaths/min)	20
Pulse oximetry on room air (SpO₂)	98%

Fig. 19.1 (a,b) Back brace typically used postoperatively for a spinal fusion surgery. The brace helps act as a reminder through proprioceptive feedback to limit bending and rotation immediately after surgery. Additionally, the brace offers compression, which can help with post-op pain and soreness.

Medical management	Hospital day 1: postoperative, ward
Medications	1. Acetaminophen prn pain 2. Ibuprofen prn pain 3. Oxycodone prn pain
Neurosurgery team	1. Monitor hemoglobin (Hgb) and hematocrit (Hct) with complete blood count (CBC). 2. Monitor for signs and symptoms related to deep vein thromboses (DVTs). 3. Manage pain, continue current regimen. 4. Incision clear/dry/intact
Precautions	Activity as tolerated Fall risk Spinal precautions: Avoid bending and twisting. Avoid lifting, pushing, and/or pulling > 20 lb for 2 weeks Avoid prolonged sitting > 30 min Brace (Fig. 19.1) Full weight bearing (FWB) bilateral lower extremity (BLE). Telemetry

Lab		Reference range	Hospital day 1: postoperative, ward
CBC	White blood cell	5.0–10.0 × 10⁹/L	6.4
	Red blood cell	4.1–5.3 million/mm³	4.7
	Hgb	14–17.4 g/dL	15
	Hct	42–52%	47%
	Platelets	140,000–400,000/μL	250
Basic metabolic panel	Glucose	70–100 mg/dL	90
	Hgb A1C	< 5.7%	6.7%
	Cholesterol	< 200 mg/dL	210
	low-density lipoprotein	< 100 mg/dL	130
	High-density lipoprotein	> 40 mg/dL	80
	Blood urea nitrogen	6–25 mg/dL	25
	Creatinine	0.7–1.3 mg/dL	1.2
	Potassium	3.7–5.1 mEq/L	4
	Sodium	134–142 mEq/L	136
	Chloride	98–108 mEq/L	100
	Calcium	8.6–10.3 mg/dL	8.4
	Magnesium	1.2–1.9 mEq/L	1.4

Pause points
Based on the above information, what are the priorities: Diagnostic tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priorities:

Diagnostic tests and measures?
Outcome measures?
Treatment interventions?

Hospital Day 2, Post-Op Day 1, Ward: Physical Therapy Examination
Subjective
Patient reports that he is “sore” along the lumbopelvic hip complex and bilateral sacroiliac joint regions. Additionally, he reports that he still feels “numbness” along the shin and dorsum of the foot, with occasional “shooting” pains along the same distribution. “My surgeon said this is normal, and it will return.”
Objective
Vital signs	Pre-treatment		Post-treatment
Blood pressure (mmHg)	130/82		132/84
Heart rate (beats/min)	75		77
Respiratory rate (breaths/min)	18		21
Pulse oximetry on room air (SpO₂)	98%		96%
Pain	2/10 along spinal incision		5/10 along spinal incision
General	Patient supine in bed, no apparent distress. Patient’s wife at bedside. Lines notable for intravenous line access. Dressing over the incision clean, dry, and intact.
Head, ears, eyes, nose, and throat	(–) congestion, sore throat, or otalgia
Cardiovascular and pulmonary	(–) chest pain, palpitations, edema, aspiration, shortness of breath, orthopnea. (–) cough, congestion, wheezing, or sputum production.
Gastrointestinal	Unremarkable
Genitourinary	(–) dysuria, frequency, urgency, blood in urine
Musculoskeletal	Range of motion (ROM)	Right	Left
		Upper extremity (UE): within functional limit (WFL). Hip flexion: 0–90 degrees Hip abduction: 0–26 degrees Hip external rotation: 0–25 degrees Hip internal rotation: 0–15 degrees Knee flexion: WFL Knee extension: WFL Ankle dorsiflexion: WFL Ankle plantar flexion: WFL	UE: WFL Hip flexion: 0–105 degrees Hip abduction: 0–35 degrees Hip external rotation: 0–30 degrees Hip internal rotation: 0–23 degrees Knee flexion: WFL Knee extension: WFL Ankle dorsiflexion: WFL Ankle plantar flexion: WFL
		Lumbar ROM limited by postoperative restrictions.
	Strength	UE: WFL Hip flexion: > 3 + /5 as demonstrated by functional mobility. Hip abduction: > 3 + /5 as demonstrated by functional mobility. Knee extension: 3 + /5 Knee flexion: 4/5 Ankle dorsiflexion: 3/5 Ankle eversion: 3 + /5 Ankle plantar flexion: 4/5 Great toe extension: 4/5	UE: WFL Hip flexion: > 3 + /5 as demonstrated by functional mobility. Hip abduction: > 3 + /5 as demonstrated by functional mobility. Knee extension: 5/5 Knee flexion: 5/5 Ankle dorsiflexion: 5/5 Ankle eversion: 5/5 Ankle plantar flexion: 5/5 Great toe extension: 5/5
	Special tests	(+) Flexion, abduction, and external rotation (FABER). (+) Active Straight Leg Raise (SLR) Test. Five Times Sit-to-Stand: 3 with rolling walker assist (untimed due to patient not completing 5 repetitions).
	Flexibility	(+) Tibial and dorsal foot pain with passive SLR at approximately 30 degrees.
Neurological	Balance	Sitting, static: supervision Sitting, dynamic: contact guard assistance. Limited range due to brace. Standing, static: supervision with rolling walker. Standing, dynamic: contact guard assistance with rolling walker. Single limb stance: unable to stand on RLE > 1 second due to decreased strength and increased pain.
	Cognition	Alert and oriented × 4
	Coordination	Finger to nose: intact bilaterally
	Cranial nerves	II–XII: intact
	Reflexes	Patellar: 2 + bilaterally Achilles: 1 + on right, 2 + on left
	Sensation	Left lower extremity (LLE): intact to light touch. RLE: diminished light touch and pinprick at L5 and S1 dermatome levels.
Functional status
Bed mobility	Rolling either direction: minimal assistance Supine to/from sit: minimal assistance
Transfers	Sit to/from stand: contact guard assistance with rolling walker.
Ambulation	Ambulated × 50 feet with contact guard assistance and rolling walker, verbal cues provided for upright posture. Gait deviations notable for decreased cadence.
Stairs	Ascend/descend five steps with contact guard assistance and minimal assist. Demonstrated step-to pattern

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I want to go home. I want to walk without a walker.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☑ Physical therapist’s	Will continue to follow daily for functional mobility training within the confines of spinal precautions and newly implemented brace. Throughout, will educate and reinforce postsurgical precautions, importance of brace. Prior to discharge, will institute a walking program and provide a home exercise program.

Bloom’s Taxonomy Level	Case 19.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. What education should the physical therapist provide to the patient regarding his diminished sensation? 5. What strategies can be provided for the patient in order to follow his post-op precautions and mobilize safely once he has been discharged to his home?
Analyze	6. How is BLE sensation tested to definitively determine the area of diminished sensation? 7. Considering this patient has restrictions with spinal flexion and rotations, what would be an appropriate technique for supine to sit transfer?
Apply	8. What functional tasks should be addressed in daily physical therapy until the patient’s discharge? 9. How should functional progression be measured?
Understand	10. What therapeutic exercise would be appropriate to prescribe on this patient’s initial evaluation? 11. What education can be provided to the patient to help diminish the risk of DVT and pulmonary embolism?
Remember	12. If the patient were to complain of mid-thoracic pain, especially after meals, what might be suspected? 13. Besides difficulty with gait and lower extremity weakness, what complaints/signs might the patient have if there is cauda equina involvement?

Bloom’s Taxonomy Level	Case 19.A Answers
Create	1. The patient is a 51-year-old man status post surgical lumbar fusion. He was previously independent with functional mobility and ADLs. He currently exhibits decreased BLE ROM, RLE strength, RLE sensation, and impaired balance. This, in combination with his newly implemented spinal precautions, brace, and pain, is contributing to his limitations in mobility. He currently requires contact guard—minimal assistance and use of rolling walker to mobilize. He will benefit from continued therapeutic interventions with integration of spinal precautions and brace; also, specific education on an exercise regimen will maximize functional mobility and safety. Will continue to follow. 2. Short-term goals: Patient will perform Five Times Sit-to-Stand in < 15 seconds within 3 days to improve BLE strength. Patient will independently perform supine to/from sit within 3 days to improve functional mobility for home. Patient will independently verbalize and implement 3/3 spinal precautions 100% of the time within 3 days to protect his spine. 3. Long-term goals: Patient will ambulate 150 feet with distance supervision and rolling walker within 7 days to improve functional mobility at home. Patient will ascend/descend 12 steps with supervision and a single handrail within 7 days to improve functional mobility at home. Patient will independently don/doff brace within 7 days to protect his spine and promote independence at home.
Evaluate	4. The physical therapist should educate the patient that a temporary alteration in sensation following surgery is normal. The patient should be educated that nerve regeneration can be slow and unpredictable and that pain may accompany nerve regeneration. Sensation should be reassessed periodically. 5. To mobilize safely while maintaining spinal precautions, the patient should: change position once every 30 minutes to prevent pressure injuries. ambulate frequently to decrease the risk of DVTs. be educated on how to assess his home living situation—remove objects and/or throw rugs from floor to decrease fall risk, ask for assistance from family/caregiver to pick up/carry larger objects. practice activity pacing and modification.
Analyze	6. To test lower extremity sensation, sensation should be tested on the UEs to ensure that the patient knows what to expect. The patient should close his eyes and respond “yes” when he feels the physical therapist’s touch. The physical therapist should lightly touch the skin in varying patterns to assess dermatome levels. The physical therapist can use Q-tip, tissue, or finger as light touch instrument. The Semmes-Weinstein filaments can also be used. 7. The appropriate technique for the supine to sit transfer would be the “log roll” technique, where the patient rolls toward his side, and proceeds to use his arms and legs to rise (like a seesaw) from side-lying to sitting at the edge of the bed.
Apply	8. Functional tasks such as bed mobility, transfers, and gait training on even and uneven surfaces should be addressed in daily physical therapy sessions. 9. Ways to objectively track functional progression include noting the amount of assistance needed, utilization of assistive devices, gait speed, gait distance, mobility deviations, or outcome measures such as the Activity Measure for Post-Acute Care (AMPAC) 6-Clicks or Five Times Sit-to-Stand.
Understand	10. Therapeutic exercises that would be appropriate to prescribe at this patient’s initial evaluation include ankle pumps, long arc quads, heel slides, and sit to stands with assistance. Acknowledgement should also be given to the UEs; therefore, light UE motions without resistance can also be prescribed. 11. To help diminish the risk of developing a DVT and/or pulmonary embolism, the patient should first be educated on signs and symptoms and why he is at risk. Further, the patient can be educated on the importance of ankle pumps, frequent mobility throughout the day, the use of an incentive spirometer, and diaphragmatic breathing.
Remember	12. If the patient were to complain of mid-thoracic pain, especially after meals, GERD “flare” (gallbladder has been removed) or stomach ulcer may be suspected. 13. Complaints/signs that could indicate cauda equina involvement include difficulty with urination, especially initiating and saddle anesthesia. Urinary retention is the most common initial (and persistent) symptom in cauda equine syndrome; however, saddle anesthesia is the most common symptom of post-op acquired cauda equine syndrome.