After Closing: Spine Postop Protocols
Open, operate, close. But “closed” doesn’t mean “finished.” While the rehabilitation phase of treatment involves less work for the doctor and more for the patient, the surgeon must stay involved and guide the process.
Dr. Carl Lauryssen, a neurosurgeon and Director of research and education at the Olympia Medical Center in Los Angeles, states, “Many surgeons think that once they are done in the operating room, then their work is complete. The postoperative phase is vital to the success of the surgery, and actually begins preoperatively.”
Part of the surgeon’s mission, says Dr. Lauryssen, is putting the brakes on a runaway mindset.
You must prepare patients so that they have reasonable expectations of the surgery, including the vital issue of pain levels. Additionally, the closer patients are to their ideal body weight the less the surgeon will have to wade through operative adiposity—postoperative rehab will also be less onerous for the patient. We live in a fast food/immediate satisfaction society and patients tend to apply that mentality to surgery. Surgeons must explain to patients that their behavior affects the outcome, meaning that we must talk to them about nutrition, refraining from smoking, realistic expectations, etc. It always amazes me how we can perform the identical surgical procedure for a given pathology, with stellar results on one side of the spectrum, and slug results on the other!
Taking microdiscectomy and lumbar spinal stenosis as examples, Dr. Lauryssen states, “Assuming that all went well, the person can go home the same day or the next. Discharge planning should be thorough at the preop clinic visit, with the surgeon and patient discussing the post operative risks. For patients, red flags include fever, pus, and redness around the incision, all of which are more likely to occur during two weeks postop. Constipation is also a problem for many patients, and the surgeon should start the patient on medication immediately after surgery.”
And if Mr. Jones does have to eat hospital food one more night? “The reason someone stays one day versus two is pain. If the patient has been working with a pain specialist and is on significant narcotics before surgery then their stay is usually longer. It is also harder to control that person’s pain post operatively, so we try to get these patients to reduce their pain meds preoperatively.”
You may have 18 people in the waiting room, but don’t skimp on preop time with the patient. “Patients should know that it is normal to have swelling in the incision region, and that it could resemble a golf ball cut in half. If there is no redness or swelling, they are fine. If they see a reddened area surrounding the operative site, they should take a permanent maker, circle it, and then assess it the next day. If the redness increased in area then they should see the doctor immediately.”
Also ensure that patients understand the nuances of postop physical sensations, recommends Dr. Lauryssen. “It is normal for specific preop pain to be significantly reduced after surgery, but there is a memory to the pain and some patients feel it come and go for the first few weeks. And if patients had numbness before surgery then they expect it to be gone afterwards. The fact is that numbness may last forever and can even be a little worse postop. On the activity front, if the patient sits or stands too long then a mild version of these symptoms can return.”
Resistance to doctor’s suggestions—bad. Resistance in the physical therapy (PT) realm—good. Dr. Lauryssen: “At six weeks postop I send patients to PT, where they start with isometric exercises and gentle range of motion movements. A good physical therapist understands the healing that is underway and that if he or she is too aggressive that the sutures—or a muscle—will tear.”
“At three months I release patients to unrestricted activity. Before that there is a logical progression of appointments and activity. Clinically, it is useless to see them in the first week; it is also difficult for them to get into a car. In the second week they are somewhat irritated and realizing that the surgery may not have done what they had expected. I see them in the third week…they are normally over the worst, and are happy to see me! Also, I don’t let them lift anything heavier than 10 pounds, for the first three weeks.”
Dr. Lauryssen covers the details with the patients…but not the incision. “I was trained to cover incisions and make them water tight. I now think they need to be aired; Dermabond is great. I recommend a ‘sailor’s shower’—they get in the shower, wet the body and then turn the water off. They soap up (avoiding the incision), and then wash their hair, rinse off, and they are done. There is no direct stream of water on the incision. They emerge and put on loose fitting clothing…no bandage.”
After all this, they may need a nap. But then they recall Dr. Lauryssen’s advice. “I allow patients to sleep however they feel comfortable, and make sure they know that medication, surgery, and anesthesia are going to alter their sleep for awhile. Sleeping pills aren’t the answer because that will just exacerbate the problem. And no napping as they need to get back to their regular schedule. Managing pain is the most common problem patients have after surgery. Pain meds need to be taken on a regular schedule for the first two weeks, even setting the alarm to wake them at night to stay ahead of the pain curve.”
“They should avoid significant bending, twisting, and lifting until the three-week visit. At that time I increase their weight limit to 20 pounds and allow them 50% range of motion. Most important is that patients avoid the combination of bending and twisting.”
To drive this, and other points home, Dr. Lauryssen makes use of the website, www.graphicsurgery.com. “This uses 3D animations without the blood and gore to educate patients about their surgery, document their viewing. It also helps to reduce liability exposure as an informed consent tool.”
Dr. Stephen Hochschuler, Chairman and Co-Founder of Texas Back Institute, is so committed to the preop part of postop that he gently corrals patients into a class of sorts. Dr. Hochschuler: “I tell patients that most surgeries I perform aren’t emergencies and that they could likely live with their situation. Now if someone is at an ‘8’ on the pain scale they will probably need surgery—but I will never tell that person that he or she will be at a ‘0’ postoperatively.”
“Twenty years ago we began filming educational videos in English and Spanish that included surgical indications and potential complications. Patients sat down with a nurse and an anatomic model, watched the video, and signed a document indicating that they saw the film and had their questions answered. Now we have interactive CDroms that include questions at the end. If patients answer incorrectly they must return to that part of the CD. We also send our patients to a website I helped develop—www.spine-health.com—which contains interactive depictions of the surgery.”
The prescription pad is underused in the postop realm, says Dr. Hochschuler. “While most doctors send patients to PT, rarely do they write a specific prescription. Rehabilitation is a team approach, and orthopedists should reach into the physical therapy world and specify the exercises that will result in the best healing process. I prescribe aerobic conditions, spine stabilization, and core strengthening. I also order kinetic chain (core stabilization) exercises, something that nine out of ten spine surgeons don’t order. All of this must be patient-specific…therapy is not therapy is not therapy.”
No one knows that better than an experienced physical therapist. Jason Brewton, Director of Physical Therapy for Texas Back Institute, states, “PT is quite effective, and most patients are committed to post surgical physical therapy. Those who don’t engage in therapy and need future surgical revision always lament that they didn’t stick with PT the first time.”
Breaking down the process, Brewton states, “The first phase involves calming the tissues, reducing swelling, and protecting the surgical repair through the use of isometrics. This is followed by the initiation of supervised PT (stabilization, restoration of flexibility, and proper body mechanics). The third phase involves restoring recreational activities, return to work, and restoration of functional capacity.”
“With fusions we have to aggressively protect the graft and promote fusion, meaning that we limit range of motion (ROM) exercises for about three months. (This also lets the tissues calm down.) The doctors want to see radiographically that the fusion is taking well before they start ROM exercises in the immediate surgical region.”
The physical therapist also dons the mother hen hat with regard to discectomies and laminectomies, says Brewton. “For these patients, we must limit flexion and extension to protect the surgical site for the first three weeks, and limit rotation for six weeks. When the surgeon has removed the lamina or a portion of the disc we want to reduce stress to the healing structures.”
Other surgeries—such as total disc replacement—are less restrictive. “There are no ROM restrictions except for in the extension plane because we could possibly dislocate the prosthesis. In general, we don’t allow any extension for the first six to eight weeks depending on how the patient is healing.”
To orthopedists who might overlook the power of physical therapy, Brewton states,
Patients are only going to value the rehab process as much as the doctors do. If surgeons don’t spend time discussing why it’s important to engage in PT then patients aren’t going to do it thoroughly. We have had patients who had surgery elsewhere and the doctor put no importance on rehab…the patient was given a list of exercises, but was essentially hung out to dry and had a poor post surgical outcome.
How to define surgical success is a growing area of interest in the field of orthopedics. All told, surgeries stand a better chance of being labeled a success if the physicians take an assertive attitude toward postoperative rehabilitation.