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DISC HERNIATION SURGERIES
♦ Surgical Procedures for Dsic Herniation:
» Indications for surgery: 
A) Absolute Indications:
Cauda Equina Syndrome
Severe motor deficit resulting from a large extruded or migrated disc fragment
Progressive neurological deficits
B) Relative Indications:
Failed conservative treatment
Significant Neurologic Deficit with significant SLR reduction
Disc rupture into a stenotic canal
Recurrent neurologic deficit
» Contraindications for surgery:
Wrong patient (poor potential for recovery, e.g., workmen's compensation patient off work for more than 2 years)
Wrong diagnosis, for example, other pathology causing the leg symptoms
Painless disc herniation
» Surgical Treatment Options:
It is not a surgical procedure but worth discussing before starting surgical options.
Chemonucleolysis is a medical procedure that involves the dissolving of the gelatinous cushioning material in an intervertebral disk by the injection of an enzyme such as chymopapain.
This leads to dissolution & fibrosis of disc and thus relief of symptoms.
Chemonucleolysis is effective on protruded and extruded disks, but not on sequestered disk injuries.
Fenestration technique for disc excision:
Prolapsed disc is excised through space created between laminae of two adjacent vertebrae, after removing ligamentum flavum.
By this technique stability of spine is not disturbed.
Discectomy (also called open discectomy) is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord.
Before the disc material is removed, a small piece of bone (the lamina) from the affected vertebra may be removed. This is called a laminotomy or laminectomy and allows the surgeon to better see and access the area of disc herniation.
Microdiscectomyuses a special microscope or magnifying instrument to view the disc and nerves. The magnified view makes it possible for the surgeon to remove herniated disc material through a smaller incision, thus causing less damage to surrounding tissue.
A laminotomy is a surgical procedure that is used to relieve pressure off the spinal canal for the exiting nerve root and spinal cord, increasing the amount of space available for the neural tissue and thus releasing the nerve(s).
A laminotomy is also a procedure used to remove the ligamentum flavum, a ligament in the spinal canal that can thicken to the point where it is actually compressing on the spinal cord, attributing to spinal stenosis.
Through a laminotomy, the ligament can be removed, therefore opening up the spinal canal and releasing the nerve(s).
Laminectomy is a procedure used in traditional open back surgeries that involves removing the lamina to increase the amount of space available for the neural tissue.
It can jeopardize stability of spine.
Lamina of one side only is removed to take out disc material.
Damage to stability of spine is much less as compared to laminectomy.
Some surgeons prefer to do spinal fusion in addition to disc excision.
It helps to stabilize spine for instability caused by degenerative changes in the intervertebral joints.
» Complications of Surgical Treatment:
Wrong level exploration
Hemorrhage requiring transfusion
Superficial wound infection
Neurologic Damage with Increased neurologic deficit
Hematoma with or without cauda equina compression
♦ Post-Operative Physical Therapy Management:
Post-operative spine rehabilitation allows for a safer and faster return to functional activities.
Surgical procedures are designed to decompress neural tissues but cannot correct poor posture and body mechanics, nor can relieve myofascial pain syndromes or remedy faulty motor patterns of synergistic activity accompanying muscle substitution that exist with low back pain.
POST-OPERATIVE REHABILITATION GOALS:
Reduction of pain
Prevention of recurrent herniation
Maintenance of dural mobility
Improvement of function
Early return to appropriate activities
Each patient's rehabilitation program should be focused to attain these goals to address following reasons:
Patients have slightly different pathoanatomic abnormalities and surgical procedures
Patients experience different levels of strength, flexibility, and conditioning after surgery
Patients' goals vary
Paients have varying psychosocial factors
Patients possess different levels of kinesthetic-proprioceptive coordination that affect their rate of motor learning
Dural stretching should begin as soon as possible in the first week after surgery.
Mobilization of the nervous system
Nerve root gliding
Neural tension exercises
The main aim of neural mobilization is to minimize the preoperative neural compromise and the post-operative inflammation in and around the epidural space which contributes to neural fibrosis and dural adhesions.
Prone lying with both knees extended on a firm surface.
Initially patient may use pillow under abdomen for comfort if required.
Ask patient to slowly flex the knee to the point of stretch.
Then slowly extend the knee and relax. Repeat the procedure.
Make sure that patient maintains the abdominal brace throughout the exercise to stabilize the lumbar spine.
Record any symptoms and the maximal amount of knee extension attained to monitor progress.
Dural stretching should be done several times a day.
Therapist must instruct the patient that this exercise may PROVOKE neural symptoms and that he or she MUST ALLOW the pain or tingling to RESOLVE TO BASELINE LEVELS before beginning the next repetition.
DO NOT use dural stretching techniques in sitting position in PHASE I & II.
Scarring of myofasical elements with collagen cross-fibers or fibrofatty tissue limits mucle broadening during contraction and connective tissue elasticity during movement. 
Muscle spasm and protective gaurding of gluteals and low back musculature may persist.
Soft tissue mobilization of the lumbar paraspinals and buttock musculature might be required to improve muscle function and reduce spasm.
CARE must be taken while performing soft tissue mobilization before third or fourth week after surgery as tissue healing might be incomplete.
Scar massage to release adherent soft tissue might be required.
Spinal mobilization using non-thrust maneuvers may be beneficial for patients in phase II if they do not have protective muscle spasm, bone disease of the spine, or hypermobile or irritable adjacent motion sengments.
Muscle energy techniques can also be used in phase II.
Thrust maneuvers (grade V or high-velocity manipulations) are CONTRAINDICATED.
Aerobic training program is progressed in intensity and udration depending on patient's tolerance.
Cross-country ski machnies, stair climbing and swimming can be started if sufficient trunk stability is achieved.
Running is NOT RECOMMENDED until after twelfth week after surgery because of degree of spinal stabiliation required and repetitive axial loading sustained by the disc.
SUMMARY OF PROPOSED EXERCISES IN PHASE II:
Supine abdominal bracing with alterante straight leg raises, progressed to abdominal bracing with unsupported lower extremity extension, progressed to abdominal bracing with unsupported upper & lower extremity extension.
Supine dural stretching, progressed to incorporate a belt or towel around the foot to enhance the stretch.
Supine partial sit-ups, progressed to partial sit-ups with rotation to facilitate oblique strengthening.
Double leg bridging, progressed to single leg-bridging and then to single leg bridging with opposite knee straight.
Prone elbow lying, progressed to partial press-up.
Prone abdominal bracing with signle leg raises, progressed to prone double leg raises.
Standing repetitive squats to 60 degrees, progressed to 90 degrees for 2 to 3 minutes.
Abdoninal bracing on all fours with single leg raise, progressed to opposite arm and leg raises.
Balance board training on both limbs, progressed in duration.
Isolated strengthening of neurologically compromised muscles.
Swiss ball sitting exercise progression (in neutral spine with abdominal brace).
Stretching of the quadriceps, gluteals, hip external rotators, iliopsoas, hamstrings and calves as required to correct myofascial limitations.
PHASE III: THE RESISTIVE TRAINING PHASE
Time: 7 to 11 Weeks
Ensure patient is independent in self-care & ADLs with minimal alterations
Increase tolerance to activities
Progress return to previous level of function
The patient in phase III should consistently perform correct body mechanics and postures without prompting and should tolerate almost all functional activities.
By phase III, patient should have good tolerance to mid-range lumbar movements and sufficient spinal stabilization, so spinal movements with load can be performed.
Modalities should only be used to augment exercise program by reducing pain.
Lifting activities can be started with gradual progression as described below:
Soft tissue healing is almost complete by this phase and so more extensive mechanical testing can be done to examine lumbar movements.
Standing motion testing (without overpressure) and seating testing can be performed safely on most patients after 6 weeks of surgery.
During spinal rehabilitation, 
FLEXIBILITY should precede STRENGTH
PROXIMAL strength should precede DISTAL strength
STRENGTH should precede COORDINATION
Functional training exercises typically begins in phase III and is focused on trunk movements that simulate activities to which patient will return.
Sports-specific training can begin if the patient as achieved sufficient active lumbar stability and spinal mobility in fully loaded positions as well as adequate myofascial flexibility and conditioning.
Proprioceptive training with balance boards and Swiss ball can ne used and progressed.
Exercise program progresses in intensity and difficulty to include rotational trunk stability, overhead activities and balance training using a balance board.
Training patient in diagonal patterns in loaded positions beter simulates rela-life situations.
MORE CONCENTRATION should be given to obliques and transverse abdominals during dynamic stabilization exerces.
Soft tissue mobilization should continue as needed to ensure a pliable surgical scar, proper gluteal and paraspinal muscle function, and soft tissue extensibility.
Spinal mobilization should be used when necessary to restore motion at hypomobile segments and reduce pain associated with movement.
Cardiovascular aerobic conditioning program should continue to progress in intensity and duration.
Patients SHOULD NOT start a running program until after twelfth week postoperatively because of high compressive and repetitive axial loads at heel strike.
When patient does resume running, it SHOULD be in the morning when the disc is maximally hydrated.
Wong, D.A. & Transfeldt, E. MacNab's Backache. Lippincott Williams & Wilkins, 4th Edition.
Maxey, L. & Magnusson, J. Rehabilitation for the Postsurgical Orthopedic Patient. Mosby. 2nd Edition.
Saal, J.A. & Saal, J.S. Postoperative Rehabilitation & Training. (Chapter)
Grosin, A.J., Cantu, R. Myofasical manipulation: theory & clinical management. New York, 1989, Forum Medicum.
Triano, J.J., Schultz, A.B. Correlation of objective measures of trunk motion & muscle function with low-back disability ratings, Spine, 1987, 12(6), 561.