Author, Scott Schreiber, DC, DACRB, MS, Cert. MDT, CKTP, CNS
Authored, September 8, 2009
Peer reviewed by the American Chiropractic Rehabilitation Board
There have been a growing number of chiropractic physicians that have been treating patients after surgical procedures. After reviewing the literature, there have been no studies involving Chiropractic Management of multilevel post surgical fusion. In fact, a review of the literature was very sparse, only a handful of case studies pertaining to chiropractic management of post surgical cases. Cases reported include wrist rehabilitation (1), post surgical neck (2), post surgical disk herniation (3), Achilles tendon rupture (4), failed back surgery (5), sacroiliac syndrome (6), and calceanal exostectomy (7).
There have been many reported complications of spinal fusion surgery (8). They include in hospital mortality, deep infection, superficial infection, deep vein thrombosis, pulmonary embolus, neural injury, donor site complications, graft extrusion, instrumentation failure and other myocardial infarction, urinary tract infections, respiratory complications, gastrointestinal, transfusion reactions, peripheral vascular complications, accidental cut or puncture during the procedure (9). Reactions to anesthesia and comorbid conditions also need to be considered (8).
There have not been any indications established for spinal fusion surgery. However, fusion has been performed in patients with spinal stenosis, degenerative disk disease, disk herniation, unstable spine (8), and significant nerve root compression (10). According to Bederman et. al., there exists no clear consensus on the ideal management for these patients despite overall improvement with surgical management.
The incidence of surgeries has increased (10), but there also has been an increase in the number of failed back surgeries (10). Information regarding chiropractic management of these failed back surgeries is sparse; however, there have been several suggested reasons why surgeries fail. These include iatrogenic changes, the original diagnosis was wrong; there was little or no rehabilitative effort after the procedure (5). In addition, Chiropractic management can occur when no other surgery is warranted. This will include physical therapy to reduce pain, remove myofascial trigger points and restore mobility and finally increase strength and aerobic capacity. It will also include work hardening and educational programs directed toward pain management and disability (5).
The role of Chiropractic manipulation is not certain as described in the literature (5, 11). The fusion regardless of instrumentation must be solid as shown on flexion/extension radiographs. Healing depends on the patient but usually takes three to five months (11).
A thirty year-old African American presented with lower back pain and right sided sciatica following an L3-S1 laminotomy, foraminotomy, and decompression with instrumentation. Before the surgery, she completed a course of Chiropractic manipulative therapy and rehabilitation, as well as interventional pain management.
Vital Signs performed included Ht, 66in, Wt 213lbs, Oral temperature 98.7°F, Blood Pressure 104/70, Pulse 75 BPM, and Respiration at 15 RPM.
The revised oswestry low back pain disability index was given and disability index was 58%. Par-Q was also given and the patient was given clearance for rehab despite initial hesitation.
Upon Physical examination, Patient presented alert and orientated to person, place, and time. The patient stated that she was depressed, agitated and angry due to the complications after surgery. Range of motion was difficult to measure due to the degree of the patient’s pain. Observed was a six inch surgical scar midline. Upon palpation tenderness and tightness was palpated along the lumbosacral erector spinae with joint dysfunction above and below the surgical fusion. Straight leg testing revealed pain and tight hamstrings bilaterally at 20°. Quadriceps tightness and lower back pain was observed bilaterally on Nicholas’ test. Gainslens’s, Yeoman’s, and Patrick’s Test were all positive for low back pain and leg pain. Gait was antalgic and guarded.
Cranial nerves, cerebellar function, coordination were all intact. Muscle strength testing of the right psoas, rectus femoris, quadriceps, hamstrings, gastronemius, soleus and peroneus muscles tested at grade 3 when compared to the left which tested at grade 5. Deep tendon reflexes 1+ bilaterally for patella and Achilles reflexes. Sensory testing of pain and light touch revealed increased sensation to the entire right leg when compared to the left leg, which was within normal limits.
At time of initial examination, a functional examination was not able to be performed due to the patient’s acute symptoms, however, will be performed when the acute symptoms resolve.
Initial treatment consisted of posture and proper lifting instruction as well as hip hinge advice. Abdominal breathing exercises and initial core strengthening consisting abdominal bracing were done in a sitting position due to the patient’s discomfort in the prone position. Also, proprioceptive balance training was used. It consisted of one-legged standing in a door way with shoes off. Additionally, the patient was given a lumbar roll and educated on maintaining a neutral spine. The patient felt relief of symptoms on the first day. During the first week, the abdominal bracing and abdominal breathing were progressed to sitting on a physioball. The patient was instructed to perform these exercises several times per day at home.
After the first week, the patient felt a decrease in leg pain; however, the low back pain was still present. Her gait and activities of daily living improved. At that point, higher level core strengthening exercises including side bridges with bent legs and bridges on back. The patient was instructed to perform the exercises using the abdominal brace combined with abdominal breathing. McKenzie examination was performed and upon repeated extension it was observed to centralize leg pain. Prone pressups were prescribed ten repetitions every hour. Proprioceptive treatment progressed to balance pad with eyes open. At this point the patient still had trouble sleeping. The patient was instructed to add the new exercises to her home exercise program.
After two weeks of therapeutic exercises, Cox Flexion-distraction technique was added to address the joint dysfunction. Sleeping became easier. Sciatic pain decreased and low back pain improved. Activities of daily living improved.
At this point a functional examination was performed. Testing included breathing observation, t-4 mobility test, squat, lunge, one leg standing, hip abduction, hip extension and sit to stand. Results from the functional examination included chest breathing, improper squat and lunge mechanics, inhibited gluteus maximus and medius bilaterally and improper sit to stand mechanics. Treatment for the findings began immediately with basic gluteus medius and maximus retraining and progressing to squats and lunges.
At five weeks after the initiation of treatment, functional activities were added. These included squats with physioball and lunges. Balance pad proprioceptive exercises included increasing the resistance and rocker board exercises. With McKenzie extension exercises, she was able to control her leg pain. Low back pain was decreasing and Activities of daily living were consistently improving.
At seven weeks after initial treatment, functional training continued. Side bridges were progressed to straight legs. Lower back extensions on the Strive™ machine were added with the overload in a bell-shaped curve. Cardiovascular training was added using a recumbent bicycle for ten minutes. McKenzie extensions were now being used for prophylaxis with occasional progression of forces if needed. Again, the patient added the new exercises to her home program.
Ten weeks included balance training on a Bosu™ ball walking lunges and core stabilization exercises. Manipulation of motion segments adjacent to the fusion was initiated. The patient felt an immediate increase in range of motion after the manipulation was performed. Future manipulation was only considered if joint dysfunction was present.
At this point, a quantitative functional capacity examination was performed to determine functional deficits. The patient results were below average for strength of the legs, low back extensors and side bridges. Quadriceps femoris were still tight bilaterally. A therapeutic exercise program consisting of side bridges, squats and lower back extension as well as quadriceps stretching was emphasized and progressed for one month upon re- evaluation. McKenzie extension exercises were prescribed prophylactically.
Three months following initial presentation, the patient’s back pain reduced and sciatica was eliminated. Sensation returned and the patient resumed all activities of daily living. She began exercising in a gym and was instructed to perform home exercises in addition to her strength program. McKenzie exercises were to be done daily to prevent sciatic pain from returning. The patient was discharged with instructions to return if her current status regressed.
Therapeutic intervention involved a combination of rehabilitation protocols complicated by a multilevel surgical fusion. A combination of diaphragmatic breathing, abdominal bracing, proprioceptive balance exercises, and McKenzie protocol progressing to functional training were used. There was no one treatment that alone seemed to elicit symptom resolution. The patient responded very well to treatment and was able to maintain her resolution of symptoms.
Manipulative therapy consisted of Cox Flexion-distraction and diversified manipulation but was used only PRN. The role of high velocity–low amplitude manipulation in post surgical rehabilitation is not understood. If a Chiropractic physician chooses to perform that modality, care should be taken and the fusion needs to be stabilized. Mobilization or non-force technique should be used at first to determine if manipulation would be appropriate.
The outcome of this case is encouraging and the avoidance of repeated surgical intervention is also encouraging. Upon reviewing the case, the quantitative functional capacity exam should be performed sooner in the course of treatment. If radicular symptoms returned an MRI and a flexion/extension radiograph would have been ordered to determine stability of the lumbar spine and any adjacent disk degeneration.
This case provides supporting evidence determining the role of Chiropractic physicians in a multidisciplinary setting, particularly in the post surgical spinal fusion arena. More research needs to be conducted to determine the role of the chiropractic physician in the care of post surgical fusion patient.
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Author’s contact information:
Scott Schreiber, DC, DACRB, MS, Cert. MDT, CKTP, CNS
Delaware Back Pain & Sports Rehabilitation Centers
2600 Glasgow Ave, Suite 210
Newark, DE 19702