Lumbar Fusion

Haley Heidt, Jordan Thielbar, Liz Hoffman, Ana Livecchi,

Madelyn Wilkinson, Ali Horning
 Surgical Procedure:
- Brief Overview of the Surgical Procedure
- The disc between two lumbar vertebrae is removed. A bone graft (from a bone bank or the patient’s pelvis) is used to fuse two
vertebrae together. In some special cases, a synthetic substance may be used instead of a bone graft. Metal plates, screws and rods
are then used to help hold the two vertebrae together while the bone graft heals. After 3-6 months, the bone graft should connect
the vertebrae above and below.
- Types of Fusions
- Posterolateral Lumbar Fusion - most common
- Posterior Lumbar Interbody Fusion
- Transforaminal Lumbar Interbody Fusion
- Anterior Lumbar Interbody Fusion
- Lateral Interbody Fusion
- Interbody Cages
- Surgical Indications
- Patients with severe back pain that is unmanageable through conservative care (PT, injections, medication, etc.) may be candidates
for surgical evaluation.
- Spinal Deformities (Scoliosis)
- Spinal Instability
- Spinal Fractures
- Lumbar DDD
- Lumbar Spondylolisthesis
- Lumbar Spinal Stenosis
Post-Operative Precautions:
● Post- Operative Precautions:
○ Wear brace as prescribed by surgeon
○ Avoid high impact or strenuous activities
○ NO bending, lifting or twisting
○ NO lifting more than 10 lbs or lifting overhead
● Overview of the timeline associated with each precaution:
○ Phase 1 → 1-5 days - 6 Weeks
■ Avoid driving, and prolonged sitting
■ NO bending, lifting or twisting
■ NO lifting more than 10 lbs or lifting overhead
■ Wear brace as prescribed by surgeon (approximately 3 months, depending on the surgeon)
○ Phase 2 → 6-10 weeks
■ Most patients are not referred to PT until 4-7 weeks post surgery.
■ No lifting greater than 10 lbs
■ No lifting overhead
○ Phase 3 → 11-19 weeks
■ Should still avoid strenuous lumbar rotation, flexion and extension
■ Should be careful with overhead lifting due to the axial load and the compressive forces placed on the spine.
○ Phase 4 → 20 weeks - 1 year
■ No restrictions
■ Return to work/ school/ etc.
 Phase I : Post-Operative 1-5 Days - 6 weeks
Expected Impairments/Limitations: Goals:
● Pain ● Indepence with:
● Restricted mobility ○ Bed mobility
○ Bed ○ Don/Doffing clothing and/or brace/corset
○ ADLs ○ Transfers
● Decreased tolerance to prolonged posturing ○ Gait
● Decreased tolerance to walking ■ With or without assistive device
● Appropriate body mechanics with ADls
Therapeutic interventions:
Rationale:
● Bed mobility
● Assistive device training ● Promote patient independence
○ Gait training ● Log rolls with bed mobility to avoid stressing
● ADLs surgical site
● Initiate abdominal exercises ● Emphasize walking to increase tolerance to upright
● Introduce neural glides/mobilization postures
● Proper body mechanics with activity to avoid re-
injury
Sample Program Phase I
●Bed Mobility/Transfers
●Abdominal Exercises:
○Belly Breathing with forced exhalation
○TA
■Supine Bracing
●3x30secs; 3 times a day
●Increase reps and duration as tolerated
■Leg fall outs
●Use as a progression when tolerated
●3x30secs; 3 times a day
●Increase reps and duration as tolerated
○Pelvic floor
■Seated pelvic floor contraction with towel
●3x30 secs; 3 times a day
●Increase reps and duration as tolerated
●Neural Glides:
○Alternate knees to chest
■Straighten lower leg w/ ankle pump x5 times each leg; 3 times a day
●Walking Program:
○Initially, x5 mins a day on level surface
■Be sure to complete/evaluate use of AD if needed
○Progression of time as tolerated
Phase II : 6-10 Weeks After Surgery
Goals: General Guidance:
-Increased activity -Common Restrictions: no lifting > 10 lbs, no
-Tissue remodeling overhead lifting
-Stabilization
-Reconditioning Anticipated limitations and functional limitations:
-Minimize patient fear and apprehension -Pain limited with ADLs
-Education to minimize sitting time and maximize walking -Limited nerve root mobility
time -Limited trunk stability
-Limited mobility of regions adjacent to surgical site
Milestones: -Limited endurance and tolerance to physical activity
-Self-manage pain
-Independence with: Criteria to move to next phase:
-Bed mobility -No increase in pain
-Donning/doffing clothing -Improved tolerance to upright posture
-Transfer
-Gait, using assistive devices as appropriate
Sample program for Phase II:
Body Mechanics Training: Stabilization: incorporate abdominal breathing
● In and out of bed/chair ● Abdominal bracing - 6x 10 sec holds 4x/week
● Lying posture ● Supine marching - 2 sets 30 reps 4x/week
● Sitting & standing ● Quadruped with arm & leg movements - 2 sets
● Dressing 10 reps total 4x/week
● Bending & reaching ● Upper and/or lower extremity activities while
● Pushing & pulling sitting on exercise ball
● Lifting & carrying
Strengthening:
● Sit to stand - 3 sets 10 reps 4x/week
● Step ups & step downs - 3 sets 10 reps each side
Nerve Root Gliding: 4x/week
● Position: knees extended while lying supine with ● Half lunges - 3 sets 10 reps each side 4x/week
the spine in neutral and the hip flexed to a
90°angle - hold for 2 seconds, perform 10 reps Cardiovascular Reconditioning:
3x/week ● Walking - 30 min 5x/week
Phase III : 11-19 Weeks After Surgery
- Milestones
- Promote return to independent lifestyle
- Develop kinesthetic sense for the muscle and
their role in protecting the spine
- Brace the spine and maintain a neutral
position
- Increase strength of trunk and extremities
- Start weight training
- Promote good cardiovascular health
- Anticipated impairments and functional limitations
- Mild pain
- Limited tolerance to upright positions (sit /
stand)
- Limited trunk, lower extremity, and upper
extremity strength
- Criteria for next phase
- No increase in pain
- No loss in functional status
- Pt has decreased reliance on formal therapy
- Clearance from physician
- Goals
- Independent with most ADLs
- Increased trunk and extremity strength
- Neutral spine while performing strengthening
exercises
- Performance of 20-30 minutes of
cardiovascular exercise daily
- General guidance
- Patients can return to work if they have jobs
that are not extremely vigorous
- Patients often go back to work at a part time
status
- Avoid vigorous lumbar rotation, flexion, and
extension
- Limit overhead lifting
Sample program for Phase III
- Progress walking tolerance to 30-60 Resistance training
minutes
- Begin to use weights after 12 weeks
- Stabilization program examples - Seated upright rowing machine b. Latissimus pulls
- Increase intensity with patients tolerance - Scapular depressions
- Supine marching - Dips
- Bridging
- Dying bug Cardiovascular training
- Squats to 90 degrees knee flexion
- Quadruped - Stair climber
- Prone over pillow on exercise ball - Brisk walking
- Planks front and side
- Standing or flotation device - assisted pool
- Continue to progress nerve root mobility
exercise
with nerve glides
Phase IV : 20 Weeks - 1 Year After Surgery
Goals: Restore pre injury status, continue home program of conditioning and stabilization

● The body finishes the remodeling phase and is adapting to the changes induced during and after surgery (up to a year)

Patient Progress/Milestones:
Criteria to progress beyond this phase:
● ● Patient achieved their therapy goals
Full restoration of their preinjury level of function
● Patient has appropriate maintenance plan
● Independent with conducting previous HEP and gym program ● PT approves discharge from therapy
● Understand pain mechanisms and management
● Understand required physical activity to reach their goals
● Patients are developing strength required for more strenuous jobs or sports
○ Must get clearance from surgeon for agility/sport-specific drills (running, cutting, jumping)
○ Pt should be able to demonstrate good trunk strength/control, good LE strength/flexibility
● Functional capacity evaluation if necessary for work

*Management

● The patient should understand that spinal care is a lifelong habit and should be maintained with regular exercises and
good body mechanics
○ Patients often develop problems above or below the fusion
● Focus more on improving function and less on pain - the latter is not possible to completely eradicate
● Incorporate cardiovascular, stabilization, strengthening, and flexibility exercises
 *Management program can be incorporated 2-3 times
Sample Program for Phase IV a week or into existing gym routine/while at work

Cardiovascular
● Can progress from walking to cycling interval (warm up and cool down each 5 min)
○ 2 min higher intensity (18-19 RPE or 75% HRmax) + 1 min moderate intensity (14-15 RPE or 50% HRmax)
○ Total: 15 min (not including warm up/cool down) → progress to 30-45 min
Stabilization
● Bird dog progression: move free arm/leg away from midline and return (3x15 with 5 sec hold, add a set each week)
● Progress planks to alternating rotating planks with plank hip dips (start with 1 min each, add 1 min each week)
● Standing kettlebell overhead press (3x15, add a set each week)
Strengthening
● Deadlift: increasing weight while decreasing reps with each set (exact weight and sets depend on pt. tolerance)
● Squat + step up
○ Squats can start with bodyweight → add weight in 5# increments (3x15)
○ Step height at 8 in (standard step) → progress to BOSU step ups → progress to stepping up on ladder (3x15)
Flexibility
● Extension based to facilitate overhead activity at work
○ Seated lumbar extension (reaching overhead with ball or light weight) 3x15 with 2 sec hold → progress to standing
● Flexion based to provide varied movement and pain relief when necessary
○ Child’s pose (30 sec hold then slowly push up into quadruped for 5 seconds, repeat 5 times or as needed)
Rationale for work/sports specific activity: Pt works as a painter. Has a gym membership (went to the gym regularly before his back
problems).
● Standing kettlebell overhead press (controlling paint roller and improving strength)
● Deadlift (picking paint cans, ladders, etc. off the floor)
● Squat + step up (picking up objects and stepping up ladder)
Prognosis and Return to Activity Decision
Long Term Prognosis
● The bone continues to remodel and adapt to the fusion for up to one year post-operation. During the rehabilitation process, the patient should
be taught long-term spinal care strategies and habits to maintain good spinal health and to prevent problems at, above, or below the level of the
fusion.
● Studies of several types of lumbar fusion all show improved outcomes up to 10 years after surgery. The need for additional surgery ranged
from 17-31% depending on the type of surgery, the lowest being posterolateral surgery and the highest being those who received an interbody
fusion.

Return to Sport/Activity/Work
● Timeline:
○ Patient may begin returning to work during Phase III (weeks 11 - 19) if the job is mostly sedentary and/or does not require much vigorous activity.
○ Later in Phase IV (20+ weeks), and with clearance from the surgeon, the patient may begin agility and sport-specific drills (example: running,
cutting, jumping).
○ A more comprehensive weight training program that is geared toward the patient’s specific needs can be started at this time, with a greater focus on
power, endurance, or skill.
● Criteria for Return:
○ Patient must be able to maintain control of a neutral spine during activities specific to their sport or activity.
○ Patient must demonstrate good trunk strength and control as well as good lower extremity strength and flexibility.
○ PT may perform a functional capacity evaluation and give the patient a work hardening program before the patient returns to full duty.
Resources
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doi:10.1097/BRS.0000000000002682

Endler P, Ekman P, Berglund I, Möller H, Gerdhem P. Long-term outcome of fusion for degenerative disc disease in the lumbar spine. Bone Joint
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Lehr AM, Delawi D, van Susante JLC, et al. Long-term (> 10 years) clinical outcomes of instrumented posterolateral fusion for spondylolisthesis.
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Mannion AF, Brox J-I, Fairbank JC. Consensus at last! long-term results of all randomized controlled trials show that fusion is no better than non-
operative care in improving pain and disability in chronic low back pain. The Spine Journal. 2016;16(5):588-590.
doi:10.1016/j.spinee.2015.12.001

Maxey L, Magnusson J. Rehabilitation for the Postsurgical Orthopedic Patient. 3rd ed. St. Louis, MO: Elsevier/Mosby; 2013.

Spinal Fusion. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/spinal-fusion/about/pac-20384523. Published November 14, 2020.

Accessed September 23, 2021.