Standard of Care: Post-Operative Spine Surgery Case Type

Standard of Care: Post-Operative Spine

1

Department of Rehabilitation Services

Physical Therapy

Standard of Care: Post-Operative Spine Surgery

Case Type / Diagnosis: (diagnosis specific, impairment/ dysfunction specific/ICD 10 codes)

ICD 10 Codes:

M43.00 Spondyloysis

M43.10 Spondylisthesis

M50.30 Other cervical disc degeneration, unspecified cervical region

M54.12 Radiculopathy, cervical region

M54.13 Radiculopathy, cervicothoracic region

S32.009A Unspecified fracture of unspecified lumbar vertebra, initial encounter for closed

fracture

M51.36 Other intervertebral disc degeneration, lumbar region

M51.37 Other intervertebral disc dengernation, lumbosacral region

M46.47 Discitis, unspecified, lumbosacral region

M51.86 Other intervertbral disc disorders, lumbar region

M51.87 Other intervertbral disc disorders, lumbosacral region

M51.06 Intervertbral disc disorders with myelopathy, lumbar region

M51.07: Intervertbral disc disorders with myelopathy, lumbarsacral region

M51.46 Schmorl’s nodes, lumbar region

M51.47 Schmorl’s nodes, lumbosacral region

M54.14Radiculopathy, thoracic region

M54.15 Radiculopathy, thoracolumbar region

M54.16 Radiculopathy, lumbar region

M54.17 Radiculopathy, lumbosacral region

M48.06 Spinal Stenosis, lumbar region

M47.817 Spondylosis without myelopathy or radicuoapthy, lumbosacral region

M54.30 Sciatica, unspecified site

M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

Q76.2 Congenital Spondylolisthesis

S12.9XXA Fracture of neck, unspecified, initial encounter

S22.009A Unspecified fracture of unspecificed thoracic vertebra, initial encounter for close

fracture

S32.009A Unspecified fracture of unspecified lumbar vertebral initial encounter for closed

fracture

S32.10XA Unspecified fracture of sacrum, initial encounter for closed fracture

S32.2XXA Fracture of coccyx, initial encounter for closed fracture

Standard of Care: Post-Operative Spine

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This Standard of Care was developed as a comprehensive tool for both orthopedic and

neurosurgical spine surgeries. It was adapted from the previous published BWH Standards of

Care: Orthopedic Spine Surgery and Operative Management of Spinal Disorders.

The intent of this protocol is to provide the clinician with a guideline for postoperative

rehabilitation of a patient after spinal surgery including but not limited to: laminectomy,

foraminotomy, discectomy, facetectomy, corpectomy, and anterior/posterior transforaminal

interbody fusion in the cervical, thoracic, and/or lumbar spine. It is not intended to be a substitute

for appropriate clinical decision-making regarding the progression of a patient’s post-operative

course. The actual post-surgical physical therapy management must be based on the specific

surgical approach, physical exam/findings, relevant co-morbidities, individual progress, and/or

the presence of postoperative complications. If a clinician requires clarification regarding a

patient’s post-surgical presentation, he or she should consult with the referring surgeon.

The most common etiologies leading to spinal surgery include spinal stenosis and disc

herniation, which often present with symptoms of back and/or radicular pain. In patients 60

years and older, the prevalence of degenerative spinal conditions ranges from 20-25%

1

. The

incidence of spine surgery has increased more than 200% in the last decade.

1

The goals of spinal surgery are to decompress the spinal canal and/or foramen to relieve pressure

on nerve roots or spinal cord while minimizing the risk of secondary instability. Surgery may

help relieve pain, paresthesias, or weakness; restore nerve function and stop or prevent abnormal

motion. Randomized trials indicate that for severely impaired patients, decompression with or

without fusion offers greater efficacy than nonsurgical treatments.

2

Outcomes of surgery are

highly dependent upon surgical technique, type of instrumentation used, and the quality of the

bony and soft tissue structures. Anatomical reconstruction and surgical soft tissue balancing are

important factors for restoration of stability and functional range of motion post-operatively.

Spine surgery can be performed from anterior or posterior direction or both and can be

performed in the cervical, thoracic and lumbar spine. In the literature, spine fusion surgery with

or without decompression has yielded similar clinical outcomes (in perceived disability, gait

speed, and overall self- health perception) after two and five year follow-up.

3

These results favor

a positive outcome for patients undergoing spine surgery regardless of their primary etiology.

Spine surgery can involve removing part or all of the disc (discectomy), the body of the

vertebrae (corpectomy), removing part or all of the lamina (laminectomy), and/or removal of part

or all of a facet (facetectomy). The spine may or may not be fixated. Fixation can be achieved

with metal instrumentation such as plates, screws, or wires; or with bone graft. The bone graft

may be one of two types: an autograft (bone taken from the patient) or an allograft (bone from a

cadaver). Bone for an autograft is most often harvested from the iliac crest from a small seperate

incision. In some cases, metal plates, screws or wires are then used in addition to the graft to

further stabilize the spine.

Spine surgery can also be used to repair a fractured or collapsed vertebrae. Two procedures that

are used include a vertebroplasty (cement is injected into a fractured vertebra through a needle)

or kyphoplasty (the surgical filling of an injured or collapsed vertebra through a balloon). A

Standard of Care: Post-Operative Spine

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kyphoplasty is used to restore the shape or height of the vertebrae if there is a deficit due to the

injury.

Indications for Surgery:

• Intractable neck or back pain that failed conservative treatment

• Radicular pain radiating into extremities

• Facet joint arthritis

• Instability

• Spinal stenosis

• Spondylosis

• Spondylolisthesis

• Ankylosing Spondylitis

• Disc protrusion or degeneration

• Injuries to the vertebrae

• Weak/unstable bone caused by infection or tumors

• Spinal cord compression

• Malignancy

Post-Surgical Complications:

Included but are not limited to:

• Dural tear (usually managed with bed rest for 24-72 hours based on the surgeon’s orders,

and/or presence of a lumbar drain.)

• Myocardial infarction

• Pulmonary embolus

• Upper extremity or lower extremity DVT

• Severe/intractable pain or headache

• New paresthesias

• New upper motor neuron dysfunction (i.e. positive Babinski, new clonus, or spasticity)

• New onset of urinary or bowel urgency

• Abnormal discharge or drainage from operative site

• Bone graft failure

• Airway complication (higher incidence in cervical spine procedures)

• Dysphagia

• Cerebral spinal fluid leak

• Surgical site infections

• Hardware failures

• Pulmonary complications

• Vertebral fractures

• Hematoma formation

• Recurrent disc herniation

• Mislocated instrumentation

Standard of Care: Post-Operative Spine

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If the patient presents with any of these new signs and symptoms, it is the responsibility of the

Physical Therapist to have a discussion with the Responding Clinician regarding the

appropriateness of a PT evaluation or intervention. These symptoms may indicate activity

restrictions. Please reference the BWH General Surgery Standard of Care for more details.

Precautions for Treatment:

• Spinal Precautions: All patients following spine surgery will be on spinal precautions.

These are: no bending, twisting or lifting greater than ten pounds for approximately 2-6

weeks based on the spinal surgery and post-operative orders Patients should also logroll

to get out of bed. This will minimize spinal rotation and flexion and decrease stress on

the surgical site. Review post-operative orders and clarify regarding precautions with the

Responding Clinician prior to treatment.

• Positioning: The patient may lay supine or side lying with no head of bed restrictions. If

the patient has an order for a back brace for stability, the patient should stay in supine or

side lying with the head of the bed less than 30 degrees until the brace is received. Once

the brace is received, the patient may have no head of bed restrictions with the brace

donned.

• Bracing: Patients may require a spinal orthosis post-operatively. This is determined by

the surgeon based on the stability of spine post-surgery. Patients who receive an order

for a spinal orthosis may be on logrolling precautions with the head of the bed less than

30 degrees until the brace is fit. The treating physical therapist should clarify that the

brace is appropriate for the patient, if the patient was measured pre-operatively or has had

a previous brace, and if the patient may don the brace supine or sitting.

▪ Once the brace is received the patient has no restrictions on the head of

the bed height as well as mobility when the orthosis is donned, but will

still have spinal precautions.

▪ For patients who require a spinal orthosis for stability a brace should

stabilize at least one level above and below the operative vertebrae.

▪ If the brace is for comfort only, the patient may be allowed out of bed

prior to the brace fitting. This is the case for most orthomolds and soft

corsets.

▪ The brace may be applied over the dressing of the surgical wound or

surgical drain sites. If patients had additional lines or drains consult with

orthotist regarding brace modifications.

▪ Refer to the Spinal Orthotics Resource Guide for further information on

specific brace types (Appendix A)

• Activity: These patients are usually weight bearing as tolerated and ambulation is

encouraged.

Standard of Care: Post-Operative Spine

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Evaluation:

Medical History: Review past medical/surgical history reported in the chart.

History of Present Illness: Review pertinent diagnostic imaging, laboratory workup and other

tests that lead to the current diagnosis and decision to pursue surgical management. Inquire

about presenting signs and symptoms, including: type, duration, impact on function, and prior

management (i.e. steroid injections, outpatient physical therapy, medications) of symptoms if

applicable.

Hospital Course: Review the type of surgery (see brief operative note and/or detailed report of

surgical procedure in the medical chart if available), as well as any remarkable intra-operative

and post-operative events.

Social History: Inquire regarding occupation, prior functional level, use of assistive devices,

home environment setup, family and caregiver support system, and patient goals.

Medications: Review current pharmacological management of the spinal dysfunction or any

comorbidities. Common medications used in the management of patients following spinal

surgery may include, but are not limited to: anti-inflammatory agents (i.e. ASA, NSAID’s,

glucocorticosteroids), narcotic/opioid analgesics (i.e. Dilaudid, Morphine, MS Contin,

Meperidine, Oxycodone, Percocet, Fentanyl), non-opioid analgesics (i.e. Acetaminophen,

Tramadol,Gabapenin), muscle relaxants (i.e. Baclofen, Diazepam, and anticoagulants/antiplatelet

therapy for DVT prophylaxis.

Examination:

This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not

intended to be either inclusive or exclusive of assessment tools.

Mental Status/Cognition: Alertness, orientation, safety awareness, ability to follow commands,

learning preferences, and understanding and use of spinal orthosis should be assessed if

applicable.

Pain: Measure using the Visual Analog Scale (VAS), Numeric Analog Scale (NAS) 0-10, or the

Functional Pain Scale. Determine activities that may increase or decrease symptoms, location of

symptoms, and nature of the pain. Intensity of pain at rest and with physical therapy treatment

should be documented at every inpatient session. Plan of action such as pre-medication should

also be included in the systems review. Other qualitative details of pain that are important to

obtain include the frequency, alleviating/aggravating factors, and descriptors of pain.

Cardiovascular/Pulmonary: Assess supine and seated heart rate, blood pressure and oxygen

saturation, as indicated based on patient presentation. Look for any changes with positioning.

Patients may have an orthostatic response to positioning.

Endurance/Ability to monitor fatigue: Examination of activity tolerance by utilizing the rate of

perceived exertion (RPE) scale or a gross subjective and objective assessment of fatigue level

Standard of Care: Post-Operative Spine

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should be documented for patients. This should detail the amount of functional activity the

patient was able to tolerate during the exam.

Integumentary: Assess the incision area, skin color edema, and presence of drains. Drains are

used to remove the edema that accumulates intra-operatively and post-operatively. The drains

are removed once the operative site’s drainage has decreased to a certain amount. Drains and

removal of drains is done on a case-by case basis determined by the surgeon. Types of drains

include but are not limited to; intrathecal lumbar drains, Jackson Pratt drains and hemovacs.

Range of motion (ROM): Upper and lower extremity quadrant screen as well as neck and trunk

as appropriate.

Strength: Assess functional strength and myotomal upper and lower extremity manual muscle

testing as appropriate. See appendix B for list of myotomes.

Sensation: Light touch in a dermatomal pattern (see Appendix B for list of dermatomes) and

proprioception. If sensation to light touch/proprioception is impaired, then further sensation

testing such as sharp/dull, or hot/cold may be indicated to rule out any further neurological

damage.

Posture/alignment: Identify a presence of a kyphosis, scoliosis, and fit of orthosis if applicable.

• Lateral View: cervical, thoracic, lumbar alignment

• Anterior View: shoulder, pelvis, and knee position

• Posterior View: scapular position, presence/absence of scoliosis, and foot position

Balance: Static and dynamic balance should be assessed in sitting and standing. Standing

balance can be assessed with use of the Romberg Test.

Functional Outcomes: Assessment of pt’s performance with bed mobility, transfer training,

ambulation and stair climbing as appropriate. The patient may benefit from use of a rolling

walker initially for support during ambulation. Patient may progress to a cane or no assistive

device as appropriate.

Functional Outcome Measures

The therapist may also use standardized testing to objectively report functional status and

impairments. Common standardized tests used this in population include the AM-PAC -

Mobility, Neck Disability Index, and the Oswestry Low Back Pain Questionnaire

4

.

Assessment:

The primary goal of inpatient physical therapy for a patient following spinal surgery is to

maximize functional independence and safety while minimizing post-surgical impairments,

activity and participation restrictions as a result of the surgery.

Standard of Care: Post-Operative Spine

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Problem List:

Common problems include but are not limited to:

Pain

Edema

Decreased range of motion

Decreased strength

Decreased sensation

Decreased proprioception

Decreased balance

Decreased endurance

Decreased bed mobility, transfers, and gait

Knowledge deficit regarding spinal precautions and bracing

Decreased independence with activities of daily living

Prognosis:

This patient population is typically in the inpatient setting for 1-3 days. This prognosis may need

to be modified due to any of the following factors: presence of co-morbidities, complications or

secondary impairments, decreased cognitive status, social and environmental barriers to

returning to previous living environment, and any other factors that may influence the patient’s

ability to use an assistive device and increase their functional independence. A majority of these

patients go home given their quick progression to a safe level of mobility and functional

independence that allows them to manage their home environment. If the patient is not able to

progress functionally for a safe discharge home, a short rehab stay may be indicated.

The predicted optimal level of improvement for these patients is to return to their previous

activities, lifestyles and jobs with or without assistive devices and adaptive equipment as

appropriate in 3-4 months.

Short Term Goals: (Measurable parameters and specific timelines to be included on evaluation)

1. Independent with their ability to demonstrate good knowledge regarding the spinal

precautions.

2. Independent with a supine, seated and walking therapeutic exercise program.

3. Independent with bed mobility via log rolling in a flat bed.

4. Independent sit to stand transfers with the least restrictive device.

5. Independent gait with the least restrictive device >=100ft.

6. The patient will negotiate up/down stairs with the least restrictive device independently

Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X_ No

Established Protocol ___ Yes, see attached. _X_ No

Standard of Care: Post-Operative Spine

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Interventions most commonly used for this case type/diagnosis:

1. Therapeutic exercise program: Progress from supine to sitting and active ROM for upper

and lower extremities if strength deficits exist. Use of weighted resistance is generally not

indicated at this time

2. Education: See below.

3. Functional Mobility Training:

• Bed mobility and supine  sit activities via log rolling

• Transfer training (bed  chair  wheelchair  commode), using adaptive

equipment, as appropriate (i.e. Rolling walker, cane)

4. Postural Training and ergonomics.

5. Balance Training: Sitting and standing activities static and dynamic activities as tolerated.

6. Gait Training

• Assistive device prescription, as appropriate

• As appropriate, progress to stair training prior to discharge home

7. Endurance Training

• Increase patient’s aerobic capacity during functional activities

• Progressively increase time and frequency of transfers out of bed to chair or

progress time, distance and frequency of ambulation.

Frequency & Duration: The frequency and duration of physical therapy intervention on an

inpatient basis will be based on the patient’s impairments and functional limitations. For most

patients, a frequency of 4-6X/week for 7-10 days or less.

Patient / Family Education

• Assess learning style, patient goals, and motivators.

• Discuss realistic expectations regarding function, appropriate level of assist that

patient requires from family, rehab progression.

• Instruct the patient and family members in the following techniques and assess their

understanding via return verbalization and/or demonstration:

o Spinal precautions (if applicable)

o Donning/doffing spinal orthosis and wearing schedule (if applicable)

o Deep breathing, coughing and splinting

o Assessing the integument around the incision and areas that are under the

brace if applicable

o Supine and seated therapeutic exercise program

o Safe mobility techniques encouraging maximal independence

o Instruction in ways to minimize inflammation and control pain

o Proper body mechanics

o Spinal Precaution

• Written instructions available within the department to facilitate patient/family

education include:

Standard of Care: Post-Operative Spine

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o Instructions for use of spinal orthoses (Hard TLSO, LSO, Soft TLSO, Soft

LSO/Warm and Form, Miami J, Philadelphia Collar)

o Post-Op Spine Patient education handout (Neuro and Ortho specific)

Recommendations and referrals to other providers.

Occupational Therapy: Consult for patients who present with impairments that affect

their ability to perform activities of daily living independently, and who may have

adaptive equipment needs. This applies to a small population of post-operative spinal

surgery patients being discharged to home.

Ortho Tech: If an inpatient has been prescribed a pre-fabricated spinal orthotic

(Philadelphia collar, Miami J, soft collar, Lumbosacral corset with or without moldable

inserts), coordinate the actual measure, fit and patient education about the prescribed

orthosis with the designated inpatient ortho tech. Inpatient therapists may fit these

devices if individual competency has been obtained; otherwise, plan accordingly with the

team or ortho tech. If the patient has not yet been out of bed, the ortho tech and assigned

physical therapist need to coordinate their services (brace fit with mobility training).

Please see the inpatient orientation manual for specific procedural instructions.

Orthotist: If a patient requires a custom made lumbosacral orthosis, thoracolumbosacral

orthosis, cervical thoracolumbosacral orthosis, Jewett brace, Minerva brace, soft pre-fab

TLSO and Miami J collar with thoracic extension. The Rehabilitation Services

Department uses an outside orthotist vendor- Hanger. These braces are used for a small

population of patients. The orthotist measures the patient for a brace and then fits them

on the same or following day in collaboration with the PT evaluation. The orthotist is

available for adjustments to the brace as needed.

Speech Language Pathology: May be indicated if a patient demonstrates impairments that

affect their ability to communicate or to swallow. Often speech is consulted with patients

undergoing cervical spine fusion via anterior approach.

Social Worker: May be indicated for patients with difficulty returning to work or social

roles, or those patients facing financial or insurance issues that may impede accessibility

of necessary resources.

Re-evaluation

• Standard Time Frame- Every 7-10 days while admitted

• A significant change in patient status (i.e.: return to the OR, acute MI, new

orthotics etc)

Discharge Planning

Commonly expected outcomes at discharge:

Most patients are discharged to home with or without home physical therapy and home

nursing services. Some patients may go to sub-acute rehab or a skilled nursing facility

Standard of Care: Post-Operative Spine

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and will continue to progress toward their physical therapy goals, and initiate home

planning as appropriate.

Criteria for Discharge home from a PT perspective:

1) Safe bed mobility, transfers, ambulation, stair climbing depending on a patient’s

social/environment factors.

2) Good understanding of precautions, weight bearing status, ROM, and safe

demonstration and use of brace and progression of mobility

3) Clean appearing wound

4) Afebrile

5) Good pain control

Consider the following resources for continued therapy:

Home VNA PT: Home PT is indicated if the patient is functionally below their baseline level of

function and presents with deficits in strength, ROM, balance, gait, functional mobility at

discharge from the acute care setting.

Outpatient PT: Outpatient physical therapy is indicated if the patient is functioning

independently in the home setting but continues to have a specific impairment or functional

limitation that requires physical therapy to progress the patient to a higher functional level.

Reviewed/Updated/Revised 2019:

Authors: Reviewed by:

Jennifer Szkolt, PT Kerry Damiano, PT

Joseph Toland, PT

Orthopedic Spine Surgery

Developed by: Carolyn Beagan, PT, March, 2009

Reviewed by:

Roya Ghazinouri,PT, Kenneth Shannon, PT, Anne O’Brien, PT

Operative Management of Spinal Disorders

Developed by: Melissa Flak, PT , March 2005

Reviewed by: Meredith Donlan, PT; Joel Fallano, PT, March 2005

Standard of Care: Post-Operative Spine

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Appendix A

ORTHOSES SPECIFICATIONS

DEPARTMENT OF REHABILITATION SERVICES

Brace Name

Levels

Supported

Purpose of Brace

Who

fits?/Who

places

brace?

How to

Order?

Epic:

Orthotech

Prebricated

Splints and

Braces

Timeframe

Soft Collar

Comfort

BWH

Ortho Tech

Extremity

Type: Spine –

choose soft

collar

Same Day

Miami J

Collar

C1 to C5

Stability/Immobilization

BWH

Ortho Tech

Extremity

Type: Spine-

choose

Miami J

collar

Same day

Philadelphia

Collar

C1 to C5

Stability/Immobilization

Short term use <=72 hr,

showering

BWH

Ortho Tech

Extremity

Type: Spine-

choose

Philadelphia

collar

Same day

Miami JTO

C1 to T1

Stability/Immobilization

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

comments

Same day

except

Sundays

Standard of Care: Post-Operative Spine

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Minerva &

SOMI

C1 to T1

Stability/Immobilization

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

comments

Same day

except

Sundays

CTLSO

C1 to S1

Stability/Immobilization

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

comments

24 Hrs for

delivery,

except

Sunday

Custom

Jewett

Low

thoracic

and

lumbar

spine

Postural

Awareness/comfort

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

comments

Same day

except

Sundays

Cash

Low thoracic

and lumbar

spine

Postural

Awareness/comfort

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

comments

Same day

except

Sundays

Hard TLSO

T5 to S1

Stability/Immobility

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

comments

24 Hrs for

delivery,

except

Sunday

Custom

Soft TLSO

Thoracolumbar

Postural

Awareness/comfort

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

Same day

except

Sunday

Standard of Care: Post-Operative Spine

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comments

LSO with

insert

lumbar

Comfort

BWH

Ortho

Tech

Extremity

Type: Spine-

choose LSO

with insert

Same day

LSO without

insert

lumbar

Comfort

BWH

Ortho

Tech

Extremity

Type: Spine-

choose LSO

without

insert

Same day

Hard LSO

T11 to S1

Stability/Immobility

Orthotist

(outside

vendor)

Extremity

Type: Spine-

select Other

-write in

comments

24 Hrs for

delivery,

except

Sunday

Custom

Appendix B

Cervical and Lumbar Spine Neurological Screen

Neurological

Level

Motor

Dermatome

C1-C2

Neck Flexion

Occiput

C3-C4

Shoulder Elevation

Supraclavicular

C5

Shoulder Abduction

Lateral Deltoid

C6

Wrist Extension

Radial Forearm

C7

Wrist Flexion

Middle Finger

C8

Thumb Abduction

Ulnar Forearm

T1

Finger Abd/Add

Medial Elbow

L1-L2

Hip Flexion

Groin

L3-L4

Knee Extension

Anterior Thigh

L4

Ankle DF

Medial Leg/Foot

L5

Great Toe Extension

Dorsum of Foot

S1

Foot Eversion

Lateral Foot

S2

Ankle PF

Posterior Calf

Standard of Care: Post-Operative Spine

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Standard of Care: Post-Operative Spine

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