Rehabilitation after lumbar disc surgery

Ostelo RWJG, Costa LOPena, Maher CG, de Vet HCW, van Tulder MW

Published Online:

February 16, 2011

A prolapsed lumbar disc (also called a 'slipped' or 'herniated' disc) is thought to be the most common cause of sciatica (pain or numbness spreading over the buttocks or legs caused by a 'pinched' or compressed nerve in the lower back). Many patients are treated effectively by a combination of non-surgical measures such as medication or physiotherapy. However, patients with persistent symptoms often have surgery. While 60% to 90% of patients will improve after surgery, some will continue to have symptoms. It is estimated that 3% to 12% of patients who have disc surgery will develop another prolapsed disc and most of these patients will have surgery again.

Active treatment programs, such as physiotherapy, in which the patient is an active participant, and advice to return to normal activities, including work, as soon as possible after surgery are common approaches.

This updated review evaluated the effectiveness of various active treatment programs for patients who had lumbar disc surgery for the first time. The review authors included 14 randomised controlled trials with 1927 participants between the ages of 18 and 65 years. Most commonly, treatment started four to six weeks after surgery, but this ranged from two days to 12 months. There was also considerable variation in the content, duration and intensity of the treatments. Most of the treatments were only assessed in one trial and their results are presented in the full review.

For programs that started four to six to six weeks after surgery, the review authors were able to pool the results for three comparisons:
- Patients who participated in exercise programs reported a slightly less short-term pain and disability than those who received no treatment.
- Patients who participated in high intensity programs reported slightly less short-term pain and disability than those in low intensity programs.
- Those in supervised exercise programs reported little or no difference in pain and disability than those in home exercise programs.

None of the included studies reported that active programs increased the rate of repeated surgery, nor did the evidence suggest that patients should restrict their activities after lumbar disc surgery. However, limitations in the methods of half of the trials suggest the results should be read with caution.

The evidence does not tell us whether all patients should be treated after surgery or only those who still have symptoms four to six weeks later.

Abstract (click to read)

Background:

Several rehabilitation programs are available for individuals after lumbar disc surgery.

Objectives:

To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery.

Search strategy:

We searched CENTRAL (The Cochrane Library 2007, Issue 2) and MEDLINE, EMBASE, CINAHL and PsycINFO to May 2007.

Selection criteria:

We only included randomised controlled trials (RCTs).

Data collection and analysis:

Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence.

Main results:

Fourteen studies were included, seven of which had a low risk of bias. Most programs were only assessed in one study. Statistical pooling was only completed for three comparisons in which exercises were started four to six weeks post-surgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises.

There is low quality evidence (three RCTS, N = 122) that exercises are more effective than no treatment for pain at short-term follow-up (WMD -11.13; 95% CI -18.44 to -3.82) and moderate evidence (two RCTs, N = 102) that they are more effective for functional status on short-term follow-up (WMD -6.50; 95% CI -9.26 to -3.74). None of the studies reported that exercises increased the re-operation rate.

There is low quality evidence (two RCTs, N =103) that high intensity are slightly more effective than low intensity exercise programs for pain in the short term (WMD -10.67; 95% CI -17.04 to -4.30) and moderate evidence (two RCTs, N = 103) that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36).

There is low quality evidence (three RCTS, N = 95) that there were no significant differences between supervised and home exercises for short-term pain relief (SMD -1.12; 95% CI -2.77 to 0.53) or functional status (three RCTs, N = 95; SMD -1.17; 95% CI -2.63 to 0.28).

Authors' conclusions:

Exercise programs starting four to six weeks post-surgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the re-operation rate after first-time lumbar surgery.

This record should be cited as:

Ostelo RWJG, Costa LOPena, Maher CG, de Vet HCW, van Tulder MW. Rehabilitation after lumbar disc surgery. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD003007. DOI: 10.1002/14651858.CD003007.pub2

Assessed as up to date:

November 15, 2007

Health topics:

Orthopaedics & trauma > Back disorders > Lumbar disc disease

Rheumatology > Back disorders > Lumbar disc disease

Cochrane Summaries

Independent high-quality evidence for health care decision making

Rehabilitation after lumbar disc surgery

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