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Segmental instabil

Fusion of the facet joints

ity, fractures,

using hardware and bone

facet joint arthrigraft. May use fusion cages

tis

or pedicle screws and rods

to achieve fixation.

Approaches can vary, and

a fusion can be done in

conjunction with other spinal procedures to decompress nerve roots.

"'These procedures may be performed in any area of [he spine when indicated. The

approach may be anterior, posterior, or posterolateral.

Sources: Adapted from GW Wood. Lower Back Pain and Disorders of lntervenehral

Disc. In ST Canale (cd), Campbell's Opcrarive Onhopacdics, Vol. 1 (9th ed). St. Louis:

Mosby, 1998; and JJ Regan. Endoscopic Spinal Surgery Anterior Approaches. In jW

Frymoyer (cd), The Adult Spine Principles and Pracrice (2nd cd). New York: Lippincott-Raven, 1997.

212 AClJrE CARE HANDBOOK FOR I'HYSICAL THERAPISTS

Figure 3-20. Lateral view o( a posterior interbody (usion with pedicle screws.

Pain that arises from spinal instability caused by degenerative disc

disease or degenerative joint disease may be treated surgically with a

spinal fusion. Anterior or posterolateral spinal fusion with decompression attemptS to fuse unstable spinal segments. This is achieved through implantation of various types of instrumentation with bone

grafting to create a single motion segment and eliminate the source of

pain, the disc.58 The spinal segments are fixed using different types of

rods, plates, and pedicle screws. The usc of interbody fusion cages

with instrumentation has become common practice for spinal fusion.

An anterior lumbar interbody fusion, posterior lumbar interbody

fusion (Figure 3-20), or combination can be performed 56 Titanium

alloy fusion cages are placed within the vertebral spaces, replacing the

degenerated disc. These cages are then packed with bone graft harvested from the iliac creSt (autograft) or from a bone bank (allograft).

This bone graft can be supplemented with osteoinductive growth fac[Qrs to facilitate fusion.59 A combination of an anterior and posterior fusion can be successful when a single approach fails.

Experimental designs of the total disc replacement have been developed to reconstruct the disc, maintain disc height, and preserve seg-

MUSCULOSKELETAL SYSTEM

213

mental motion of the spine .60 Developers of the artificial disc

replacement believe that restoring mobility will decrease degeneration

of spinal segments above and below the affected segment." Artificial

disc implantation has been occurring in Europe, and clinical trials arc

beginning in the United States. Many generations of the total disc

design have shown promise, and if clinical trials are favorable, the

total disc replacement may become a tool to combat back pain.61

Complications that can occur postoperatively from spinal surgery

are neurologic injury, infection, cauda equina syndrome, dural tear

with cerebrospinal fluid leak, and nonunion, as well as general surgical complications noted in previous seccions.

Physical Therapy IlIleroelltioll after Spillal Surgery

In the acute care setting, physical therapy should emphasize early

functional mobilization, education on proper body mechanics, gait

training, and assessment of assistive devices to increase patient safety.

Patients should be educated on movement precautions to minimize

bending and twisting with activity, lifting restrictions per the surgeon,

and use of braces or corsets if prescribed .

•

Patients should be taughr to logroll to get out of bed. The body

rolls as a unit, minimizing trunk rotation. Functional mobility

training should begin the first postoperative day. Ambulation

should be stressed as the only formal exercise postoperatively for

spinal surgery to promote healing of all tissues.

• Symptoms, such as radiating pain and sensory changes present

before surgery, may persist for a significant period postoperatively

secondary to edema surrounding the surgical site. Patients should

be educated to this fact and told if any significant increase in pain

or change in bladder and bowel function occurs, the patient should

notify the nurse, surgeon, or both, immediately.

Clinical Tip

• For surgical procedures with an anterior approach, the

patient should be given a splinting pillow and educated in

its use to promote deep breathing and coughing. A corset

can be use to aid patient comfort with activity.

214

ACtITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

o Rolling walkers are useful to promote a step-through

gait pattern and decrease stress on the spine caused by lifting a standard walket. Patients should progress to a cane or no assistive device to promote upright posture.

o

If an iliac crest bone graft is harvested through a second

incision, a patient may complain of increased pain at the

surgical site. Ice can decrease swelling at the donor site.

With this rype of graft, a patient wiiJ likely need an assistive

device to increase safery with ambulation and decrease pain.

o

If interbody fusion cages are used, the patient should be

encouraged to sit in a chair as soon as possible to increase

compression on the cage and promote bone ingrowth. Sitting time can be unlimited according to patient comfort.56

o Patients who have undergone spinal fusion should be

educated about the adverse effect that cigarette smoking

has on the success of fusion.·' The health-care team

should emphasize smoking cessation, or the patient should

be given the appropriate resources to assist with this task.

o The physical therapist should always check orders for

braces used by the surgeon and any other restrictions on

activity. Braces are usually worn when the patient is out of

bed. If necessary, a surgeon may limit raising the head of the

bed. Reverse Trendelenburg (putting the whole bed at a 45-

degree angle, with head up) can assist with patient ADLs.

o Treatment should be coordinated with the administration of pain medication. Patients should be educated in

relaxation techniques or breathing exercises to help manage their pain. The physical therapist should also be aware

of any psychosocial factors that can interfere with patient

recovery. If necessary, consult the psychiatric or chaplain

services to assist with a patient'S coping skills.

Soft Tissue Surgeries

There is a wide variety of soft tissue surgeries encountered in the

acute care orthopedic setting. The majoriry of these surgeries are

aimed at improving joint stability by repairing the functional length

of muscles, tendons, and ligaments. Common soft tissue surgeries

include tendon transfers, muscle repairs, fasciotomies, cartilage resec-