Not all cases in multimodal care and rehabilitation interventions help to get rid of back pain. Back surgery is needed when nonsurgical care does not help and weakness of the extremity progresses because of a pinched nerve. The healing process after back surgery requires time and patience to restore the natural rhythm of the spine. Nevertheless, unfortunately, about 4-6% of patients need to undergo revision surgery within a few years.

Key takeaways:
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    If nonsurgical care does not help and weakness of the hand or leg increases, surgical intervention is needed.
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    The sooner a person starts exercising and using other treatments, the quicker back pain can be reduced.
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    Some patients need to undergo revision surgery after a few years.
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    Multidisciplinary rehabilitation after back surgery is essential to help restore natural spine movement.

When is back pain concerning?

Patient concerns tend to grow when their back pain interferes with their work and daily lives. Back pain can affect a person's capacity to work, but the ability to manage the pain is most important for people who suffer from chronic back pain. When an employee suffers from debilitating back pain, the employee and employer must find a reasonable solution that works for both parties.

It is important for the employee to go on sick leave — returning only when the pain subsides — if the pain is so intense that the person can't properly do their job. The reduction of pain depends on the patient's strong will and adherence to physiotherapist rehabilitation instructions. The sooner the person starts doing the prescribed exercises and other treatments, the quicker pain-relieving results will be achieved.

Sometimes back pain can be very sharp and reduce arm or leg sensation — numbness, tingling, or weakness can often be felt in the extremities. This kind of sensation indicates the impingement of spinal nerves. If it is in the lumbar part, lumbosacral nerves are pinched, and pain radiates to the leg. This condition needs care. A physician must conduct a physical examination to evaluate the patient's condition. The physical examination might include manual muscle testing, sensory testing, and functional tests. If these tests are positive, noninvasive visualization such as magnetic resonance imaging (MRI) must be performed to confirm disc herniation.

Tips for managing pain without surgery

Nonsurgical care is the most recommended option before deciding to undergo surgery. In most cases, it helps, and there is no need for surgical intervention. Here are some tips on how to manage back pain:

  • Avoid bed rest
  • Exercise therapy
  • Pharmacotherapy
  • Spinal manipulation and acupuncture
  • Multidisciplinary rehabilitation

When do I need surgery?

Usually, surgery becomes necessary to live a normal, active life when the herniated disc is displaced and irritates the pinched nerve root. However, according to a study, six weeks of nonsurgical care must be taken before moving forward with surgery. If nonsurgical care does not help and symptoms progress, and weakness of the hand or leg increases, surgical intervention is needed because the loss of the sensory and muscle force can cause irreversible damage. Surgery aims to remove loose degenerated materials from the intervertebral space, decompress the affected area, and relieve symptoms.

A surgeon can perform a discectomy to remove the damaged part of a spinal disc using different methods, including open, mini-open, or endoscopic surgery. Studies show that complications of discectomy surgeries occurred in only 2.7% of patients. Of those patients, the issues primarily consist of dural tears, blood transfusions, and neural injuries.

Laminectomy is another surgery in which bone or soft tissue is removed to relieve pain associated with spinal arthritis. Sometimes laminectomy is performed using a technique called fusion. In this procedure, bone structures are removed and replaced with another piece of bone or metal. A study shows that laminectomy surgery is more successful when combined with fusion. In addition, laminectomy plus fusion surgery shows better physical recuperation during 2-year follow-ups than laminectomy alone.

What to expect after back surgery

About 4% to 6% of patients need to undergo revision surgery within two years. Successful surgical outcomes, coupled with rehabilitation results, are very individualized. Even with successful surgeries, about 9.1% of patients still need revision surgery within eight years.

The factors that may increase the recurrence of lumbar disc herniation are gender (it is more common in males), being younger, decreased sensory and motor skills, diabetes, smoking, and work that requires manual, repeated lifting. Moreover, another important factor of symptomatic recurrent lumbar disc herniation is a large annular defect which is more than six mm.

To strengthen the disc, annular repair surgery is performed, thereby sustaining the clinical benefits of the primary discectomy.

In the long term, most patients feel better after a discectomy. Most patients claim overall improvement in their leg and back pain and are satisfied with how they can function. After 8-10 years, most patients could still function, as they could maintain improved mobility.

It is very important to take rehabilitation after back surgery seriously. Studies show that rehabilitation during the first few months has the most beneficial effect on recovery.

Moreover, intensive supervision after spine surgery is necessary to maintain patients’ motivation because home-based programs after surgery do not show such good results as it is expected.

Rehabilitation after back surgery

After spine surgery, starting a rehabilitation program as soon as possible is important. The primary exercises for rehabilitating after back surgery include aerobic exercises such as walking, recumbent biking, and aquatic exercises. However, it's also very important to do cardiovascular exercises before surgery. Studies show that preoperative aerobic exercises decrease the length of stay and disability questionnaire scores in the postoperative period.

Soft-tissue mobilization is another complementary therapy that restores lymphatic flow and increases blood circulation and healing processes. Additionally, nerve mobilization helps to restore and increase the range of motion, decreases postoperative nerve tension, and reduces scar tissue adherence to the nerve.

Motor control and strength exercises

It is important to strengthen back muscles and restore the balance of back and abdominal wall muscles. The exercises for trunk control need to be performed in a ‘neutral spine’ position because research has proved it is safer and more effective during the rehabilitation period.

Joints mobilization

Every part of the body needs to maintain a good range of motion. This is true for the lumbar spine, where surgery was performed, but it is also important for restoring mobility in the thoracic spine and hip joint. Additionally, flexibility in other parts of the body is necessary to keep a good posture, increase functional mobility, and decrease stress in the healing areas.

Understanding what is required for properly rehabilitating after spine surgery is the cornerstone of recovery because it keeps the patient motivated, increases satisfaction and gratitude, and reduces anxiety. Furthermore, the load of rehabilitation exercises must increase gradually to continue strengthening. Starting from very light exercises to more difficult ones. Back pain needs multimodal care and interventions. The healing process after back surgery or nonsurgical treatment requires time and patience. Back surgery is not the only option and should be considered as a last resort. Therefore, before deciding to go under the knife, patients should consider nonsurgical, rehabilitative treatment.

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