Introduction
The leading cause of disability in the world, lower back pain, is a frequently seen condition in physical therapy.
Many individuals opt to undergo a lumbar microdiscectomy, the most commonly performed spinal procedure with over 300,000 performed each year in the United States alone.
Low back pain alone affects over 80% of adults at some point in their life and accounts for $200 billion per year in medical spending.
The below case details the progress made throughout 10 weeks of physical therapy for a 30-year-old male patient with persistent chronic hip and posterior thigh pain after a lumbar microdiscectomy surgery (L5-S1).
History of Condition
The patient reports nearly 3 years of worsening low back, hip, and posterior thigh symptoms. He had seen several physical therapists and chiropractors initially for back pain management. After 6 months of minimal progress, he received an MRI and was told he had arthritic damage in the lumbar spine (L3-S1).
Per physician recommendation, he received a subsequent steroid injection at L4-5 with moderate, but brief alleviation. Prior to back pain, he had never suffered a notable orthopedic injury and enjoyed various fitness classes, jogging, and surfing.
Approximately 2 years later, he experienced a substantial increase in back pain with new symptoms in the glute and posterior thigh for the first time. He received additional steroid injections 3 and 6 months following this exacerbation, but only experienced temporary relief. Shortly thereafter, the patient was performing a gentle stretching routine when he felt an immediate sharp pain traveling down his leg. He was unable to walk for several days following.
Due to worsening symptoms, and the substantial impact on his quality of life, the patient underwent a lumbar microdiscectomy operation the following month with immediate relief. However, he experienced a resurgence of hip and thigh pain 6 weeks after.
As a result, the patient discontinued the prescribed post-operative exercises (cat-cow, piriformis and hamstring stretches). At 12 weeks post-lumbar discectomy, the patient was leaning over while doing laundry and felt a sharp pain in his spine and has been managing symptoms with 600-800 mg of ibuprofen per day ever since (~10 weeks).
Lumbar Microdiscectomy Surgery
Lumbar microdiscectomy surgery is a minimally invasive procedure involving partial removal of the disc material placing pressure on the spinal cord or associated nerves.
Typically, it is recommended for patients experiencing leg pain for more than 6 weeks and who have found little relief with conservative treatment (medications, physical therapy). Outcomes are decreased when the surgery is delayed more than 6 months after the initial onset of symptoms.
Overall success rates are reported to be 90-95%, with 5-10% of patients experiencing a re-herniation in the future. Some sources have found ~71% of patients to experience complete back pain resolution as a result of the operation. While faster relief of symptoms is found with a lumbar microdiscectomy, long-term benefits are no greater than with conservative treatment.
Evaluation
At initial examination, the patient notes no back symptoms. His primary complaint is an ache in the left hip and posterior thigh, fluctuating in severity from a 4/10 to 7/10 pain, with the highest intensity in the morning and evening. He actively avoids tasks involving bending over at home doing laundry, lifting groceries, and has difficulty with stepping in and out of the shower. Has not attempted any form of exercise, prolonged walking, or jogging since exacerbation.
Objective Findings:
Aggravating:
Child’s pose
Toe-touch
Seated spinal flexion
Posterior pelvic tilt
Single leg balance
Sciatic nerve glide
No pain with palpation
Moderate tone in lumbar paraspinals, QL
Stiffness in the low thoracic and lumbar spine
Limited mobility of surgical scar
(+) Straight Leg Raise test
Deep squat: thighs reach parallel, limited ankle dorsiflexion, and lumbar segmentation
Decreased range of motion: hip flexion and internal rotation, ankle dorsiflexion
Rehabilitation
The following overview is a brief outline of the interventions implemented for this individual throughout 10 weeks of physical therapy to reduce persistent pain following the lumbar microdiscectomy procedure. While specific to the presentation and goals of this patient, it is representative of a course of therapy for a patient with chronic pain following a lumbar microdiscectomy or any individual with back or radiating pain.
Early (Weeks 1-3)
The primary goal of this stage was to identify pain aggravators and modifiers.
Balancing these categories is essential for promoting tolerance to treatment, but also progressing in aspects of the plan of care that may provoke symptoms. Not only is this appropriate for a patient post-lumbar microdiscectomy, but also for any individual experiencing chronic or persistent pain. For example, hamstring lengthening and spinal flexion were provoking, while diaphragmatic breathing and calf and quad lengthening were primary alleviating factors.
Also emphasized early:
Pain science education
Multifactorial pain experience: role of stress, sleep, nutrition, and beliefs about recovery
Overall favorable prognosis of low back pain and lumbar microdiscectomy procedure
Imaging findings do not always correlate with back or radicular symptoms
Promotion of movement within established pain guidelines
Neuroscience behind pain perception
Promotion of mobility
Hamstring, calf, and quad lengthening
Spinal segmentation
Sciatic nerve glides
Scar tissue mobilization, other manual techniques
Middle (Weeks 4-7)
The goal of this phase of treatment centered on promoting tolerance to spine flexion, core strengthening and coordination, and progressing hip mobility work. Given the patient’s directional preference of extension, first calming symptoms in the early stage were key prior to introducing flexion mobility.
Spinal flexion and segmentation
Segmental bridging
Spine Controlled Articular Rotations (CARs)
Core strength
Bird dogs
Supermans
Dead bugs
Hip mobility
90/90 position
Hip CARs
Late (Weeks 8-10)
In the final weeks of care, the focus centered on promoting tolerance to a regular strength routine and further progressing spine and hip mobility. These are all in preparation for return to consistent exercise and maintenance of pain-free daily activity.
Strength circuit: planks, squats, lunge variations
Mobility: toe touch, deep squat
Outcome
By week 10, the patient no longer relied on ibuprofen and has symptoms fluctuating from 0/10 to 2/10. Overall describes provocation of symptoms as tightness, rather than a sharp, debilitating pain.
He now tolerates walking around the community, carrying groceries, lifting tasks required for a recent apartment move, sitting for prolonged periods, and navigating the shower.
He still notes occasional irritation when bending over for laundry. He has been progressing through the strengthening circuit as well. He also received a follow-up MRI halfway through treatment as recommended by his surgeon, which showed no disc re-herniation and the expected healing following lumbar microdiscectomy surgery.
Conclusion
While specific to the individual described above, this outline represents a brief overview of what one might expect when seeking physical therapy care for back pain or following a lumbar microdiscectomy procedure.
References
Daly CD, Lim KZ, Lewis J, et al. Lumbar microdiscectomy and post-operative activity restrictions: a protocol for a single blinded randomised controlled trial. BMC Musculoskelet Disord. 2017;18(1):312.
Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:968–974.
Kulkarni AG, Tapashetti S. Outcomes of Discectomy in Young Adults With Large Central Lumbar Disc Herniations Presenting With Predominant Leg Pain. Global Spine Journal. 2020;10(4):412-418.
Shamim MS, Parekh MA, Bari ME, Enam SA, Khursheed F. Microdiscectomy for lumbosacral disc herniation and frequency of failed disc surgery. World Neurosurg. 2010;74(6):611-6.
