Rehabilitation after Lumbar Spine Surgery

Date of last update: February, 2025

About Rehabilitation after Lumbar Spine Surgery

Pain and disability caused by lumbar disc herniation, spondylolisthesis, and stenosis are common reasons for lumbar surgery referrals. Lumbar disc herniation with radiculopathy is the most frequent cause for low back surgery in adults under 65. Spondylolisthesis and stenosis account for a significant portion of spinal surgeries as well.

Post-surgical rehabilitation aims to achieve and maintain optimal function, minimize muscle weakness or kinesiophobia, and promote recovery. Individual outcomes depend on health status, the severity of the condition, and the type of surgery performed. Recovery is best supported through a combination of post-surgical rehabilitation strategies aligned with patient goals.

The World Health Organization defines rehabilitation as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.” Individualized plans, selected through shared decision-making and informed by continuous monitoring, ensure alignment with the patient's objectives. Management can be delivered in-person, virtually or through hybrid care.

About the Care Pathway

Purpose: This pathway offers structured, evidence-based guidance for clinicians delivering conservative care, covering key steps of the clinical encounter. It also serves as a resource for referral or co-management for those not directly providing conservative care.

Development: This pathway draws on current best practices synthesized from clinical guidelines wherever available and systematic reviews where guidelines are not available. Where evidence is evolving or conflicting, guidance is refined using the most robust available sources. Input from clinicians, educators, and researchers facilitates alignment with real-world needs and encourages ongoing improvement. Content is periodically reviewed to ensure recommendations remain current and evidence based.

Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

Updates to care: The online care pathway is updated on the website, with notifications provided via social media. Updates are made when they impact clinical decision-making or provide useful guidance, particularly based on new systematic reviews or clinical guidelines.

Care Pathway for Rehabilitation after Lumbar Spine Surgery

1. Record Keeping

Document findings and recommendations using structured notes (e.g., SOAP format) at each visit, adhering to jurisdictional standards.
Maintain a copy of the surgical report to inform treatment planning and ensure alignment with surgical outcomes.

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2. Informed Consent

Obtain and document verbal consent for history taking, examinations, and contact in sensitive areas; secure written consent for treatments per jurisdictional standards.

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3. Health History

Apply cultural awareness and trauma-informed care principles.
Sociodemographic: Age, gender, sex, race/ethnicity.
Main concern: Post-surgical recovery, including functional status, mobility limitations, residual symptoms, and pain management needs.
Surgical history: Reasons for surgery, type of surgery, complications, in-patient rehabilitation experiences.
Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids), supplements, trauma/injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
Previous treatments: Document treatments for the pre-surgical condition, including prehabilitation (“pre-hab”) interventions, their effectiveness, and any adverse events.
Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
Flag considerations: Identify red, yellow, and orange flags for potential referrals [see Sections 4 – 6].

Outcome Assessment: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

Pain: Pain scales (e.g., NRS) and diagrams.
Function and Participation: Evaluate impact of post-surgical pain on daily activities (PSFS, WHODAS, ODI, RMDQ).
Recovery: Self-rated recovery scales.
Quality of Life: SF-12.
Sleep Quality: PSQI
Work/school Status: Monitor return to activities.
Individual Goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely) o guide recovery. Clinicians should help patients establish realistic and reasonable ("R") goals based on their full clinical presentation and prognosis [see Section 10], ensuring expectations align with likely recovery outcomes.
Patient Feedback: Gather and integrate patient experience and satisfaction.

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4. Red Flags: Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

Cauda equina syndrome (CES): Severe back pain, saddle anesthesia, bladder/bowel dysfunction, bilateral radicular signs, progressive lower limb weakness, decreased perineal sensation, reduced anal sphincter tone. Note: Despite decompression surgery, CES can still occur postoperatively due to hematoma or excessive scar formation compressing neural structures.
Infection: Redness/swelling/heat near the wound, fever, chills, fatigue, malaise, flu-like symptoms, difficulty breathing, wound discharge with foul odour or red streaks extending from the wound.
Deep vein thrombosis (DVT) / Pulmonary embolism (PE): Pain/redness/warmth/swelling in popliteal region, calf, or groin; difficulty breathing, chest pain, coughing, dizziness (indicative of PE).
Dural tear/cerebrospinal fluid leak: Positional headache, neck pain, nausea/vomiting, cranial nerve signs.
Progressive neurological deficits: Increasing weakness, sensory loss, or worsening radiculopathy—potentially due to post-surgical hematoma, scar formation, hardware migration, or implant malposition.

ACTION: Refer to appropriate medical provider:

Hardware failure/implant migration /spinal fracture: Progressive pain unresponsive to care, new focal radicular deficits, osteoporosis, corticosteroid use, female, older age (>60), history of spinal fracture/cancer. Potential complications include hardware breaching the pedicle, impinging the neural foramen, or—though rare—vascular injury (e.g., aortic or iliac vessel puncture).
Post-surgical spondylolisthesis: Focal radicular deficits, progressive/unresponsive back pain. Consider referral in cases of new-onset spondylolisthesis secondary to hardware failure or progressive instability. If unrelated to surgical complications, conservative management may be appropriate.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.
Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

Triage: Ensure primary management by medical/psychiatric providers.
Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
Social: Lack of family/social support, limited connections.
Socioeconomic: Employment status, financial stress, litigation/compensation.
Environmental/cultural: Social inequality, unsafe/unsupportive environments, adoption of the “sick role” post-surgery, which can impact recovery and prognosis. In some elective surgical cases, this is a "soft" criterion considered when determining surgical candidacy.
Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers:

Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).
Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
- - PHQ-9 (depressive symptoms)
  - GAD-7 (anxiety symptoms)
  - FABQ (fear related to physical activity/work)
  - PCS (catastrophic thoughts)
  - ORT (opioid risk)

7. Physical Examination

Observation:
- Inspect for abnormalities:
  - Skin: Signs of infection, wound healing status.
  - External contours: Deformity.
- Evaluate posture, balance, movements, gait patterns.

Range of Motion:
- Assess active, passive, and resisted movements in flexion, extension, lateral flexion, and rotation.
- Consider post-surgical limitations, particularly in cases of instrumented fusion, where restrictions may be structural and non-modifiable.

Palpation:
- Examine bone and muscular areas for tenderness, swelling, muscle tightness, or temperature changes.
- Assess scar mobility and pain, as early scar mobilization may help prevent chronic post-surgical scar pain while avoiding keloid formation.

Neurological Examination:
- Compare preoperative and postoperative status to assess recovery of neurological deficits.
- Motor strength testing: Assess for asymmetry or weakness in key muscle groups:
  - L2: Hip flexors (hip flexion)
  - L3: Quadriceps (knee extension)
  - L4: Tibialis anterior (foot dorsiflexion)
  - L5: Extensor hallucis longus (big toe extension)
  - S1: Gastrocnemius (plantar flexion)
  - S2: Hamstrings (knee flexion)
- Sensory testing: Assess for sensory deficits in dermatomal distributions:
  - L3: Medial thigh at the knee
  - L4: Medial calf
  - L5: Top of foot and toes
  - S1: Lateral foot and little toe
- Reflex testing: Assess for asymmetry, diminished/absent reflexes:
  - L4: Patellar reflex
  - L5: Medial hamstring reflex
  - S1: Achilles reflex
- Balance testing: e.g. tandem gait, Romberg’s test

Special/Orthopedic Tests: Select as appropriate based on clinical judgment, considering post-surgical stability.

Advanced Diagnostics:
- Radiography is not routinely recommended in the absence of red flags or specific individual factors (e.g. contraindications to treatment).
- Understand imaging limitations post-surgery due to hardware artifact:
  - MRI with contrast: Useful for detecting post-surgical scarring causing ongoing radicular symptoms.
  - CT scan: Useful for evaluating hardware failure.

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8. Selection Criteria for Post-Lumbar-Surgery Rehabilitation

Individuals are eligible for this rehabilitation pathway if they meet the following criteria:

1. Pre-surgical condition:

Individual underwent surgery for lumbar radiculopathy (due to disc herniation), neurogenic claudication (due to lumbar stenosis), or spondylolisthesis.

2. Surgical intervention:

Applicable surgeries include:
- Micro-discectomy (with or without endoscopic tubes)
- Decompression with instrumented fusion
- Discectomy with foraminectomy/foraminotomy
- Foraminotomy
- Discectomy with laminectomy, hemilaminectomy
- Laminectomy with fusion
- Lumbar intervertebral bone grafting and fusion (usually in the context of decompression and instrumented fusion)
- Spinal fusion
- Lumbar disc herniation nucleotomy
- Lumbar transforaminal endoscopic surgery.

3. Signs/Symptoms: Individual exhibits no red flags (e.g., infection, post-surgical complications)

4. Post-surgical phase & rehabilitation timing:

Microdiscectomy: Patients are typically cleared for rehabilitation by 6 weeks post-op.
Fusion procedures: Patients are usually cleared within 10–12 weeks, depending on the extent of fusion.

9. Rehabilitation after Lumbar Spine Surgery

Rehabilitation aims to monitor for complications, promote recovery, and restore function. A multimodal approach—integrating clinician expertise, patient preferences, and individual needs—is recommended. Informed consent should follow a comprehensive report of findings, and rehabilitation should be dynamic, guided by patient feedback and progression.

Systematic Review Supported Interventions:

1. Supervised Exercise Therapy (Yu et al., 2024; Manni et al. 2023)

Develop individualized programs targeting core strength, mobility, posture, and reduction of kinesiophobia.
Evidence supports benefits in pain reduction, improved function, and enhanced quality of life.
Align programs with patient history, capabilities, and goals.
Monitor psychological responses to exercise; refer to medical/mental health providers if signs of distress or aversion arise.
Early rehabilitation considerations:
- Walking is typically recommended immediately post-op.
- Isometric training (e.g., pelvic floor/Kegel exercises) may begin 10 days post-op if the incision is healed.

2. Education and Self-Management (Yu et al., 2024; Manni et al. 2023)

Provide tailored, evidence-based information in various formats (written, digital, visual) to empower individuals.
No single education type demonstrated superiority; however, education should cover:
- Pain education (understanding post-surgical pain, expectations, and coping strategies).
- Scar education (healing timelines, scar mobilization, and pain management).
- Movement education (safe post-surgical movement patterns and gradual return to activity).
Combining education with supervised exercise may improve outcomes.
Behavior graded activity, incorporating goal-setting and positive reinforcement, may help increase healthy behaviors and reduce pain.
Home exercises may assist in reducing kinesiophobia.
Address modifiable prognostic factors that may impact recovery.

3. Medication: (Consult a medical provider). (Yu et al., 2024)

Acetaminophen is commonly used for pain management post-surgery.
NSAIDs are not commonly recommended post-surgically as they may interfere with healing and increase bleeding risk.
Pregabalin is not recommended (may increase low back pain).

4. Scar Therapy & Wound Healing

Scar mobilization techniques may help prevent chronic post-surgical scar pain if introduced at the appropriate stage of healing.
Clinician-focused resources:
- Wound Healing - Physiopedia
Patient-focused resources:
- Incision Care After Surgery
- Incision & Surgical Wound Care: Sutures, Stitches, Steri-Strips & Staples
- Wound Care After Surgery
- Surgical Wounds (Gov of Ontario)

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10. Prognosis

Surgical intent and patient expectations: Surgery for low back pain (LBP) is not commonly performed, as most procedures target leg-related symptoms rather than chronic back pain itself. Many patients are not explicitly informed that surgery is unlikely to resolve LBP, leading to frustration when back pain persists post surgically despite improved leg symptoms. Pre-surgical education is critical to aligning expectations with likely outcomes and ensuring patient satisfaction.

Structural relief through surgery: While surgery can provide meaningful improvement for individuals with LBP related symptoms – particularly for clearly defined pathologies such as disc herniation with sciatica or spinal stenosis – it primarily addresses the mechanical aspect of the condition. Long-term pain relief depends on addressing functional impairments and contributing factors such as physical deconditioning and psychosocial influences.

Long-term success after surgery: Recovery outcomes are influenced by patient selection, presurgical expectations, and adherence to a structured postsurgical rehabilitation plan that includes physical conditioning, psychological support, and lifestyle modifications. Prehabilitation ("pre-hab") interventions may enhance postsurgical recovery by improving strength, mobility, and overall surgical readiness.

Risk of persistent or recurrent symptoms: Some people experience prolonged or recurrent symptoms, sometimes referred to as ‘failed back surgery syndrome’ (FBSS). Factors associated with poorer outcomes include hypertension, intermittent claudication, Modic changes, unrealistic presurgical expectations, and inadequate functional improvement post-surgery.

Psychosocial influences and screening: Psychosocial factors – such as depression, anxiety, fear-avoidance beliefs, and catastrophizing – can affect post-surgical outcomes. Proactive screening before and after surgery, along with timely mental health referrals, can improve adherence to rehabilitation, reduce distress, and improve patient satisfaction.

(Krzanowska et al 2022; McIsaac et al 2025; Rushton et al 2018; Weinstein et al 2006, 2010; Xu et al 2022).

11. Ongoing Follow-up

Adjust treatment plan: Continuously realign the treatment plan based on the patient’s evolving goals, feedback, clinical outcomes, and professional judgment.
Referral/co-management: Consider referring or co-managing the patient with other providers if there is no significant improvement within the established treatment timeline (e.g., 6-8 weeks).

12. Criteria for Discharge

Discharge criteria: Establish clear criteria, such as achieving initial goals, reaching a plateau in progress, or significant improvement/management of signs and symptoms.
Post-discharge planning: Discuss strategies for self-management and provide guidance on potential follow-ups or future care needs.

References

Government of Alberta. My Health Alberta. Microdiscectomy in the low back. 2023.

Krzanowska E, et al. The frequency and risk factors for surgery dissatisfaction in patients undergoing lumbar or cervical surgery for degenerative spinal conditions. Psychology, Health & Medicine, 2022.

Manni T, et al. Rehabilitation after lumbar spine surgery in adults: a systematic review with meta-analysis. Archives of Physiotherapy, 2023.

Oosterhuis T, et al. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev, 2014.

McIsaac DI, et al. Relative efficacy of prehabilitation interventions and their components: systematic review with network and component network meta-analyses of randomised controlled trials. BMJ, 2025.

Rushton A, et al. Physical prognostic factors predicting outcome following lumbar discectomy surgery: systematic review and narrative synthesis. BMC Musculoskeletal Disorders, 2018.

Weinstein JN, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation. The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA, 2006.

Weinstein JN et al. Surgical Versus Nonoperative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcomes Research Trial. Spine, 2010.

Xu W, et al. Risk factors for failed back surgery syndrome following open posterior lumbar surgery for degenerative lumbar disease. BMC musculoskeletal disorders, 2022.

Yu H, et al. Effectiveness of postsurgical rehabilitation following lumbar disc herniation surgery: A systematic review. Brain Spine, 2024.

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