A 78-year-old male was admitted to the hospital for a scheduled L2-S1 posterior decompression, posterolateral fusion with autograft, and posterior instrumented fusion. The patient has a history of chronic low back pain and lumbar radiculopathy into bilateral lower extremities with failed conservative management that included medications and physical therapy. Diagnostic imaging revealed L2-S1 spinal stenosis. During surgery, the patient sustained significant blood loss of 2000 mL. Past medical history is significant for hypertension, gastroesophageal reflux disease, and anemia. Past surgical history is significant for appendectomy. The patient's inpatient hospital medication list includes Vicodin (for moderate pain), Demerol and morphine (for breakthrough pain), Flexeril, Tramadol, acetaminophen, Protonix, and Enalapril. Due to adverse drug reactions, Vicodin, Demerol, and morphine were recently discontinued and the patient was placed on Ultram. Chart review revealed the following significant values: hemoglobin 9.3, hematocrit 26.7, and heart rate around 120 beats per minute. Due to these values and the patient being symptomatic of anemia, a blood transfusion was ordered. The patient was on bedrest for the first 8 hours postsurgery, and he stood at the edge of the bed the previous evening with help from the nursing staff. The orthopaedic surgeon indicated that the patient should ambulate with a thoracolumbosacral orthosis (TLSO) and follow postoperative spine precautions. The patient lives with his wife in a two-story home, with both the bedroom and bathroom located on the second floor. There are four steps to enter the home with bilateral railings and 12 stairs to the second floor with one railing. The patient owns the following durable medical equipment (DME): standard walker, rolling walker, commode, crutches, and TLSO. The patient's wife expressed concerns about her ability to care for her husband at home. A physical therapy consultation was ordered by the orthopaedic surgeon on postoperative day 1 (POD 1).
Based on the patient's diagnosis and surgery, what do you anticipate will be the contributors to activity limitations?
What are the examination priorities?
What are the most appropriate physical therapy interventions during the acute phase of healing?
What precautions should be taken during physical therapy examination and interventions?
What are the possible complicating factors presented that could impact the patient management process?
- AUTOGRAFT: Graft that is harvested from the patient
- DECOMPRESSION: Surgical procedure involving removal of the lamina or surrounding structures to relieve pressure on the spinal cord or nerve roots
- DURAL TEAR: Complication of spine surgery in which the dura mater is torn
- FUSION: Surgical procedure in which two or more adjacent vertebrae are fused together with or without instrumentation
- THORACOLUMBOSACRAL ORTHOSIS (TLSO): Rigid back brace that may be used postoperatively to protect the spine by limiting excessive motion
Describe conservative and surgical management for chronic low back pain (LBP) and lumbar spinal stenosis (LSS).
Understand the ...
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