In reply to Lyn Gregson and Lenny Aronsten.

I was interested to read the protocol from Lenny but would 
look forward to anyone producing "guidelines of treatment" 
[rather than a rigid protocol] produced by a team rather 
than following the classical medical model.

At the hospital where I work we have developed fairly loose 
guidelines of treatment with several differences, 
particularly in the initial inpatient phase.  Rather than 
just considering discectomies, we tend to apply this to 
surgery where there has been decompression of the nerve 
roots, whether by discectomy or bony decompression by 
trimming osteophytic overgrowth of the apophyseal joints.  
We have not done the classical laminectomy for several 
years.

Postop	Patients are allowed to log roll into any position, 
	provided they are lying flat.  By the way, what is 
	a Jordan frame and what is it for?

Day 1/2	Continue log rolling and commence nerve root 
	sliding exercises but not by SLR.  These are done 
	as follows :

		Lying flat supine and lifting head - the 
		theory being that this will pull the nerve 
		roots in past the decompression surgery 
		site.

		Lying flat supine with roll under knees to 
		flex hips.  One knee is extended with the 
		foot in equinus and then nerve root sliding 
		is accomplished by dorsiflexing the foot as 
		far as leg pain allows.  The foot then 
		returns to equinus before the knee is 
		flexed to allow the foot to rest on the 
		bed.  This will tend to pull the root out 
		past the surgery site.

		This is then repeated with the other leg 
		and this will tend to pull the root across 
		towards the other side.

	Progression of these exercises is by increasing the 
	size of the knee roll and progression is only 
	allowed when full dorsiflexion can be comfortably 
	attained in either leg.

	The aim of these exercises is to re-establish the 
	natural nerve root sliding capability of the 
	central nervous system with the spinal canal 
	without ANT.  There may well still be 
	some considerable irritation of the nerve root, 
	particularly if the compression has been 
	severe.  Conventional back exercises at this stage 
	do not resolve the issue of trying to reduce 
	adhesions developing at the surgical site.

	Getting in/out bed in sidelying rather than sitting 
	up [ie being in long sitting] to reduce incidence 
	of leg pain and prolonged nerve root irritation.

	Patients are allowed to mobilise if no leg pain, 
	but sitting is limited for toilet purposes [I would 
	add that female patients do not appear to be 
	adversely affected considering that their sitting 
	frequency is considerably more than their male 
	counterparts].  Lightweight corsets are considered 
	mandatory by one surgeon but these are only applied 
	before they go home [ie after they have mobilised] 
	which often means they end up sitting more.  They 
	are not worn in bed.

Day 3/4	Gradual increase in activity in terms of mobilising 
	but still limited time sitting [meals if only a 
	short time] and continuing their nerve root sliding 
	exercises, aiming to achieve at least 40 degrees at 
	the hip with a larger knee roll.

Most patients are discharged at about 5 days unless their 
is continuing leg pain from nerve root irritation or due to 
LP headache from CSF leak with a dural tear or nick.  It is 
sometimes quite difficult to persuade some that hiding this 
with codeine does nothing to stop the leak and only 
prolongs the agony.  In my experience most of these resolve 
spontaneously over a few days with bedrest [trying at 
times to see if symptoms recur but not pushing the 
upright position] but occasionally there has to be a resort 
to a blood patch.

All patients are then referred for further physiotherapy as 
an outpatient [department, GP surgery or whatever is the 
local arrangement] to gradually increase activity to 
maximum attainable fitness over the next three months, much 
along the lines of Lenny's programme. I believe that SLR in 
the later stages of rehabilitation is a useful tool to 
regain final sliding capability but hopefully by this time 
the nerve root irritation should have settled.

However, I have to disagree with SLR as an exercise in 
the immediate post-op or rehab phase.  It seems to me that 
persisting with SLR as a means of root sliding could be 
counterproductive as the sliding is effectively being given 
proximally with a very crude movement requiring 
considerable effort by the hip flexors [largely attached to 
the anterior aspect of the lumbar spine], rather than a 
much finer movement generated distally with the leg preset 
in a more relaxed position.  Looking at the literature 
there appears to be a body of evidence to suggests that SLR 
alone is not necessarily the best way to mobilise an 
irritated central nervous system.

Anthony Morgan
James Paget Hospital
Norfolk




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