Surgery for the lower back pain or sciatica that you might be experiencing is never a decision that is taken lightly. In fact the avoidance of surgery is one of the primary concerns amongst many with pain in the lower back. However in some circumstances the surgical route is one which ends up being considered.
Fortunately the need for lower back surgery is incredibly rare. What’s even more uncommon is the need for emergency surgery. This is often the case for the person with Cauda Equina symptoms. With this in mind we know that the surgical option is one which is perhaps “scheduled” weeks or months in advance. Because this is the case, we can infer that it is not a foregone conclusion that surgery must be done, as if it was, you would be among the “emergency surgeries” mentioned previously.
This reality should be considered in a positive light as it means that we can take some actions that can help us avoid the need for surgery and/or improve the prospective outcome of a surgery if it is to be done.
Before we get into the meat of this week’s episode, we want to make a quick reference to resources on the NHS website’s section on low back (lumbar spine) surgery:
“To help you recover from your operation and reduce your risk of complications, it helps if you’re as fit as possible before surgery.”
This is very important! Over the years we’ve seen individuals with surgery lined up, sometimes months in advance, resigning themselves to doing nothing “productive” until after surgery because they don’t want to “make things worse”. All the while continuing on with all the daily life activities which have undoubtedly contributed to the worsening of their back injury in the first place. This continuation whilst the body continues to de-condition further makes little sense, and is even advised against.
This is a source of great frustration as an approach like this simply creates a greater hill to climb afterwards. We’ve seen so many both in clinical practice and as members of the program working to avoid surgery in this same timeframe, with success. Ultimately doing nothing is doing something and often it amounts to adding needless additional challenges post-operation.
That being said, sometimes the surgical approach is one that is undertaken, so from here out, we’ll try to give you the most comprehensive guide to what you should be doing if you’re looking to recover from lower back surgery in the most effective way.
Understanding Your Lower Back Surgery
One of the most important first steps when it comes to your lower back is understanding the surgical intervention that is being recommended. Is there scope to use minimally invasive techniques or will the surgery be more involved? All of this should be discussed with you at your appointment with the relevant specialist surgeon.
Naturally if it is a more involved procedure then you are going to have a different recovery time frame compared to if it is going to be a less involved procedure. For example, some lower back surgeries might involve overnight stays in hospital for 1 to 4 days. In other cases, you’ll go home sooner. As you can imagine the details of this are going to be dependent on the procedure, and the success of the surgery.
It can be helpful if you write down some of the following questions ahead of your appointment with the surgeon so you can get a good idea of what to expect recovery wise. Ask these before your surgery, and then again after the surgery as sometimes the answers can change.
- Am I going to be able to walk out after surgery or will I need aids?
- How long before I can walk again unaided
- How long before I can go up stairs
- How long before I can get out of a chair on my own
- How long before I can lift a kettle
- How long before I can carry shopping bags
- How long before I can carry my 2 year old son/daughter/grandson/granddaughter
- How long before I can walk the dog
- How long before I can go back to work
This might sound a little ridiculous but this is important as unfortunately the support after surgery can sometimes be lacking and one of the real challenges individuals face when they’re coming out the other side of lower back surgery is knowing when they can start doing specific exercises again.
We will come back to these points later on, the list above is also by no means exhaustive, but meant to cover specific tasks that perhaps place varying degrees of impact or strain on the lower back.
Recovery From Lower Back Surgery Starts Before Surgery Is Even Considered
From the information towards the end of the last section it becomes evident therefore that activities of daily living are maintaining the degradation of our lower back, for example, getting out of chairs in such a way that rounds the lower back. The continual weakening of the core and back musculature, not to mention the legs, continues with the continued abstinence from purposeful activity too. This has the effect of further worsening the status quo.
As mentioned on the NHS website and agreed upon by numerous surgeons, the better the conditioning of the patient the better the prospects of recovery post surgery, the less likelihood they have of surgery “failing” or being required again.
You might be thinking, “yes but I’m in pain every day!” We understand, however, if that pain is not stopping you doing the myriad of daily activities while you wait the 6 weeks or more for the surgery then you can and should be doing something more productive. For some the rehabilitative principles that we’ll discuss later on will not all be possible and we appreciate that, however we can all set about learning and understanding that the simple things make a big difference and through education and guidance you can start modifying the activities of daily living BEFORE you have the surgery.
Let us take things back to that example of getting out of a chair. Something many awaiting surgery will continue to do regardless. Is it not perhaps a good idea to start learning to do this correctly, perhaps even building a movement pattern that will help you improve chances of surgical success afterwards? You’re getting out of chairs anyway, why not get into the habit of being able to do it well.
Sounds sensible no?
Yet so many will be terrified of doing a squat thinking “no no, that’s exercise and I’m booked for surgery!” only to sit down in a chair for dinner.
The bottom line here is to take an honest look at the actions you are performing every day, regardless of whether you are in pain or not, and compare those to simple exercises that can improve the status quo, your movement habits and muscular control. Then follow those exercises and education around them to help make use of this time.
Surgery is not a decision to be taken lightly. Surely you’d want to do whatever you can to increase the likelihood of success, increase the smoothness of recovery post op and ultimately get back to doing what you love!?
The Process of Healing: Understanding Your Body’s Natural Recovery Mechanisms
Before we get into the specifics of the exercises in the different stages post operation, you must have an appreciation for the healing process. If your surgeon has been through things correctly, with you then you’ll have an idea of precisely what is being done. You’ll also be aware that even the least invasive surgical techniques still involve some degree of tissue damage. This is damage your body needs to heal from.
At the same time as their being damaged, in certain cases you’ll have immediate relief as the pressure from the disc herniation onto the nerve root is removed, or the osteophytic bar irritating the nerve root has been removed. Whatever the case you’ll also have been dosed up with pain killers, and possibly some local ones via injection at the time too – in conjunction with the anesthetic.
All this to say that the surgery has been a success but you are left with tissue damage, this now needs to go through the process of healing. If you saw last week’s podcast on Chronic Back Pain you’ll recall we mentioned healing and how so many interfere with the healing process and this is why a simple back injury becomes a chronic one.
Well now is your chance to make it right!
Healing will be trying to take place over the coming weeks. Some of the tissues heal more swiftly, the skin for example, other tissues like the ligaments and the nerves heal slowly. Know that your body will do this healing at the natural pace, but in the interim you need to make sure you’re not doing things to interfere with that healing process. Hence why the advice in the former section can make such a difference!
While you’re still dosed up on painkillers your academic understanding of your lower back and how it works will be vital to help support it when it is early on in the healing process, and as these tissues start to move into a remodeling phase of healing the role and importance of your exercises shifts too. In this phase you’re helping the tissues restore strength and even build on what was there before. These are the areas we’ll be covering next so pay attention.
Early Stage Exercises: Building A Strong Foundation
The questions we mentioned earlier are so important to help you understand the sorts of strain your body is capable of bearing and when. We have already compared the squat to getting out of a chair, we could compare a lunge to going up stairs and the addition of resistance to carrying shopping or lifting a child. These real world examples help you frame things more clearly as asking the surgeon “when can I do exercise” is such a wide ranging question it’s practically useless. Are we talking about running a marathon or going to crossfit games or are we talking about walking around the house? What “exercise” means to different people and different healthcare professionals is so inconsistent we should always look for specifics to provide clarity.
Gentle Walking To Aid Recovery
Invariably after lower back surgery you will be advised that walking is a good idea, for short stints regularly. This has a number of benefits, first and foremost it keeps you mobile. The area in your back will have the propensity to build inflammation if you’re too still as, like we discussed in previous sections, post surgery the tissues are going through a healing process. Walking helps with this process by also offering some small amounts of movement through the spine. One of the concerns is that there may be adhesions formed between layers of tissue that have been disrupted during the surgical procedure. By keeping the body moving in a limited way through activities such as low grade walking, we are able to keep the region moving a little bit to help prevent stasis and stagnation.
Many will be given what are described as a gentle range of motion exercises such as knee hugs or child’s pose, movements that flex your lower back and eliminate the lordosis. We however would strongly discourage such actions. Walking offers a great way of putting small amounts of movement through the lower back. These sorts of stretches on the other hand offer large degrees of movement which will stretch the tissues which are working to heal and “contract” together again to restore integrity. These exercises are fundamentally at the root of many early back pain interventions when the original injury was first done. They are unwise then, and they are unwise here for the same reasons.
Safe Spine Stabilisation Exercises After Low Back Surgery
Your lower back becomes injured when it is pulled off balance and too much stretch and/or compression goes through certain tissues in the lower back. The area that has been operated on will be vulnerable as you can imagine, until complete healing takes place the lower back is compromised. With this in mind a very early activity will be to start learning to stabilize the spine through stabilising isometric exercises.
Ideally you’d have begun learning these long before the surgery, the big problem is that people don’t learn these before the surgery. An inability to do them in the past has likely contributed significantly to the poor healing in the first instance and maybe even the injury itself. Learning from scratch takes a little time and a little trial and error so it is always better to have done that BEFORE surgery. Yet another reason why rehabilitation should begin beforehand.
That being said, if you are going to begin learning spinal stabilisation there are safer ways to do it, these are the sorts of techniques we teach in the Phase 1 and Phase 2 of the Back In Shape Program. Off weight bearing we can begin to experiment with the engagement of core musculature, and then test the ability to maintain a neutral spine as a light movement is applied. The goal here, for example, with a simple psoas engagement, is that as your knee gently lifts up, the spine is held still and does not pivot, twist or bend.
The above example could be considered very safe, although even that, some find concerning. Which is why we asked those questions earlier. Let us face it, if you’ve been cleared to walk to your car get in, and then get out again to go home, roll over in bed to get out of bed, lift your knee to put on your underwear, you are already doing MANY tasks that are more strenuous than this without even thinking about it.
So do the exercises!
The tasks mentioned above will likely be approved by your surgeon, “of course you can get dressed, just be careful”. This however gives no practical advice or route to develop skill and safe movement. The exercise mentioned above on the other hand does. And does so without you having to negotiate the load of your entire torso on your recovering lower back.
From here, you can start to explore other exercises that will progressively exert a little more challenge on your core. So long as you pay very close attention to your spine and hold it steady these exercises are great options, an example would be a modified dead bug. Again, although with a little more movement possible, we are asking our core to stabilize the lower back as the leg moves. There are variations of nearly all exercises to allow you to incrementally increase or decrease the difficulty to ensure good form. All the while remember, when doing basic variations of this properly, there is going to be less strain on the back than the myriad of tasks you’ve already been cleared for in the days following surgery.
We reiterate once more, the utility of asking those 9 questions to provide a reference from the surgeon following your lower back operation.
One of the final beginners exercises might surprise you, however you’ll very quickly see why it is so important. The Squat. Let us face it, before the end of your first day at home you will have done a handful of squats, if not more. You’ll have likely visited the bathroom, the dining table, maybe the lounge chair, you’ll perhaps have done some short bouts of walking, and you’ll finish your day likely sitting onto the bed as you go to sleep.
Make no mistake, these are all squats.
They are all opportunities to squat correctly, or to squat in a way that exerts more force through your lower back, the lower back that is healing after a significant surgical intervention.
The unavoidable reality of getting in and out of chairs more or less instantly following surgery on your lower back, let alone getting in and out of your car, is one you cannot ignore. And let us face it, if the surgeons were that concerned about this you’d be sent home in a wheelchair by ambulance to negate the need to do any of this. And perhaps you were. All the more reason to ask question number 4: “How long before I can get out of a chair on my own?”
The point here is that this exercise from experience is done poorly, without stabilizing the spine, and therefore learning to do such an activity sooner rather than later gives you the opportunity to put in place good habits right away, decreasing the likelihood of your daily activities interfering with the healing process after your lower back operation.
Intermediate Stage Exercises: Strengthening Your Body
This next stage of activities should then be undertaken using the framework from the 9 questions as well as based on how you’re feeling and what you’re doing on a daily basis. Always take a look at the daily activities you’re voluntarily doing and compare those to exercises. Know that exercises at this stage can really be vastly different in their level of strain depending on HOW you do the exercise. For example, If you’re cleared to go up stairs, you are doing small lunges, this is a complex task that involves you stabilizing your back whilst upright, then generating enough force with one leg only to propel the body up to the next step. As this happens your core musculature has to balance the lop-sided force coming up the legs to make sure the back stays stable. You’ll likely also be leaning forwards slightly, and therefore increasing load through the spine.
Going Up Stairs With Your Low Back After Surgery
Let us look at this in a little more detail firstly, the bad example. As you start out you drive through a weak leg with poor control and your knee moves inwards as your arch collapses, this creates twisting of the leg as you try to generate the power to go up the step. That then pulls on your pelvis and the pelvis shifts to one side. This puts an off balance pressure through your lower back, particularly at L5, S1 and then L4, L5, likely the site of surgery. On top of that your rib cage then bends to the side further off balancing you. Your torso then tilts forward rounding your lower back, putting more pressure on that same segment. Then to top it all off, you lean forwards further compounding the whole process by increasing the compression going through your spine, again that segment of the back that’s been operated on the epicenter of where these forces localize.
This all sounds a bit extreme, maybe even scary, but chances are you hadn’t even considered this. Well when a reverse lunge is done, with a shallow depth it replicates the same movement above. However the difference is that you have set aside some time to do it with focus and intention, you’ve been taught HOW to do the movement properly, without all of those erroneous movements creeping in and straining your lower back.
Instead, you use the skills you learned of spinal stabilisation from earlier exercises off weight bearing, and apply them with practice when you do your SHALLOW reverse lunges. You have control, perhaps doing them in front of a mirror, or even recording them.
Because let’s face it, you’re serious about your recovery and getting better.
You see, this exercise sounds scary, a reverse lunge, but it has a very simple variation which is incredibly safe, WHEN YOU LEARN TO DO IT PROPERLY. Then as you become more confident you can progress this exercise over weeks, months and even years ahead as we’ll explore later, to build a robust and complete recovery.
We talk in detail in a previous episode about strengthening your core to fix your lower back pain and fundamentally the same rules apply at this stage with post-surgical lower back rehab as they do to any other back rehabilitation.
Advanced Stage Exercises: Restoring Function & Preventing Recurrence
Some will reach this stage sooner than others, and the important thing is that you recognise, all will need to get to and through this stage of the rehabilitation. Here you are looking to make your performance positively impact your daily life and drive the final remodeling process.
As the injured site, and site of operation are “healed” now, the remodeling and restructuring of these tissues is vital. Taking the exercises that you’ve likely already been doing, and enhancing them with resistance bands or weights will allow you to continue to stimulate the tissues at the site of surgery, as well as those around it, to become stronger and more resilient. At this stage you will really have two focusses.
Building A Resilient Lower Back For The Long Term
Firstly, looking at the tasks you have to and want to do on a daily basis and one off basis.
Take a look at what that might involve, for example, if you like gardening and have some heavy pots that need moving multiple times a year, let us suppose they’re 15kg. Another example we use all the time, going on holiday, you’re likely to be carrying at some point, a 20-25kg bag AT LEAST. Then we have moving household furniture, carrying growing children or grandchildren, the list goes on. One thing is for sure that you will be exposing your back to load. So your exercises should reflect this inevitability. Adding resistances to make sure central movements such as a hip hinge, squat and reverse lunge or split squat are possible with a reasonable amount of resistance added. This way you condition your body’s healing and remodeling to strengthen proportionately. The further you drive this process the less likely you are to face a challenge of load bearing beyond what you’re conditioned for. So if you decided to stop using more than 5kg on your squats or hip hinges, you’ve made a big mistake! Even a shopping bag could weigh more than that and children or grandchildren certainly will!
Building In Hip Mobility To Ensure You Can Move Properly
Note the placing of this section. With more mobility comes less stability and greater requirement from muscles to stabilise. Adding in flexibility however is essential to long term health as it enables you to perform the movements mentioned above with the fullest possible range of motion. Working on your hip flexibility will also help take strain off your lower back. The more free your hips are, for example, on a squat, the later your lower back will be pulled into the movement. You’ll find that daily activities become easier and easier and your movement more fluid. A proper stretching regimen to compliment your strengthening work will be the perfect strategy. A simple lower body stretching routine like this one will offer you a great way to unwind the hips and keep everything supple as you continue your progress.
Strategies To Help Prevent Back Pain Recurrence
Ultimately if you follow the plan above, you will find that you have success using your surgery as a gateway to resolving your lower back pain. If you’re reading this and have a couple of months before your lower back surgery is scheduled, then enact the points we discussed in this post now! You might find you join the growing number of people who get to the week before surgery and decide they no longer need it! Granted, 2 months will not be long enough to completely resolve the issues in your lower back, but it will be long enough to make enough progress to give you the hope and confidence that you can get through this without the need for the risks associated with surgery on the spine.
So many who end up having surgery have tried “exercises” before so they’re naturally disheartened. Perhaps that’s you? Unfortunately so many get caught out doing the wrong sorts of exercises and they don’t work, or the expectation of time frames is wrong and not communicated effectively. Evaluate if the above principles discussed today have been implemented in your prior rehab efforts, if not, we would encourage you to have another go ahead of the surgery, what have you got to lose?
If you’re coming out the other side of surgery and really want more guidance because perhaps your rehab has been non-existent or you’ve been left to your own devices like so many others. Check out the Premium membership using the link below and start a program that will get you to where you want to be, following the principles we discussed here. Plus you’ll be part of a community of others who are in the same position as you, with support from our expert team.