Post-Operative Protocol: Laminectomy & Discectomy

PHASE 1 — Immediate Post-Op (Recovery Room / Day 0)

Monitoring

• Vitals every 15 minutes for 1 hour, then every 30 minutes
• Neurological checks: lower limb motor power, sensation, and reflexes every hour for the first 4–6 hours
• Monitor for cauda equina symptoms: new bilateral leg weakness, perineal numbness, or loss of bladder/bowel control → surgical emergency
• Urine output monitoring (catheter usually removed within 24 hours if ambulatory)
• Wound drain output (if placed): remove when output < 30 mL/8 hours

Position

• Head of bed 30° elevation
• Log-roll technique for all position changes — no twisting the spine
• Pillow between knees when side-lying

Pain Management

• Multimodal analgesia (reduces opioid requirement):
  • Paracetamol (acetaminophen) 1 g IV/PO q6h scheduled
  • NSAIDs (e.g., ketorolac IV initially, then ibuprofen PO) — avoid if renal concerns or peptic ulcer history
  • Gabapentin/pregabalin for neuropathic component (radicular pain)
  • Opioids (tramadol or oxycodone) PRN for breakthrough pain
• Note: Recent evidence (2025) suggests opioid utilization is declining post-discectomy with effective multimodal protocols [PMID: 41127341]

Wound Care

• Keep dressing intact for 48 hours
• Monitor for haematoma: expanding swelling, neurological deterioration → urgent exploration
• Epidural haematoma risk: <0.5% but presents with rapid neurological decline → emergent MRI + surgical evacuation

PHASE 2 — Day 1–2 (Ward)

Mobilisation

• Ambulation begins Day 1 (within 24 hours) — this is the single most important post-op instruction
• Sit at edge of bed → stand with assistance → short corridor walks
• No prolonged sitting > 20–30 minutes initially (increases intradiscal pressure)
• Sitting encouraged in upright chairs (not soft sofas); hips at 90°

Physiotherapy Assessment

• Breathing exercises and chest physiotherapy (prevent atelectasis)
• Teach proper body mechanics: straight back, no trunk rotation, hip-hinge technique for bending
• Demonstrate correct log-roll technique for getting in/out of bed
• Compression stockings + early ambulation for DVT prophylaxis
• LMWH (e.g., enoxaparin) per institutional protocol if high DVT risk

Bladder & Bowel

• Confirm adequate voiding before discharge; urinary retention occurs in up to 5–10% post-lumbar surgery
• Stool softeners (lactulose or docusate) — avoid straining with Valsalva, which increases IVD pressure
• High-fibre diet and oral hydration encouraged

PHASE 3 — Discharge (Usually Day 1–3)

Discharge Criteria

• Pain controlled on oral analgesia
• Independent ambulation (with or without walking aid)
• Voiding adequately
• No neurological deficits compared to pre-op baseline
• Wound dry and intact
• Patient/carer educated on red flags

POST-OP PATIENT INSTRUCTIONS (Discharge)

Wound Care

• Keep wound dry for 10–14 days
• Sponge baths only until staples/sutures are removed (usually Day 10–14)
• No swimming or submersion until wound is fully healed
• Report: increased redness, swelling, warmth, purulent discharge, or fever > 38°C
• Postoperative wound infection rate: 0.2–3% — most are superficial staphylococcal, occurring within first 10 days — Grainger & Allison's Diagnostic Radiology

Activity Restrictions (First 6 Weeks)

Medications at Home

• Paracetamol scheduled (not PRN) for first 1–2 weeks
• NSAIDs with food for 2 weeks (omeprazole co-prescribed if needed)
• Stool softeners × 2 weeks
• Wean gabapentin/pregabalin gradually (do not stop abruptly)
• Avoid alcohol with opioids; cease opioids as soon as feasible

Sleeping Position

• On side with pillow between knees (neutral spine)
• On back with pillow under knees (reduces lumbar lordosis)
• Avoid sleeping prone for 6 weeks

REHABILITATION PROGRAMME

Week 1–2: Rest & Gentle Mobilisation

• Short walks (5–10 minutes), 3–4 times daily, increasing as tolerated
• Gentle ankle pumps, heel slides (lying) to maintain circulation
• No formal PT exercises yet — let wound settle

Week 2–6: Early Rehabilitation

• Core stabilisation (transversus abdominis activation): pelvic floor exercises, abdominal bracing
• Stretching: gentle hamstring and hip flexor stretches (reduce nerve tension)
• Posture education: lordosis restoration, ergonomic workplace setup
• Aquatic therapy: pool walking from ~Week 4–6 (if wound healed)
• McKenzie technique: directional preference exercises under PT guidance

Week 6–12: Progressive Strengthening

• Progressive lumbar stabilisation: bird-dog, bridges, dead-bug exercises
• Aerobic conditioning: cycling (stationary), swimming, brisk walking
• Nerve mobilisation exercises if residual radiculopathy persists
• Return to work assessment (occupational therapy if manual job)

Week 12+: Return to Function

• Progressive loading: advance to gym-based strengthening (under supervision)
• Functional movement training: safe squatting, hip-hinge pattern
• Sport-specific rehabilitation if applicable
• Monitor: most patients experience significant improvement by 3–6 months; persistent radiculopathy up to 12 months can still continue to improve — Miller's Review of Orthopaedics 9th Edition

RED FLAGS — RETURN TO EMERGENCY IMMEDIATELY

FOLLOW-UP SCHEDULE

ANTICIPATED OUTCOMES

• Pain relief: 80–90% of patients achieve significant leg pain (radiculopathy) relief
• Back pain: Variable — surgery primarily addresses leg symptoms, not axial back pain
• Neurological recovery: Deficits present pre-operatively may take weeks to months to recover; some residual numbness is common
• Recurrence: Re-herniation at same level in ~5–10% — Miller's Review of Orthopaedics 9th Edition
• Return to prior activity: Most patients return to full activity by 3–6 months

Key textbook references: Miller's Review of Orthopaedics 9th Edition | Grainger & Allison's Diagnostic Radiology | Rockwood & Green's Fractures in Adults 10th Ed | Schwartz's Principles of Surgery 11th Ed